Abdominal Viscera 4

■ a major part in the fossa (body of the gallbladder), The arterial supply to the gallbladder (Fig. 4.106) is the
which may be against the transverse colon and the cystic artery from the right hepatic artery (a branch of the
superior part of the duodenum; and hepatic artery proper).
■ a narrow part (neck of the gallbladder) with mucosal The gallbladder receives, concentrates, and stores bile
folds forming the spiral fold. from the liver.

Left hepatic artery Left gastric artery

Right hepatic artery Hepatic artery proper Liver Gallbladder

Cystic artery

Supraduodenal artery
Gastroduodenal artery
Cystic duct Cystic artery
Right gastric artery
Abdominal aorta
Superior mesenteric artery
A Splenic artery B

Fig. 4.106 Arterial supply to the liver and gallbladder. A. Schematic. B. Laparoscopic surgical view of cystic duct and cystic artery.

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 Abdomen

The pancreas is (secondarily) retroperitoneal except for

Pancreas a small part of its tail and consists of a head, uncinate
The pancreas lies mostly posterior to the stomach process, neck, body, and tail.
(Figs. 4.107 and 4.108). It extends across the posterior
abdominal wall from the duodenum, on the right, to the ■ The head of the pancreas lies within the C-shaped
spleen, on the left. concavity of the duodenum.

Aorta
Inferior vena cava

Right kidney

Tail

Body
Neck

Head

Left kidney

Jejunum
Duodenum

Uncinate process
Superior mesenteric vein

Superior mesenteric artery

Fig. 4.107 Pancreas.

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 Abdominal Viscera 4

Superior mesenteric artery

Left lobe of liver
Splenic artery
Pancreas
Pancreas Stomach
Portal vein Left colonic
Gallbladder Splenic vein flexure

A
B
Right lobe of liver Left kidney
Aorta Spleen
Inferior vena cava Inferior vena cava Left renal vein

Right crus Left crus Vertebra Aorta

Fig. 4.108 Abdominal images. A. Abdominal computed tomogram, with contrast, in the axial plane. B. Abdominal ultrasound scan.

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 Abdomen

■ Projecting from the lower part of the head is the unci- papilla. Surrounding the ampulla is the sphincter of
nate process, which passes posterior to the superior ampulla (sphincter of Oddi), which is a collection of
mesenteric vessels. smooth muscles.
■ The neck of the pancreas is anterior to the superior The accessory pancreatic duct empties into the
mesenteric vessels. Posterior to the neck of the pancreas, duodenum just above the major duodenal papilla at the
the superior mesenteric and splenic veins join to minor duodenal papilla (Fig. 4.109). If the accessory
form the portal vein. duct is followed from the minor papilla into the head of the
■ The body of the pancreas is elongate and extends pancreas, a branch point is discovered:
from the neck to the tail of the pancreas.
■ The tail of the pancreas passes between layers of the ■ One branch continues to the left, through the head of
splenorenal ligament. the pancreas, and may connect with the pancreatic duct
at the point where it turns inferiorly.
The pancreatic duct begins in the tail of the pancreas ■ A second branch descends into the lower part of the
(Fig. 4.109). It passes to the right through the body of the head of the pancreas, anterior to the pancreatic duct,
pancreas and, after entering the head of the pancreas, and ends in the uncinate process.
turns inferiorly. In the lower part of the head of the pan-
creas, the pancreatic duct joins the bile duct. The joining The main and accessory pancreatic ducts usually com-
of these two structures forms the hepatopancreatic municate with each other. The presence of these two ducts
ampulla (ampulla of Vater), which enters the descending reflects the embryological origin of the pancreas from
(second) part of the duodenum at the major duodenal dorsal and ventral buds from the foregut.

Bile duct
Accessory pancreatic duct

Minor duodenal papilla Main pancreatic duct

Major duodenal papilla

Hepatopancreatic ampulla

Fig. 4.109 Pancreatic duct system.

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 Abdominal Viscera 4
The arterial supply to the pancreas (Fig. 4.110)
In the clinic
includes the:
Annular pancreas
■ gastroduodenal artery from the common hepatic artery The pancreas develops from ventral and dorsal buds from
(a branch of the celiac trunk), the foregut. The dorsal bud forms most of the head, neck,
■ anterior superior pancreaticoduodenal artery from the and body of the pancreas. The ventral bud rotates around
gastroduodenal artery, the bile duct to form part of the head and the uncinate
process. If the ventral bud splits (becomes bifid), the two
■ posterior superior pancreaticoduodenal artery from the
segments may encircle the duodenum. The duodenum is
gastroduodenal artery,
therefore constricted and may even undergo atresia, and
■ dorsal pancreatic artery from the inferior pancreatic
be absent at birth because of developmental problems.
artery (a branch of the splenic artery), After birth, the child may fail to thrive and may vomit due
■ great pancreatic artery from the inferior pancreatic to poor gastric emptying.
artery (a branch of the splenic artery), Sometimes an annular pancreas is diagnosed in utero
■ anterior inferior pancreaticoduodenal artery from the by ultrasound scanning. The obstruction of the duodenum
inferior pancreaticoduodenal artery (a branch of the may prevent the fetus from swallowing enough amniotic
superior mesenteric artery), and fluid, which may increase the overall volume of amniotic
■ posterior inferior pancreaticoduodenal artery from fluid in the amniotic sac surrounding the fetus
the inferior pancreaticoduodenal artery (a branch of (polyhydramnios).
the superior mesenteric artery).

Left gastro-omental artery

In the clinic
Splenic artery Left gastric artery
Pancreatic cancer
Greater pancreatic Pancreatic cancer accounts for a significant number of
artery deaths and is often referred to as the “silent killer.”
Celiac trunk
Malignant tumors of the pancreas may occur anywhere
Common hepatic
artery within the pancreas but are most frequent within the head
Gastroduodenal and the neck. There are a number of nonspecific findings
artery in patients with pancreatic cancer, including upper
abdominal pain, loss of appetite, and weight loss.
Depending on the exact site of the cancer, obstruction of
the bile duct may occur, which can produce obstructive
jaundice. Although surgery is indicated in patients where
there is a possibility of cure, most detected cancers have
Dorsal pancreatic typically spread locally, invading the portal vein and
artery
superior mesenteric vessels, and may extend into the
Inferior porta hepatis. Lymph node spread also is common and
pancreaticoduodenal artery these factors would preclude curative surgery.
Anterior inferior Given the position of the pancreas, a surgical resection
pancreaticoduodenal artery is a complex procedure involving resection of the region
Posterior inferior
of pancreatic tumor usually with part of the duodenum,
pancreaticoduodenal artery necessitating a complex bypass procedure.
Superior mesenteric artery
Posterior superior pancreaticoduodenal artery

Fig. 4.110 Arterial supply to the pancreas. Posterior view.

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 Abdomen

As the common hepatic duct continues to descend, it

Duct system for bile is joined by the cystic duct from the gallbladder. This
The duct system for the passage of bile extends from the completes the formation of the bile duct. At this point,
liver, connects with the gallbladder, and empties into the the bile duct lies to the right of the hepatic artery
descending part of the duodenum (Fig. 4.111). The coales- proper and usually to the right of, and anterior to, the
cence of ducts begins in the liver parenchyma and contin- portal vein in the free margin of the lesser omentum.
ues until the right and left hepatic ducts are formed. The omental foramen is posterior to these structures at
These drain the respective lobes of the liver. this point.
The two hepatic ducts combine to form the common The bile duct continues to descend, passing posteriorly
hepatic duct, which runs near the liver, with the hepatic to the superior part of the duodenum before joining with
artery proper and portal vein in the free margin of the the pancreatic duct to enter the descending part of the
lesser omentum. duodenum at the major duodenal papilla (Fig. 4.111).

Gallbladder

Needle

Right hepatic duct

Left hepatic duct

Common hepatic duct

Cystic duct Common
hepatic duct

Bile duct Cystic duct

Bile duct

Descending
part of
duodenum B

Descending part of duodenum

A Main pancreatic duct

Fig. 4.111 Bile drainage. A. Duct system for passage of bile. B. Percutaneous transhepatic cholangiogram demonstrating the bile duct system.

336