Surgical Anatomy of the Extrahepatic Biliary System

Variations related to GB include agenesis, floating, and left-sided GB. The right hepatic duct (RHD) is less angulated than the left hepatic duct (LHD). The LHD has a longer extrahepatic course (2–3 cm) and is located at the base of segment IV. Variation in the hilar confluence is noted in nearly 40% due to segmental ducts, more commonly that of the RHD, joining at different levels. Cholecystectomy involves the identification of specific landmarks to guide safe dissection, exposure of the hepatocystic triangle (HCT) to delineate the cystic duct and artery, and mobilization of the GB from the cystic plate. Rouviere’s sulcus (RS) represents the plane of the extrahepatic portal pedicle. Cystic artery is the most variable structure in the HCT. To achieve CVS, the HCT is cleared of all fibrofatty tissue, leaving behind only two structures: the cystic duct and the cystic artery. The distal 1/3 of the GB is dissected off the cystic plate (CP).