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i Aug., 1942] THE GALL-BLADDER AtfD ITS VEINS : STONHAM 475 THE GALL-BLADDER AND ITS VEINS so ably described by Flint (1923) and since the technical difficulties in this may at By F. V. STONHAM \J operation times be very drainage is some MAJOR, I.M.S. formidable, safeguard against the consequences of closure of Anatomy textbooks describe and depict a the abdomen with a divided unrecognized a cystic vein corresponding to the cystic artery accessory artery or duct which has not been terminating in the right branch of portal vein. secured. Works on operative surgery usually do not refer The likelihood of venous bleeding, so far as to the cystic vein at all, but many surgeons, I I am aware, is seldom considered. In post- believe, regard this vessel as non-existent, and mortem examinations, especially in cases of consider that the venous blood of the gall- asphyxia due to hanging or opium poisoning, I bladder always passes directly to the liver have not infrequently observed a cystic vein of through anastomoses between small venous large size, which would be quite capable of channels of the two organs. In performing the causing severe or dangerous bleeding. It is classical type of operation cholecystectomy it is possible that in some cases of haemorrhage during customary first to dissect out and identify the or following operations on the biliary tract the biliary ducts, and then the cystic artery and its origin has not been arterial, but venous. Com- of the omentum parent trunk as well. It does not appear usual pression gastro-hepatic would to control from veins to bother about any venous channels, though it be expected bleeding is usually considered to be preferable to com- connected with the portal system as well as mence the dissection of the gall-bladder from branches of the hepatic artery because in both the region of the ducts to avoid obscuring the cases the compression would be proximal. The field by the blood which oozes from the denuded above-mentioned observation has prompted me area of the liver. The disadvantages of com- to carry out fifty dissections on fresh subjects mencing the dissection from the fundus seem to most of which were young and healthy, and have been somewhat exaggerated. However, death had been due to violence. Venous with the exception of Thorek's technique (1938) drainage of the gall-bladder was found to be of which has recently been strongly endorsed by the following types :? Bailey and Love (1939) in which the gall- Type I: the commonest (figure 1).?Direct bladder is partly removed and the remainder anastomosis occurs between the small venules coagulated by diathermy and sutured, and in of the gall-bladder and the liver. These can be on of a section some cases where the organ is removed by the traced histological study passing plamp method advocated by Tucker (1938), it- at right angles through the area where the gall- is of the is almost universal practice to insert a drainage bladder attached to the inferior surface tube down to the site of the operation. This is done partly to allow exit of the blood and bile which exudes from the raw area of the liver, and also bile from any accessory hepatic duct which may have been overlooked and divided, and Partly because the comparative frequency of Post-operative haemorrhage following chole- cystectomy has earned for this operation some notoriety. This is perhaps somewhat undeserved smce, in my experience, except in difficult cases where operative trauma makes drainage im- seems to come out of the perative nothing much Fig. 1.?Type I. Small venules anastomose tube. However, on account of the great with vessels in the liver. frequency of anatomical variations which may be been encountered in this region, which have liver by connective tissue. In addition, small straight veins are formed by the anastomosis of .veniiles on the inferior surface of the gall- bladder, which again break up into small branches before they enter the liver. These vessels run roughly at right angles to the long axis of the gall-bladder. They are small and not always apparent to the naked eye unless congested. Type II: nine cases (figures 2, 4 and 5).? A single venous trunk of comparatively large size corresponding to the cystic artery joins the right branch of the portal vein, as in anatomv textbooks, or terminates elsewhere. Type III : two cases (figure 3).?The cystic veins are as in type II but are multiple. 476 THE INDIAN MEDICAL GAZETTE [Aug., 1942 Type IV : two cases.?This is a combination anomalies, the healthy gall-bladder is remark- of types I and II. Though the gall-bladcler ably constant in shape, size and in its relation varies considerably in position in relation to the to other viscera. Cases of congenital absence of this organ are rare. Kennon (1933) has described a case of double gall-bladder and cystic ducts. The principal variations that are encountered are in connection with its relation to the liver and to the visceral peritoneum. In the series under discussion all the gall-bladders appeared healthy except one, and only one contained stones and this occurred in a young female, and the stones consisted of a few hard white calcium stones and there was no macroscopic evidence of previous inflammatory mischief. I am aware that the is sometimes buried in the II. vein the gall-bladder entirely Fig. 2.?Type Cystic joins right substance of the liver but I have not branch of the portal vein passing in front of yet the hepatic duct. encountered a case either at operation or dissec- tion. Sometimes the viscus is suspended from the liver by a species of mesentery and these cases are eminently suited to removal by Tucker's (1938) simple and rapid operation. Murray (1933) has described a case of torsion in a gall-bladder which was attached only by a pedicle consisting of the cystic duct and the blood vessels and he found reference to only two such cases in the literature. It is, however, extremely common to find the gall-bladder enclosed in a peritoneal fold continuous with the gastro-hepatic omentum, which unites the under surface of the liver to the transverse Fig. 3.?Four cystic veins (arteries have been mesocolon and the transverse colon itself. This omitted from diagram for clearness). Three is referred to as the cholecystico-duodeno-colic join the portal vein and one passes in front ligament, which is probably better named by the of the ducts and ends in a vein right gastric less accurate but briefer term cystico-colic which passes direct to the liver. ' ' ligament \ This normal' structure is very ' ' apt to be regarded as an adhesion due to previous inflammation. In one case I found that this structure had drawn the transverse mesocolon upwards forming a deep hollow in its under surface and the branches of the colic vessels arched upwards and passed in close relation to the caudal aspect of the gall-bladder before they reached the bowel. In no case were the vessels of the gall-bladder found to anastomose with the colic vessels. Such a union if it occurred would almost certainly be of Fig. 4.?Portal vein enters the liver in front pathological consequence. Oozing from this site of the ducts and arteries. not infrequently occurs at operation when inflammatory adhesions are separated. In all cases where a cystic vein of type II or III was present the gall-bladder was either very loosely attached to the liver, or else it lay, often loosely invested, in a cystico-colic ligament. Apparently it is the closeness of this attachment to the liver which determines the manner of the venous return. The gall-bladder, liver, and part of the pancreas are developed from the foregut from a Fig. 5.?Single cystic vein joins an abnormal diverticulum which passes into the septum right gastric (coronary vein). transversum. It at once bifurcates into pancreatic and hepatic elements. vertebrse and in its distance from the midline as That part which is destined to form the liver seen in radiographs, and while the ducts and and gall-bladder again bifurcates, and presum- vessels very commonly exhibit anatomical ably, to begin with, each has its own independent Aug., 1942] A WATER-EMULSION PYRETHRUM SPRAY : RUSSELL & OTHERS 477 blood supply. Subsequently, when the gall- bladder becomes firmly united to the liver, anastomosis between the venous systems of the two organs results in disappearance of the cystic vein. In cases where this does not occur, or its occurrence is hampered after rotation of the gut by abnormal coalescence of the dorsal part of the free edge of the ventral mesogastrium with the transverse colon and its mesentery, the cystic vein persists. The cystic vein usually passes anterior to the hepatic duct and arteries and joins either the right branch of the portal vein, the main trunk of the portal, or terminates in the coronary vein. It is pointed out that the last vein, not un- commonly, does not end in the portal vein, but follows the course of either the right, or, as in one case, the left gastric artery; and passes up in front of the portal vein and enters liver independently (figure 5). This was seen in four cases. In one case the portal vein twisted spirally round the left side of the arteries and ducts and then bifurcated and entered the liver as an anterior relation, the right branch receiv- ing the cystic vein (figure 4). The surgical importance of such an abnormality is obvious.

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