Anatomy of the Gallbladder

Ioannis N. Gerogiannis; Razhan K. Ali; Mark Sidhom; Georgios Bointas; Eirini Tsoutsou

doi:10.5772/intechopen.1011083

Abstract

This chapter, Anatomy of the Gallbladder, serves as a foundational exploration of the gallbladder’s structure, positioning, and physiological significance within the hepatobiliary system. It delves into the organ’s gross anatomy, histological layers, vascular supply, lymphatic drainage, and innervation, highlighting its relationship with the liver, bile ducts, and surrounding structures. The chapter also examines anatomical variations and their clinical implications, offering insights into their relevance in surgical and diagnostic contexts. By providing a detailed overview, this section lays the groundwork for understanding gallbladder pathophysiology, disease management, and surgical interventions, positioning the reader to navigate subsequent topics in hepatobiliary medicine and surgery with a deeper anatomical perspective.

Keywords

gallbladder
anatomical variations
cystic artery
cystic duct
lymphatic drainage
gross anatomy

Author Information

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Ioannis N. Gerogiannis *
- Department of General Surgery, Kingston Hospital, London, UK
Razhan K. Ali
- Department of General Surgery, Kingston Hospital, London, UK
Mark Sidhom
- Department of General Surgery, Kingston Hospital, London, UK
Georgios Bointas
- Department of General Surgery, Kingston Hospital, London, UK
Eirini Tsoutsou
- Department of Thalassaemia, Gennimatas General Hospital, Athens, Greece

*Address all correspondence to: drgerogiannis@gmail.com

1. Introduction

The gallbladder is a relatively small organ located in the right upper quadrant of the abdomen. The gallbladder, which is pyriform in shape, is located in a fossa on the lower surface of the right lobe of the liver. It plays a crucial role in the digestive system by storing and concentrating the bile produced by the liver.

2. Orthographic origin and etymology

The term “gall bladder” is a compound noun formed within English by combining “gall” and “bladder.” According to the Oxford English Dictionary (OED), the earliest recorded use of “gall bladder” dates back to 1676 in the writings of John Cooke [1].

The word “gall” originates from Old English “gealla,” which is consistent with similar terms in other Germanic languages, such as Old Saxon “galia,” Middle Dutch “galle,” and Old High German “galla,” all referring to bile.

The term “bladder” comes from Old English “blǣdre,” meaning a blister or bladder, and is related to similar words in other Germanic languages.

Thus, “gall bladder” literally means “bile bladder,” describing the organ’s function as a storage sac for bile [1].

3. Embryology

The gallbladder arises from an endodermal outgrowth of the ventral side of the foregut at about the 4th week of embryonic life, together with the liver and bile ducts. This outgrowth appears as a cystic diverticulum just caudal to the newly formed hepatic duct and cephalad to the ventral pancreatic bud, just before the latter rotates to its dorsal position on the 32nd day. By day 35, the pedicle that connects the gallbladder to the hepatic duct is transformed into the cystic duct. In the 12th week, the production of bile begins, and the gallbladder and bile ducts become functional, storing the bile produced by the live (Figure 1) [2].

Figure 1.
Embryo (5th week of development). The gallbladder is present on the ventral side of the foregut, together with the liver and the hepatic duct. The pancreatic duct has already moved into its dorsal position.

4. Gross anatomy

4.1 Organ anatomy

The gallbladder is divided into three main sections:

Fundus: This is the rounded distal portion of the gallbladder, often extending beyond the inferior border of the liver. Clinically, the fundus is located at the level of the ninth costal cartilage, where the lateral edge of the right rectus abdominis muscle intersects the costal margin.
Body: It is located between the fundus and the neck and is adjacent to the visceral surface of the liver.
Neck (infundibulum): This tapered segment connects the gallbladder to the cystic duct, which subsequently joins the common hepatic duct to form the common bile duct [3].

The cystic duct is a tube that connects the neck of the gallbladder to the common bile duct. It is typically 2–4 cm long and 2–3 mm in diameter, but this can vary [4]. However, it is difficult to predict the size of the lumen of the cystic duct. This is mainly because the mucosa of the lumen has multiple folds, making it appear as a spiral and tortuous tube. The spiral valve of Heister is a recognized block of valves made by the mucosal folds of the cystic duct together with smooth muscle fibers and a framework of connective tissue [3]. The role of the Heister valves, although several scientists have attempted to explain it, is not entirely clear; there may be an element of controlling the inflow outflow of the bile to and from the gallbladder, or/and the valves are just a development secondary to the evolution of the human adjusting to the erect posture [5]. Variations in the length and insertion of the cystic duct have been observed. It can range in length from 0.8 to 11.5 cm. In terms of insertion, the cystic duct can end in several places. The most frequent insertion is into the common hepatic duct, followed rarely by the right hepatic duct, the duodenum, and then the left hepatic duct [6].

Another anatomical entity evident in the majority of the population is the Hartmann’s pouch. It presents as an outpouching of the gallbladder wall located in the area between the neck and the cystic duct. Finally, when the gallbladder is folded between the fundus and the neck, giving the appearance of a cap, it is called a Phrygian cap. This is seen in less than 6% of the general population and has no pathological significance (Figure 2) [7].

Figure 2.
Gross anatomy of the gallbladder and related ducts. Please note Hartmann’s pouch and Heister valves. The Phrygian cap is also demonstrated.

4.2 Location and topographic relations

The gallbladder is positioned in the right upper quadrant of the abdominal cavity. Its direction is oblique and therefore the fundus is more lateral and at a lower level than the neck, which is closer to the midline (Figure 3).

Figure 3.
Position of the gallbladder and its direction.

Except for the superior surface of its body, which attaches to the liver via areolar tissue, the gallbladder is generally covered by peritoneum. In some cases, the peritoneum fully surrounds the gallbladder, forming a short mesentery that attaches it to the liver.

The gallbladder maintains several important anatomical relationships:

Superiorly: It is in direct contact with the liver, specifically segments IVb and V [6]. Posteriorly: The gallbladder is related to the superior part of the duodenum, hepatic flexure, and the proximal transverse colon [3]. Inferiorly: It is adjacent to the transverse colon and, in some cases, the superior portion of the duodenum or the pyloric end of stomach [3].

More specifically, the fundus is completely covered by peritoneum and typically projects beyond the liver’s sharp margin. Its anterior surface touches the peritoneum of the anterior abdominal wall, approximately where the transpyloric and midclavicular lines cross. Caudally, it lies above the right colic flexure and the proximal third of the transverse colon [3].

Cranially, the body of the gallbladder is attached to the liver while the rest of it is covered just with visceral peritoneum [3].

The neck of the gallbladder, like the body, is covered with visceral peritoneum in its majority, except the superior surface connects to the liver through loose areolar tissue containing the cystic artery and often a small lymphatic gland. Finally, inferiorly, it relates to the first part of the duodenum [3].

The cystic duct lies at the cranial part of the lesser omentum, and its course is above the first part of the duodenum. It also routes briefly parallel to and adheres to the postero-lateral aspect of the common hepatic duct.

The cystic artery is located parallel to the cystic duct, just cranial to it [3].

5. Vascular anatomy of the gallbladder

5.1 Arterial supply

5.1.1 The cystic artery and other branches

The cystic artery is the main arterial blood supply of the gallbladder. This typically arises from the right hepatic artery (Figure 4).

Figure 4.
Arterial supply of the gallbladder. a. corresponds to “artery.”

In most people, this artery passes through a small anatomic space called Calot’s triangle—also known as the hepatobiliary triangle. The common hepatic duct, cystic duct, and inferior border of the liver form the boundaries of this triangle [8, 9].

The cystic artery usually divides into superficial (anterior) and deep (posterior) branches. The superficial branch provides blood supply to the peritoneal surface of the gallbladder while the deep branch supplies the hepatic surface of the gallbladder.

Small arterial branches may also arise from the cystic artery to supply blood to the cystic duct and adjacent bile ducts [10, 11, 12, 13].

5.1.2 Variations in the cystic artery

Anatomic variations of the cystic artery are frequent, and incidences reported varied between 18.5% and 24.5% based on the population studied and imaging or dissection methods [12, 13]. Although the most frequent origin of the cystic artery is from the right hepatic artery, its origin, order of branching, and course may be changed because of embryological remodeling of the hepatic arterial tree [14].

5.1.2.1 Double cystic arteries

A “double” cystic artery arises when two distinct arteries supply the gallbladder, each coming from separate sources. Its incidence varies widely, reported from 2% up to 25% [14, 15]. Recognizing this anomaly is crucial, as it can raise the risk of bleeding if unrecognized during surgery.

5.1.2.2 Aberrant origins of the cystic artery

From the superior mesenteric artery: Documented but rare [16].
From the left hepatic artery: Uncommon and can complicate dissection [17].
From the common hepatic artery: Risk of accidental ligation leading to hepatic ischemia [18].
From the gastroduodenal artery: Requires careful intraoperative identification [19].
From the left gastric artery: Extremely rare, though clinically relevant during procedures in the upper GI region [18].

5.1.2.3 Moynihan’s hump

This variation describes a tortuous cystic artery that crosses over the common hepatic duct. It can be mistaken for the cystic duct, potentially causing ligation of the hepatic artery or bile ducts by accident [19].

5.1.2.4 Accessory cystic arteries

Small additional arteries may branch from the hepatic or gastroduodenal arteries. Missing one of these arteries during surgery can lead to unexpected bleeding if only the main cystic artery is ligated [20].

5.1.2.5 Course of the cystic artery

In some cases, the cystic artery passes either in front of or behind the common hepatic duct. This variation can increase the likelihood of misidentification or injury during gallbladder removal [21].

5.2 Venous drainage

Venous return from the gallbladder occurs through cystic veins, which typically follow two main pathways [8, 9]:

Direct drainage into the liver parenchyma: Small veins may flow directly into hepatic sinusoids rather than first entering the portal vein.
Drainage into the portal system: Cystic veins commonly drain into the portal vein (often its right branch) or small tributaries of the right portal vein.

Clinically, these routes are significant because they can serve as channels for gallbladder cancer to spread to the liver.

5.3 Lymphatic drainage

Lymphatic drainage from the gallbladder primarily goes to the cystic lymph node (often called the node of Lund), then to the hepatic and celiac lymph nodes. This pathway is important for understanding the potential spread of gallbladder tumors [8, 9].

6. Gallbladder innervation

6.1 Anterior hepatic plexus

The anterior hepatic plexus receives contributions from the sympathetic and parasympathetic systems. The sympathetic fibers derive from the celiac plexus, and the parasympathetic fibers derive primarily via the hepatic division of the anterior vagal trunk.

The pathway of the gallbladder’s innervation starts with the hepatic branch of the anterior vagal trunk and travels through the hepatogastric ligament. Then, it joins the anterior hepatic plexus near the proper hepatic artery. From there, nerve branches accompany both superficial and deep branches of the cystic artery, reaching mainly the peritoneal aspect and the gallbladder bed.

The distribution of the nerves is primarily concentrated in the cystic duct and neck of the gallbladder, and fewer fibers extend toward the body and fundus. Notably, vagal branches do not directly reach the gallbladder independently but merge into the anterior hepatic plexus first [22].

6.2 Posterior hepatic plexus

The posterior hepatic plexus originates from the right side of the celiac plexus.

The pathway of the innervation starts and runs along the dorsal side of the portal vein. It is typically composed of four to five nerve fascicles divided into two bundles and predominantly accompanies the upper common bile duct and portal vein.

The Posterior Hepatic Plexus sends branches to gallbladder (primarily cystic duct and neck). It is also to the liver, the proximal descending duodenum, and the lower common bile duct.

It needs to be noted that the Posterior Hepatic Plexus shows abundant communication with the anterior hepatic plexus [22].

6.3 Phrenic nerves

The phrenic nerves derive mainly from the right phrenic nerve, occasionally from both right and left phrenic nerves. They are sometimes absent (in 20% of cases in Yi et al.’s study) [22].

The pathway of the innervation starts from the phrenic nerve branches that pass anteriorly toward the liver’s hepatic portal, along the sagittal sulcus of the liver.

Their role likely includes sensory innervation contributing to referred pain in gallbladder pathology (shoulder-tip pain) [22].

7. Anatomical variations of the gallbladder

The gallbladder has several variations in its anatomy based on:

7.1 Morphological

The gallbladder exhibits various anatomical variations, both common and rare. One frequent variant is the Phrygian cap, where the fundus folds back on itself, which is important to recognize to avoid confusion. Another common variant is the sigmoid-shaped gallbladder. Less often, septations may occur, either congenital or resulting from chronic cholecystitis, and can be single or multiple. When numerous, these septations can create a characteristic “honeycomb” appearance.

Hartmann’s pouch, also known as the infundibulum, refers to a localized outpouching near the gallbladder neck, adjacent to the body. This finding is often linked to cholelithiasis and may represent a pathological change rather than a normal anatomical variant. According to van Eijck et al. [23], Hartmann’s pouch is considered a morphologic entity rather than a distinct anatomical structure [21]. A floating gallbladder, suspended by a peritoneal mesentery, is a rare variant that may increase the risk of torsion. Also uncommon are diverticula, which involve all layers of the gallbladder wall and should be differentiated from Rokitansky-Aschoff sinuses, which are mucosal outpouchings [24].

7.2 Congenital

7.2.1 Agenesis of the gallbladder

Gallbladder agenesis (GA) is a rare congenital anomaly where the gallbladder is completely absent, though the bile ducts remain normal. It is often discovered incidentally during surgery or autopsy, with most cases identified in patients around their mid-1940s. GA is more commonly seen in autopsy reports than surgical findings.

Gallbladder agenesis (GA) is often associated with other congenital abnormalities, affecting up to 30% of patients. These can involve multiple body systems, including the gastrointestinal, urinary, cardiovascular, and skeletal systems. Reported conditions include intestinal obstructions, abnormal intestinal positioning, kidney malformations, and limb anomalies such as fused fingers or toes, with genitourinary issues being particularly common.

While gallbladder agenesis (GA) typically occurs sporadically, there are cases where multiple family members are affected, hinting at a possible hereditary component. GA has also been linked to certain genetic syndromes, such as trisomy 18, and to prenatal exposure to teratogenic substances, like thalidomide [25].

7.2.2 Hypoplasia of the gallbladder

Hypoplastic gallbladder shares a similar etiology with gallbladder agenesis, in that the gallbladder bud is incompletely developed, or the solid primordium has failed to recanalize. Conditions like biliary atresia, chronic cholangitis, cystic fibrosis, and hepatitis in neonates are linked to this congenital anomaly. Approximately 33% of patients with a hypoplastic gallbladder experience symptoms, compared to 54% who remain asymptomatic. This rare condition should be considered when the gallbladder is not identified intraoperatively. Hypoplasia is less frequently reported than agenesis and is typically observed in children as a rudimentary structure, whereas in adults, it can result from post-inflammatory processes [26].

7.2.3 Duplication of the gallbladder

This anomaly occurs with an incidence of about 1 in 4000. However, the exact prevalence is difficult to determine, as it is typically only recognized in symptomatic cases or as incidental findings during laparotomy, imaging, or autopsy. There are two main types of gallbladder duplication described: (i) The Vesica fellea divisum or bi-lobed gallbladder and (ii) The Vesica fellea duplex or double gallbladder. In the Vesica fellea divisum, the lumen of the gallbladder is divided into two chambers, and embryologically, they share a common origin. In the Vesica fellea duplex, there is a dual embryological origin, and there are two gallbladders with their own cystic duct each. The differential diagnosis includes gallbladder diverticula, gallbladder fold, Phrygian cap, choledochal cyst, pericholecystic fluid, and focal adenomyomatosis. Simultaneous removal of both gallbladders during surgery is advised to prevent cholecystitis and biliary colic in the remaining organ [27].

7.3 Ectopic gallbladder

An ectopic gallbladder is a rare anatomical anomaly of the biliary system. The biliary system as a whole or just the gallbladder is located in an abnormal anatomical position. Several anatomic locations have been reported in literature. The majority of them can be pathogenic because of related factors such as torsion of the gallbladder, cholestasis, and internal hernia (via the foramen of Winslow). Ectopic gallbladder should ideally be diagnosed preoperatively to avoid intra- and post-operative complications and to ensure safe management of the patient’s associated conditions [28].

The ectopic gallbladder has an incidence of 0.1–0.7%. It can be found in various positions, including left-sided, transverse, retroperitoneal, or floating. Ectopic gallbladders have also been reported in areas such as the lesser omentum, retroduodenal space, falciform ligament, abdominal wall muscles, and even within the thorax [29].

7.3.1 Left-sided gallbladder

A true left-sided gallbladder is an extremely rare anomaly where the gallbladder lies in the left abdomen without a right-sided round ligament. In contrast, a false left-sided gallbladder is not an abnormality of the gallbladder itself, but rather an issue with the round ligament.

Embryologically, a left-sided gallbladder could happen in two ways: (i) the gallbladder primordium deriving from the normal gallbladder bud (from the hepatic diverticulum) moves to the left side instead of remaining on the right side. In this case, the developing peritoneum forces the gallbladder primordium to stay fixed to the undersurface of the left lobe of the liver. Furthermore, the cystic duct’s entry remains normal (with the common bile duct). (ii) There is Vesica fellea duplex or double gallbladder formation, but the right one becomes atrophic and finally disappears, and the left one remains as the main one. In this second case, the cystic duct’s entry is abnormal (with the common bile duct or the left hepatic but from the left) [30].

7.3.2 Suprahepatic gallbladder

This variant is the rarest, with an incidence ranging from 0.026% to 0.7%. It is typically associated with a right liver love, which is defective in size. The latter may result from a congenital cause that can lead to cirrhotic hypoplasia, malformation, vascular injury of the liver, or the presence of diffuse cholangiocarcinoma. It is hypothesized that when the right lobe is absent, the gallbladder is reoriented, and the colon is displaced upward. This aligns with reports of suprahepatic gallbladders and the upward migration of the hepatic flexure [31].

8. Microscopic anatomy of the gallbladder

The histology of the gallbladder is similar to most of the intraperitoneal organs and its wall is composed of three layers from the inside out: the mucosa, the muscularis propria and the serosa. The muscularis mucosae and the submucosa are absent in gallbladder.

The mucosa consists of one layer of columnar epithelium with microvilli above the lamina propria. The latter contains mainly vascular and lymphatic tissue together with connective tissue. During the fasting period, when the gallbladder is distended and full of bile, the mucosa is smooth, but when it is not distended (postprandial) a presence of mucosal folds is noted. Even though these folds are irregular and not standard in size, they look similar to the villi of the mucosa of the small bowel. Sometimes In cross-section, there are formations seen in the mucosal folds shown as crypts and looking like tubular glands. However, the true glands are evident only at the neck of the gallbladder.

The muscularis propria contains mainly smooth muscle fibers with tissue made of collagen, nerves, vessels, lymphatics, and fat between them. This layer plays a key role in the expulsion of bile [24].

Starting from the mucosa layer and extending to the layer around the smooth muscles without crossing them, there are crypts that are called Rokitansky-Aschoff sinuses. These are invaginations of the epithelium that look like diverticula and vary in depth and size. Rokitansky-Aschoff sinuses are pathognomonic of chronic cholecystitis but can be found also in the normal gallbladder [32].

The outer layer is the serosa which is present at the area of the gallbladder wall which is not attached to the liver surface. This layer is the visceral peritoneum [24].

9. Frequently used surgical terms based on anatomical landmarks

9.1 The Calot’s triangle

It was first described in 1891 by Jean François Calot in his doctoral thesis with the title “De la cholecystectomie.” He described it as the isosceles triangle with specific boundaries: inferiorly by the cystic duct, medially by the common hepatic duct, and superiorly by the cystic artery [33].

In the modern era of laparoscopic biliary surgery, a different definition was agreed upon for Calot’s triangle, which is the triangle with boundaries superior to the inferior surface of the liver, inferior to the cystic duct, and medial to the common bile duct [32, 33, 34, 35]. Another name for the Calot’s triangle is the cystohepatic or hepatocystic triangle [33].

9.2 The critical view of safety

This term refers to a specific identification of the anatomical structures of the hepatocystic triangle, which in most cases ensures a safe dissection during cholecystectomy. According to Strasberg et al. [36], the critical view of safety consists of the following elements: (i) identification of two tubular structures leading to the gallbladder after careful dissection of the fibrous tissue of the hepatocystic triangle and (ii) adequate dissection of the gallbladder (one third) from the cystic plate [35]. This is applicable to laparoscopic cholecystectomy, which followed the initial “critical view of safety” of open cholecystectomy in early 1995 [37].

10. Conclusion

A detailed knowledge of the anatomy of the gallbladder plays an essential role in many aspects of clinical practice. From basic surgical assessment in primary care, teaching in medical schools, preoperative management, through to complex surgical procedures and postoperative care, it is essential to have and be aware of all anatomical variations.

Not recognizing these vascular subtleties may result in significant complications such as inadvertent injury to major vessels, persistent bleeding post-operatively, or liver ischemia.

Failure to recognize anatomical subtleties can lead to significant complications such as inadvertent injury to major vessels, persistent postoperative bleeding, liver ischemia, or damage to the bile ducts or other vital structures.

With the availability of modern imaging techniques such as CT angiography or MR angiography, along with intraoperative adjuncts including cholangiography or ICG fluorescence, the surgeon is in a better position to recognize and avoid such perils. As the detailed knowledge regarding nuances of gallbladder anatomy continues to evolve, comprehensive preoperative planning and accurate intraoperative navigation will provide the basis for optimal patient management.

Acknowledgments

The methodology used for this chapter involved searching relevant international literature, including published manuscripts and scientifically proven web-based information, as well as published books.

All authors contributed to collecting data and information from the above sources. After analyzing the data and enriching it with information from their areas of medical expertise, they wrote a draft. They also agreed to review the chapter before submission.

Ioannis Gerogiannis conceived and designed the original idea for this chapter. He revised and approved the final version prior to publication. He also designed all the figures using a drawing display. His signature on each figure confirms its originality and ownership.

Conflict of interest

The authors declare no conflict of interest.

Notes/thanks/other declarations

Figures are designed by Ioannis Gerogiannis using the XP pen Artist Pro 19 (Gen 2) ® Drawing Display with an X3 Pro Slim Stylus.

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32. Campos A, Abu, Kamesh M, Hacking C, et al. Gallbladder. Radiopaedia.org; [Internet]. 2024 Available from: https://radiopaedia.org/articles/gallbladder?lang=us [Accessed: Feb 23, 2025]
33. Abdalla S, Pierre S, Ellis H. Calot’s triangle. Clinical Anatomy. 2013;26(4):493-501. DOI: 10.1002/ca.22170
34. Haubrich WS. Calot of the triangle of Calot. Gastroenterology. 2002;123:1440
35. Nagral S. Anatomy relevant to cholecystectomy. Journal of Minimal Access Surgery. 2005;1:53-58
36. Strasberg SM, Brunt LM. Rationale and use of the critical view of safety in laparoscopic cholecystectomy. Journal of the American College of Surgeons. 2010;211(1):132-138. DOI: 10.1016/j.jamcollsurg.2010.02.053
37. Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. Journal of the American College of Surgeons. 1995;180(1):101-125

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[31] 31. Hessey JA, Halpin L, Simo KA. Suprahepatic gallbladder. Journal of Gastrointestinal Surgery. 2015;19(7):1382-1384. DOI: 10.1007/s11605-015-2771-x

[32] 32. Campos A, Abu, Kamesh M, Hacking C, et al. Gallbladder. Radiopaedia.org; [Internet]. 2024 Available from: https://radiopaedia.org/articles/gallbladder?lang=us [Accessed: Feb 23, 2025]

[33] 33. Abdalla S, Pierre S, Ellis H. Calot’s triangle. Clinical Anatomy. 2013;26(4):493-501. DOI: 10.1002/ca.22170

[34] 34. Haubrich WS. Calot of the triangle of Calot. Gastroenterology. 2002;123:1440

[35] 35. Nagral S. Anatomy relevant to cholecystectomy. Journal of Minimal Access Surgery. 2005;1:53-58

[36] 36. Strasberg SM, Brunt LM. Rationale and use of the critical view of safety in laparoscopic cholecystectomy. Journal of the American College of Surgeons. 2010;211(1):132-138. DOI: 10.1016/j.jamcollsurg.2010.02.053

[37] 37. Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. Journal of the American College of Surgeons. 1995;180(1):101-125