Right and left hepatic ductsleaving the lobes of the liver of the same name, form a common hepatic duct... The width of the hepatic duct ranges from 0.4 to 1 cm and averages about 0.5 cm.The length of the bile duct is about 2.5-3.5 cm.The common hepatic duct, connecting with the cystic duct, forms a common bile duct... The length of the common bile duct is 6-8 cm, width is 0.5-1 cm.
In the common bile duct, four sections are distinguished: supraduodenal, located above the duodenum, retroduodenal, passing behind the superior horizontal branch duodenum, retropancreatic (behind the head of the pancreas) and intramural, located in the wall of the vertical branch of the duodenum (Fig. 153). The distal part of the common bile duct forms a large duodenal papilla (vater nipple), located in the submucosal layer of the duodenum. The large duodenal papilla has an autonomous muscular system consisting of longitudinal, circular and oblique fibers - the sphincter of Oddi, which does not depend on the muscles of the duodenum. The pancreatic duct approaches the large duodenal papilla, forming, together with the terminal section of the common bile duct, the ampulla of the duodenal papilla. Various options the relationship between the bile and pancreatic ducts should always be taken into account when performing surgery on the greater duodenal papilla.
Fig. 153. The structure of the biliary tract (diagram).
1 - left hepatic duct; 2 - the right hepatic duct; 3 - common hepatic duct; 4 - gallbladder; 5 - cystic duct; b _ common bile duct; 7 - duodenum; 8 - accessory pancreatic duct (Santorini duct); 9 - large papilla of the duodenum; 10 - pancreatic duct (Wirsung duct).
The gallbladder is locatedon the lower surface of the liver in a small depression. Most of its surface is covered by the peritoneum, with the exception of the area adjacent to the liver. The gallbladder capacity is about 50-70 ml. The shape and size of the gallbladder can undergo changes with inflammatory and cicatricial changes. Allocate the bottom, body and neck of the gallbladder, which passes into the cystic duct. Often a bay-like protrusion forms at the neck of the gallbladder - Hartmann's pocket. The cystic duct often flows into the right semicircle of the common bile duct at an acute angle. Other options for the inflow of the cystic duct: into the right hepatic duct, into the left semicircle of the common hepatic duct, high and low confluence of the duct, when the cystic duct accompanies the common hepatic duct for a large extent. The wall of the gallbladder consists of three membranes: mucous, muscular and fibrous. The mucous membrane of the bladder forms numerous folds. In the area of \u200b\u200bthe bladder neck and the initial part of the cystic duct, they are called Geister valves, which, in the more distal parts of the cystic duct, together with bundles of smooth muscle fibers, form the Lutkens sphincter. The mucous membrane forms multiple protrusions located between the muscle bundles - the sinuses of Rokitansky - Ashoff. In the fibrous membrane, more often in the area of \u200b\u200bthe bed of the bladder, there are aberrant hepatic tubules that do not communicate with the lumen of the gallbladder. Crypts and aberrant tubules can be a place of microflora retention, which causes inflammation of the entire thickness of the gallbladder wall.
Blood supply to the gallbladder is carried out through the cystic artery, going to it from the neck of the gallbladder with one or two trunks from its own hepatic artery or its right branch. There are other known variants of the discharge of the cystic artery.
Lymphatic drainagehappens in the lymph nodes gate of the liver and lymphatic system the liver itself.
Innervation of the gallbladder carried out from the hepatic plexus, formed by the branches of the celiac plexus, left vagus nerve and the right phrenic nerve.
Bile, produced in the liver and entering the extrahepatic bile ducts, consists of water (97%), bile salts (1-2%), pigments, cholesterol and fatty acids (about 1%). Average flow rate of bile secretion by the liver is 40 ml / min. In the interdigestive period, the sphincter of Oddi is in a state of contraction. When a certain level of pressure in the common bile duct is reached, the Lutkens sphincter opens, and bile from the hepatic ducts enters gall bladder... In the gallbladder, bile is concentrated due to the absorption of water and electrolytes. At the same time, the concentration of the main components of bile (bile acids, pigments, cholesterol, calcium) increases 5-10 times from their initial content in the hepatic bile. Food, acidic gastric juice, fats, getting on the mucous membrane of the duodenum, cause the release of intestinal hormones into the blood - cholecystokinin, secretin, which cause contraction of the gallbladder and simultaneous relaxation of the sphincter of Oddi. When food leaves the duodenum and the contents of the duodenum again become alkaline, the secretion of hormones into the blood stops, the sphincter of Oddi contracts, preventing further flow of bile into the intestine. About 1 liter of bile enters the intestines per day.
Surgical diseases. Kuzin M.I., Shkrob O.S. and others, 1986.
Common bile duct has a length of 5 to 15 cm (usually 8-10 cm). He, like the common hepatic duct, is located along the free edge of the hepato-duodenal ligament. To the left and somewhat anteriorly is the hepatic artery. The portal vein runs behind the hepatic artery, located closer to it. than to the common bile duct. The common bile duct runs behind the initial part of the duodenum, then continuing down and to the right. It runs along the groove or tunnel formed by the head of the pancreas and the beginning of the descending part of the duodenum. The common bile duct enters the wall of the duodenum and connects to the pancreatic duct, forming a common canal that opens into the duodenum with a large duodenal papilla.
Common bile duct can be divided into four segments:
1. Supraduodenal, usually 20 mm long. This segment is most easily accessible when surgical operations... Together with the common hepatic duct, it provides good access for choledochotomy and revision biliary tract.
2. Retroroduodenal segment 15-20 mm long.
3. Infraduodenal extra-pancreatic segment 20-30 mm long. It follows the descending part of the duodenum in a notch or tunnel along the head of the pancreas. The pancreas and the common bile duct are not fused with each other, therefore, the tissue separating them is well expressed, except in cases of chronic pancreatitis in the region of the pancreatic head. In such cases, it is almost impossible to separate the common bile duct and pancreas. Fibro-tissue infiltration and thickening of the pancreas can lead to obstruction of the common bile duct. If there is no fusion of the common bile duct with the pancreas, a retropancreatic choledochotomy can be performed to remove the impacted calculus that cannot be removed by supraduodenal or transduodenal sphincterotomy.
4. Intraduodenal, or intramural, segment. As soon as the common bile duct crosses the wall of the duodenum, its caliber is significantly reduced, and the walls become thicker. This must be borne in mind when interpreting a cholangiogram. It should also be borne in mind that a radiopaque substance that enters the duodenum during intraoperative cholangiography may cause overlap of shadows that hide a clear picture of the intramural segment of the common bile duct. In these cases, the radiograph must be repeated and a clear image of the terminal section of the common bile duct should be achieved. The length of the intramural part of the common bile duct is very variable, but always greater than the thickness of the duodenal wall. This is due to its oblique trajectory when crossing the wall of the duodenum. The length of the transduodenal part of the common bile duct is 14-16 mm.
There are three main ways common bile compounds and pancreatic ducts:
1. Most often, the common bile duct and pancreatic duct join shortly after penetrating the duodenal wall, forming a short common tract.
2. Both ducts run in parallel, but do not connect and flow separately into the greater duodenal papilla. Sometimes the pancreatic duct can drain 5-15 mm below the papilla.
3. Pancreatic duct and common bile duct connect at a higher level, before entering the duodenal wall, forming a longer common canal. In rare cases, a type 1 or 3 compound forms an expansion called an ampoule.
Vater papilla and its study
Abraham Vater in 1720 (491 lectured at the university Wittenberg (Germany), entitled "Novus bills diverticulum", in which he described a diverticulum located at the distal end of the common bile duct. Vater thus described the common bile duct diverticulum as the rarest example of choledochocele. Subsequently, he was unable to find a second such case. He never mentioned the duodenal papilla, the ampoule was also not described by him. Nevertheless, in the medical literature, the large duodenal papilla and ampulla bear his name. The formation, called the ampulla of Vater, is a duct formed by the junction of the common bile and pancreatic ducts as they pass through the wall of the descending part of the duodenum to the place where it flows into the greater duodenal papilla. It is usually a short, duct-shaped segment rather than an ampulla. Sometimes it can be longer. This duct can expand if the duodenal papilla is obstructed as a result of inflammation or impingement of the calculus. Probably, it can reach a larger diameter without obstruction due to postmortem autolysis of the common bile and pancreatic ducts. Like other authors, we believe that the term "ampoule" should not be used. The lesion in question is a duct, not an ampulla. The eponym "Vaterova" should also not be used, since Vater never mentioned it (10). Some authors believe that the mistake in the name of the ampoule came from Claude Bernard, who in 1856 in his book, quoting Vater, said: “Ampoule commune nomme ampoule de Water,” and wrote “Vater” with W instead of V.
Vater never did not mention the papilla of the duodenum, which bears his name. The duodenal papilla was first described by Francis Glisson in England in 1654 (151 in the first edition of his book Anaromie Heparis, the second edition of which was published in 1681. Some authors believe that the first great duodenal papilla was described by Gottfried Bidloo of Hague in 1685 Others attribute this to Giovanni Domenico Santorini (42) in 1724, which is why in some texts the duct is called the papilla Santorini Santorini gave an excellent description of the duodenal papilla of the dog, sheep and bull, but he was not the first to do this and did not add anything new to his description ...
Sphincter Oddi, alongside with duodenal papilla, was also first described by Francis Glisson in 1654. Glisson described the annular muscle fibers of the terminal section of the common bile duct, arguing that they serve to close the common bile duct in order to avoid reflux of the duodenal contents. In 1887 (36), Ruggiero Oddi also described the terminal sphincter of the common bile duct and associated it with the physiology of bile secretion. Thus, we have found that the papilla described by Glisson is called Oddi. The ampoule, named after Fater, has not been described by anyone, there are serious doubts that it exists at all in the norm, and yet it is still called the ampoule of Fater.
In 1898, Hendrickson (17) in the USA studied the sphincter at the end common bile duct... He added details unknown at the time. In 1937, Schwegler and Boyden studied the Oddi sphincter, and Boyden later added a lot to our knowledge of the Oddi sphincter.
To avoid confusion in terminology, in what follows we will consider vater papilla terms, Santorini papilla, Bedloo papilla, duodenal papilla and duodenal papilla (large duodenal papilla) as synonyms.
The bile ducts are a tubular system in the body that often requires treatment. The common hepatic duct is the most painful part of the biliary system. Even the man leading healthy image life, is not insured against the occurrence of health problems (this is especially true digestive system). Therefore, you need to know what problems lie in wait and how the therapy is carried out. If you start a therapeutic course of any disease on time, then it will go away faster and bring fewer problems.
The bile ducts are a system of channels that are designed to drain bile into the duodenum from the liver and gallbladder.general characteristics
Bile is an auxiliary enzyme that is secreted in the human liver to improve digestion. In humans, the bile ducts are a system of channels, bile is excreted through them into the intestine. The liver's bile ducts open into the duodenum, which leads to the stomach. The system of pathways and bile ducts vaguely resembles the image of a tree: the crown of the tree is the small canals located in the liver, the trunk is the common hepatic duct connecting the duodenum with the liver. The movement of bile is carried out with the help of pressure, it is created by the liver.
Biliary tract: structure
The structure of the canal is not very complicated. All small ducts originate in the liver. The fusion of the left and right canals (both are in the liver) forms a common hepatic. The canals carry the burning formed by the hepatic lobes. The bile duct forms in the bladder, then it connects to the common hepatic canal and forms the common bile duct. The kink of the gallbladder may indicate anomalies in its development. Common hepatic duct strictures are not normal. They occur as a result of strong blows to the liver area.
Congenital pathologies and developmental anomalies of the biliary tract
Congenital pathway anomalies are a defect from which no one is immune. Anomalies should be detected in the hospital or in the first year of a child's life. Otherwise, it can be fatal or exacerbate health problems in older age. So far, there is no universally recognized classification of anomalies of this organ. Scientists also disagree on whether pathologies are hereditary. Most often, they appear if during pregnancy a woman led an unhealthy lifestyle or took illegal drugs. There are such types of congenital abnormalities:
- pathway atresia;
- hypoplasia of interlobular intrahepatic bile ducts;
- common duct cysts.
Biliary atresia
Atresia is an obstruction of the lumen of some or all of the extrahepatic bile ducts. The main feature - rapidly developing jaundice in newborns. If it is physiological, then you should not be afraid. It will go away in 2-3 weeks after the baby is born.
In addition to the jaundice color, the child does not experience any discomfort, feces and urine are normal, but the amount of bilirubin in the blood is increased. It is worth making sure that its level does not rise too rapidly. To speed up its removal, you need to lay the child on a well-lit surface under indirect sunlight.
But, if feces and urine are unnatural yellow color, the child vomits and vomits, feels constant anxiety, then this is not obstructive jaundice, but atresia of the pathways. She appears 2-3 days after birth. The pathways are not able to excrete bile, this leads to an increase in the size of the liver and its hardening, in addition, the angle is sharpened. Doctors advise taking an X-ray at 4, 6 and 24 hours for an accurate diagnosis. Atresia can lead to acute liver failure at 4-6 months and the death of a child at 8-12 months. It is treated only by surgery.
Hypoplasia of interlobular intrahepatic bile ducts
This disease is due to the fact that the intrahepatic ducts are unable to excrete bile. The main symptoms of the disease are similar to atresia, but they are not so pronounced. The disease sometimes goes away and is asymptomatic. Sometimes itching occurs at 4 months of age, but itching does not stop. The disease is in addition to other diseases, for example, of cardio-vascular system... The treatment is difficult. Sometimes it leads to cirrhosis of the liver.
Common bile duct cysts
Common gallbladder cyst. This disease manifests itself in children 3-5 years old. Children experience sharp bouts of pain, especially during depression; at an older age, there is nausea and vomiting. The skin has an uncharacteristic jaundice tinge, feces and urine of an uncharacteristic yellowish color. Temperature rise is common. Ruptures and peritonitis, malignant cyst tumors are possible. It is treated by removing the cysts from the affected organ.
Damage to the bile ducts
Channel breaks are very rare. They are able to provoke swipe in right side... Damage of this kind quickly leads to peritonitis. It is worth noting that with ruptures of other organs, it is very difficult to diagnose damage to the ducts. In addition, in the first hours there are no signs, except painful sensations. In addition, in the presence of an infection, the situation can be greatly aggravated by a sharp increase in temperature. It is treated only with urgent surgical intervention, sometimes the inflammation is fatal.
Diseases of the bile ducts
Diseases of the bile ducts are characterized by discoloration of the skin (it turns yellow), itching, pain in the right side. It is constant with frequent intensification and vomiting, then the pain is referred to as hepatic colic. Pain increases after severe physical activity, long driving and eating spicy, salty food. The pain increases when the right side is pressed.
The main symptom of chronic cholecystitis is acute pain in the right side.Chronic cholecystitis is a disease caused by a virus. Due to the inflammation of the gallbladder, it enlarges. This entails painful sensations in the right side. The pain doesn't stop. If the diet is disturbed or if there is a strong shock, the pain increases. The proper treatment is prescribed by a gastroenterologist. Eating a simple diet is important for your health.
Cholangitis of the biliary tract
Cholangitis is an inflammation of the biliary tract. The disease is caused by pathogenic bacteria. The cause is inflammation of the gallbladder. Sometimes it is purulent. With this disease, the excretion of bile from clogging of the channels worsens. The patient experiences severe pain on the right, bitterness in the mouth, nausea and vomiting, loss of strength. This disease is characterized by the fact that on early stages effectively treated folk remedies, but later only by operation.
Biliary dyskinesia
Dyskenisia is a violation of the tone or motility of the biliary tract. It develops against the background of psychosomatic diseases or allergies. The disease is accompanied by mild pain in the hypochondrium, bad mood, depressed. Constant fatigue and irritability also become constant companions of the patient. Men and women report problems in their intimate life.
Cholelithiasis
Scheme of localization of stones in the gallbladder. Cholangiolithiasis is the formation of stones in the bile ducts. A large number of cholesterol and salt can lead to this disease. At the moment of the onset of sand (the precursor of stones), the patient does not experience any discomfort, but as the grains of sand grow and pass through the biliary tract, the patient begins to notice severe pain in the hypochondrium, which is given to the scapula and arm. The pains are accompanied by nausea and vomiting. To speed up the process of stone release, you can increase physical activity ( the best way - walk up the steps).
Cholestasis of the biliary tract
Cholestasis is a disease in which the flow of bile into the intestines decreases. Symptoms of the disease: itching of the skin, darkening of the color of urine and yellowing of feces. Yellowness is noted skin... The disease sometimes leads to the expansion of the bile capillaries, the formation of blood clots. May be accompanied by anorexia, fever, vomiting, and flank pain. There are such causes of the disease:
- alcoholism;
- cirrhosis of the liver;
- tuberculosis;
- infectious diseases;
- cholestasis during pregnancy and others.
Blockage of the bile ducts
Blockage of the channels is the result of other diseases of the digestive system. Most often it is a consequence gallstone disease... Such a tandem is found in 20% of humanity, and women suffer from this ailment 3 times more often than men. In the early stages, the disease does not make itself felt. But after the transfer infectious disease the digestive system begins to progress rapidly. The patient's temperature rises, itching of the skin begins, feces and urine acquire an unnatural color. The person is rapidly losing weight and suffers from pain in the right side.
The bile ducts are a complex transport route for hepatic secretions. They go from the reservoir (gallbladder) into the intestinal cavity.
The bile ducts are an important transport route for hepatic secretions, ensuring their outflow from the gallbladder and liver to the duodenum. They have their own special structure and physiology. Diseases can affect not only the gallbladder itself, but also the bile ducts. There are many disorders that interfere with their functioning, but modern methods monitoring allows you to diagnose diseases and cure them.
Biliary tract is an accumulation of tubular tubules, through which bile is evacuated into the duodenum from the gallbladder. Regulation of the work of muscle fibers in the walls of the ducts occurs under the action of impulses from the nerve plexus located in the liver (right hypochondrium). The physiology of the excitation of the bile ducts is simple: when the receptors of the duodenum are irritated by the action of food masses, nerve cells send signals to nerve fibers. From them to muscle cells a contraction impulse is received, and the muscles of the biliary tract relax.
The movement of secretion in the bile ducts occurs under the influence of pressure exerted by the lobes of the liver - this is facilitated by the function of the sphincters, called the motor, gallbladder, and tonic tension of the vascular walls. A large hepatic artery feeds the tissues of the bile ducts, and the outflow of oxygen-poor blood occurs into the portal vein system.
Bile duct anatomy
The anatomy of the biliary tract is rather confusing, because these tubular formations are small in size, but they gradually merge, forming large canals. Depending on how the bile capillaries will be located, they are divided into extrahepatic (hepatic, common bile duct and cystic duct) and intrahepatic.
The beginning of the cystic duct is located at the base of the gallbladder, which, as a reservoir, stores excess secretion, then it merges with the hepatic duct, and a common canal is formed. The cystic duct leaving the gallbladder is divided into four sections: supraduodenal, retropancreatic, retroduodenal and intramural canals. Leaving at the base of the duodenal papilla of Vater, a section of a large bile vessel forms the mouth, where the channels of the liver and pancreas are transformed into a hepato-pancreas ampulla, from which a mixed secret is released.
The hepatic canal is formed by the fusion of two lateral branches that transport bile from each part of the liver. The cystic and hepatic tubules will flow into one large vessel - the common bile duct (common bile duct).
Large duodenal papilla
Speaking about the structure of the biliary tract, one cannot but recall the small structure into which they will fall. The large papilla of the duodenum (DC) or Vater nipple is a hemispherical flattened eminence located at the edge of the fold of the mucous layer in the lower part of the DC, 10-14 cm above it there is a large gastric sphincter - the pylorus.
The dimensions of the Vater nipple range from 2 mm to 1.8-1.9 cm in height and 2-3 cm in width. This structure is formed when the biliary and pancreatic excretory tracts merge (in 20% of cases, they may not join and the ducts extending from the pancreas open slightly higher).
An important element of the large duodenal papilla is, which regulates the flow of mixed secretions from bile and pancreatic juice into the intestinal cavity, and also does not allow intestinal contents to enter the bile ducts or pancreatic canals.
Pathology of the bile ducts
There are many disorders of the functioning of the biliary tract, they can occur separately, or the disease will concern the gallbladder and its ducts. The main violations include the following:
- blockage of the bile ducts (gallstone disease);
- dyskinesia;
- cholangitis;
- cholecystitis;
- neoplasms (cholangiocarcinoma).
The hepatocyte secretes bile, which consists of water, dissolved bile acids, and some metabolic waste products. With the timely removal of this secret from the reservoir, everything functions normally. If there is stagnation or too fast secretion, bile acids begin to interact with minerals, bilirubin, creating deposits - stones. This problem is common in the bladder and biliary tract. Large calculi clog the lumen of the bile vessels, damaging them, causing inflammation and severe pain.
Dyskinesia is a dysfunction of the motor fibers of the bile ducts, in which there is an abrupt change in the pressure of the secretion on the walls of the vessels and the gallbladder. This condition is an independent disease (neurotic or anatomical in origin) or accompanies other disorders, such as inflammation. Dyskinesia is characterized by the appearance of pain in the right hypochondrium a few hours after eating, nausea, and sometimes vomiting.
- inflammation of the walls of the biliary tract, can be a separate disorder or a symptom of other disorders, for example, cholecystitis. Manifested in a patient inflammatory process fever, chills, profuse secretion of sweat, pain in the right hypochondrium, lack of appetite, nausea.
- the inflammatory process, covering the bladder and bile duct. The pathology is of infectious origin. The disease proceeds in acute form, and if the patient does not receive timely and high-quality therapy, he becomes chronic. Sometimes, with permanent cholecystitis, it is necessary to remove the gallbladder and part of its ducts, because the pathology prevents the patient from living normally.
Neoplasms in the gallbladder and bile ducts (most often they occur in the area of \u200b\u200bthe common bile duct) are a dangerous problem, especially when it comes to malignant tumors... Rarely held drug treatment, the main therapy is surgery.
Methods for examining the bile ducts
Methods for the diagnostic study of the biliary tract help detect functional disorders, as well as track the appearance of neoplasms on the walls of blood vessels. The main diagnostic methods include the following:
- duodenal intubation;
- intraoperative choledo- or cholangioscopy.
An ultrasound examination detects deposits in the gallbladder and ducts, and also indicates neoplasms in their walls.
- a method for diagnosing the composition of bile, in which the patient is parenterally injected with an irritant that stimulates contraction of the gallbladder. The method allows you to detect a deviation in the composition of the hepatic secretion, as well as the presence of infectious agents in it.
The structure of the ducts depends on the location of the liver lobes; the general plan resembles a branched crown of a tree, since many small vessels flow into large vessels.
The bile ducts are the transport line for the hepatic secretion from its reservoir (gallbladder) into the intestinal cavity.
There are many diseases that disrupt the functioning of the biliary tract, but modern research methods can detect the problem and cure it.
The extrahepatic bile ducts include: right and left hepatic, common hepatic, cystic and common bile ducts. At the gate of the liver, the right and left hepatic ducts, ductus hepaticus dexter et sinister, exit from the parenchyma. The left hepatic duct in the liver parenchyma is formed when the anterior and rear branches... The anterior branches collect bile from the square lobe and from the anterior part of the left lobe, and the posterior ones from the caudate lobe and from the posterior part of the left lobe. The right hepatic duct is also formed from the anterior and posterior branches that collect bile from the corresponding parts of the right lobe of the liver.
Common hepatic duct duct hepaticus communisformed by the fusion of the right and left hepatic ducts. The length of the common hepatic duct ranges from 1.5 to 4 cm, the diameter is from 0.5 to 1 cm.
Sometimes the common hepatic duct is formed from three or four bile ducts. In some cases, there is a high fusion of the cystic duct with the bile ducts in the absence of a common hepatic duct (Fig. 21). (V.I.Shkolnik, E.V. Yakubovich).
Fig. 21. Gallbladder and bile ducts:
1 - ductus hepaticus sinister; 2 - ductus hepaticus dexter; 3 - ductus hepaticus communis;
4 - ductus cysticus; 5 - ductus choledochus; 6 - ductus pancreaticus; 7 - duodenum;
8 - collum vesicae felleae; 9- corpus vesicae felleae; 10- fundus vesicae felleae.
Sometimes both hepatic ducts or one of them open directly into the gallbladder in the area of \u200b\u200bits bed.
Behind the common hepatic duct is the right branch of the hepatic artery; in rare cases, it runs anterior to the duct.
Cystic duct ductus cysticushas a length of 1-5 cm, an average of 2-3 cm, a diameter of 0.3-0.5 cm. It passes in the free edge of the hepato-duodenal ligament and merges with the common hepatic duct, forming a common bile duct. The cystic and common hepatic ducts can be connected at an acute, right or obtuse angle. Sometimes the cystic duct spirally bends around the common hepatic duct. The figure shows the main options for connecting the cystic and common hepatic ducts.
The common bile duct opens, as a rule, together with the pancreatic duct on the duodenal papilla papilla duodeni major. At its confluence there is a ring-shaped pulp.
The ducts most often merge and form an ampoule 0.5-1 cm long. In rare cases, the ducts open separately into the duodenum (Fig. 22).
Fig. 22. Variants of the connection of the cystic and common bile ducts.
The location of the large papilla is very variable, therefore it is sometimes difficult to detect it when dissecting the duodenum, especially in cases where the intestine is deformed due to any pathological process (periodiduodenitis, etc.) Most often, the large papilla is located at the level of the middle or lower third of the descending posterior medial part of the duodenum, rarely in upper third her.
The hepatic duodenal ligament is more clearly defined if the upper part of the duodenum is pulled downward, and the liver and gallbladder are raised upward. In the ligament on the right, in its free edge, there is a common bile duct, on the left - its own hepatic artery, and between them and a little deeper - the portal vein (Fig. 23).
Fig. 23. Topography of formations enclosed in the hepatoduodenal ligament:
1 - ductus hepaticus communis; 2 - ramus sinister a. hepaticae propriae; 3 - ramus dexter a. hepaticae propriae; 4 - a. hepatica propria; 5 - a. gastrica dextra; 6 - a. hepatica communis; 7- ventriculus; 8 - duodenum; 9 - a. gastroduodenalis; 10 - v. portae; 11 - ductus choledochus; 12- ductus cysticus; 13 - vesica fellea.
In rare cases, the cystic duct is absent, and the gallbladder communicates directly with the right hepatic, common hepatic, or common bile ducts.
Common bile duct ductus choledochushas a length of 5-8 cm, a diameter of 0.6-1 cm. Four parts are distinguished in it: pars supraduodenalis, pars retroduodenalis, pars pancreatica, pars intramuralis (Fig. 24).
Pars supraduodenalis
Pars retroduodenalis
Pars pancreatica
pars intramuralis
Fig. 24. Sections of the common bile duct
In addition to these basic formations, smaller arterial and venous vessels are located in the hepatoduodenal ligament (a. Et v. Gastrica dextra, a. Et v. Cystica, etc.), lymphatic vessels, lymph nodes and hepatic plexus. All these formations are surrounded by connective tissue fibers and adipose tissue.
