The gall-bladder lies in the fissure of the gall-bladder, with its fundus just about level with the edge of the liver and its body pointing inward, upward, and backward; its neck, which is S-shaped, is near the right end of the portal fissure. It is 7.5 cm. (3 in.) long and 2.5 to 3 cm. (1 to 1 1/4 in.) in diameter. It holds one to one and a half ounces. Below, it rests on the transverse colon and first part of the duodenum. It is attached to the liver, but not very strongly, by connective tissue and the peritoneum. According to Brewer (Annals of Surgery, 1899, vol. xxix, page 723) one-third to one-fourth of its surface is uncovered by peritoneum: in 5 cases in 100 it had a distinct mesentery. The tip (fundus) of the gall-bladder lies in contact with the abdominal wall at the tip of the ninth costal cartilage, where the right linea semilunaris strikes the costal margin, and just at the outer edge of the rectus muscle, which is about 7.5 cm. (3 in.) from the median line (Fig. 431).

Hepatic, Cystic, And Common Ducts

The hepatic duct is formed by the union of the right and left branches in the portal fissure. It is about 2.5 cm. (1 in.) long and 6 mm. (1/4 in.) wide. The cystic duct is smaller in diameter than the hepatic and 3 to 4 cm. (1 1/4 to 1 1/2 in.) long and joins it as it emerges from the portal fissure. Both the neck of the gall-bladder and the cystic duct contain constrictions of the mucous membrane - Robson and Moynihan call them valves - which obstruct the passage of a probe or stone. Hence gall-stones are frequently found impacted or lodged in the neck of the gall-bladder or somewhere in the course of the duct. The cystic artery lies above the duct. The common duct is formed by the union of the hepatic and cystic ducts at the edge of the portal fissure, and empties into the duodenum about the middle of its second portion on its inner wall. It is 7.5 cm. (3 in.) long and 6 mm. (1/4 in.) or more in width. It passes almost directly downward, inclining a little to the right, between the folds of the lesser omentum, in front of the foramen of Winslow, behind the first portion of the duodenum, and then between the pancreas and the inner wall of the second portion of the duodenum. It is, at this part, in two-thirds of the cases, completely surrounded by pancreatic tissue. As it passes through the duodenum, which it pierces obliquely, it expands into the ampulla of Vater and receives the pancreatic duct, or duct of Wirsung. Above, it lies directly on the portal vein, with the hepatic artery to its left. About half of the duct, 3 to 4 cm. (1 1/4 to 1 1/2 in.), is above the duodenum and half behind it.

Fig. 431.   The biliary passages. The edge of the liver has been raised, exposing its under surface; the first portion of the duodenum and anterior surface of the pancreas has been removed, exposing the common bile duct and blood vessels.

Fig. 431. - The biliary passages. The edge of the liver has been raised, exposing its under surface; the first portion of the duodenum and anterior surface of the pancreas has been removed, exposing the common bile-duct and blood-vessels.

The hepatic artery passes along the upper edge of the pancreas, to which it gives branches; it then gives off the superior pyloric to the lesser curvature of the stomach, the gastroduodenal (see page 403), and finally right and left terminal branches. The left supplies the left lobe of the liver, the right crosses usually behind but sometimes in front of the bile-ducts and terminates in the right lobe, after first giving off the cystic artery. This runs between the cystic and hepatic ducts and has superficial branches which ramify on the surface of the gall-bladder and deep branches which run up the grooves on each side between the gall-bladder and liver.

It is these branches which bleed when the gall-bladder is removed. One of the deep arteries may be much larger than the other or altogether lacking. Some very fine branches come directly from the liver.

Lymphatic nodes are found in the portal fissure and accompanying both the common and cystic ducts. They are especially involved in carcinoma.

The kidney pouch is a name given to the space in front of the right kidney. The foramen of Winslow opens into it from the left and the abdominal wall is to its right. The liver is above and the duodenum and transverse colon below. Liquids from the lesser peritoneal cavity and bile-passages flow into this hollow, which can be drained by a tube inserted through a "stab-wound" made through the abdominal wall just to the outside of the right kidney.