克氏外科学19版chapter 55.pdfVIP

CHAPTER 55 BILIARY SYSTEM Patrick G. Jackson and Steven R.T. Evans may overlie the common hepatic or right hepatic ducts, thus anatomy and physiology placing these structures at risk during the performance of a lapa- general considerations in biliary tree pathophysiology roscopic cholecystectomy. benign biliary disease Above the cystic duct lies the common hepatic duct, drain- malignant biliary disease ing the left and right hepatic duct systems. The confluence of metastatic and other tumors these structures lies at the hilar plate, which is an extension of Glisson’s capsule. The absence of any vascular structures overly- ing the bile ducts at this location allows exposure of the bifurca- tion by incising this layer at the base of the segment IV, lifting ANATOMY AND PHYSIOLOGY the liver off these structures, known as lowering the hilar plate, Biliary anatomy is extremely variable, and precise knowledge of and is generally used to expose the remainder of the extrahepatic the normal and anatomic variants is critical to surgical interven- biliary tree for resection or reconstruction. tion in the biliary tree. The distal common bile duct (CBD) inserts into the duodenum via the ampulla of Vater, passing Vascular Anatomy through the sphincter of Oddi. Ascending from the duodenum,