Fig. 131. Gall-Bladder, Bile Ducts, and Surrounding Structures 



Female. 



On the body of a woman, aged 55, a large window, 57-2 inches long by 4 inches 

 ivide ivas made fitroiigh the skin of the right hvpochoiidi'iac region. The window 

 aperture is diminished throiigli the deeper layers. The Liver and Gall-Bladder 

 have been drawn upwards and to the right while the Stomach and Duodenum, 

 have been draivn downwards. By removal of a part of the Anterior layer of 

 the Hepato-diiodenal fold the structures at the iiilum of the Liver have been 



exposed. 



This figure shews the window with its inner boundary situated ^^th inch 

 from the middle Hne. At the margin of the window, especially at the outer margin, 

 the various la^-ers i^f the abdominal wall are to be seen: External Oblique Muscle. 

 Internal Oblique Muscle, Transversalis Muscle ; at the upper and lower margins 

 — the Rectus Muscle and its sheath together with the lumina of the severed 

 vessels which run behind the muscles: Superior Epigastric Branch of the Internal 

 Mammary Artery (cf. Fig. 1 1 g) and the Deep Epigastric from the External 

 Iliac A^ter}^ 



In this figtire the Liver and Gall-bladder have been drawn upwards and 

 to the right in order to shew the structures in the Hepato-Duodenal Fold, but the 

 natural position of the GaU-bladder is shewn in Fig. 124. 



The fundus of this organ, which is normal, extends a little way beyond 

 the lower border of the Liver at the point where this viscus leaves the Co.stal 

 Arch {8th or gth Costal cartilage) and runs obliquely upwards into the epigastric 

 region. The fundus is i ^/..th to 2 inches from the middle line so that access is 

 gained to it by a longitudinal incision from the costal arch through or along the 

 outer border of the Rectus Muscle. 



In pathological conditions, the gall-bladder may be so shrunken as to be 

 hidden under cover of the li\'er, but when distended or the seat of a neoplasm, it 

 ma)' be easily palpated and even become of such a size as to be mistaken for an 

 ovarian cyst. 



The size of the Gall-bladder varies greatlv from iV.ith inches (as in this 

 instance) to 5V2 inches long. It is covered by peritoneum on its free surface 

 only (cf. Fig. 133). The Gall-bladder is directed backwards and inwards. Its 

 duct (iVsth to iVoths inches long) has always an acute S curve and it joins 

 the hepatic duct at an acute angle (the length of the hepatic duct is one inch). 



The Hepato-Duodenal Fold forms the Anterior boundary of the Foramen 

 of WiNSLOW : the arrangement of the structures in this fold are : — 



To the Right: Common Bile Duct. 

 To the Left: Hepatic Artery. 

 Behind: Portal Vein. 



