Surg Clin N Am 88 (2008) 1159–1174

Biliary Anatomy and Embryology

Khashayar Vakili, MDa,b,
Elizabeth A. Pomfret, MD, PhD, FACSa,b,c,*
a
Department of Hepatobiliary Surgery and Liver Transplantation, Lahey Clinic,
41 Mall Road, Burlington, MA 01805, USA
b
Tufts University School of Medicine, 145 Harrison Avenue, Boston, MA 02111, USA
c
Live Donor Liver Transplantation, Lahey Clinic, 41 Mall Road, Burlington, MA 01805, USA

Biliary tract pathology is commonly encountered and it can also present

significant diagnostic and therapeutic challenges to the practitioner. One of
the main challenges is attributable to the variability in the anatomy of the
biliary system. The development of the liver and biliary system is a complex
process that can lead to numerous anatomic variations. A thorough knowl-
edge of this anatomy is essential in radiologic, endoscopic, and surgical
approaches to the biliary system.
This article briefly describes the basic embryology of the biliary system
but the main focus is on its anatomic variations. The current descriptions
of the biliary anatomy are based on studies using cadaver dissection, resin
casts, direct surgical observations, or radiologic contrast studies.
Couinaud’s [1] description and classification of the biliary tree pattern is
widely used. As part of our preoperative planning for living donor liver
transplantation, potential donors undergo helical CT scanning of the liver
with subsequent three-dimensional (3D) reconstruction of the hepatic
vasculature and biliary system. The axial images are processed at MeVis
Medical Solutions (Bremen, Germany). Preoperative knowledge of the bili-
ary and vascular anatomy greatly enhances the efficiency and safety of the
donor hepatectomy operation. Our operative experience has shown that
the 3D reconstructions have proved to be extremely accurate. We have re-
viewed the 3D biliary reconstructions of 178 healthy potential living liver
donors to study anatomy and to assess the frequency of normal variation.
This article includes representative reconstruction images from the most
commonly encountered biliary anatomic variations. The advantage of using

* Corresponding author. Department of Hepatobiliary Surgery and Liver

Transplantation, Lahey Clinic, 41 Mall Road, Burlington, MA 01805.
E-mail address: [email protected] (E.A. Pomfret).

0039-6109/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.suc.2008.07.001 surgical.theclinics.com
1160 VAKILI & POMFRET

these images is that they are an accurate representation of what is encoun-

tered surgically. Furthermore, the topographic relationship between the vas-
cular and biliary anatomy can be better appreciated with the 3D images.

Embryology of the biliary system

The biliary system and liver originate from the embryonic foregut. Ini-
tially, at week four, a diverticulum arises from the ventral surface of the
foregut (later duodenum) cephalad to the yolk sac wall and caudad to the
dilation that will later form the stomach. The development of the liver in-
volves an interplay between an endodermal evagination of the foregut and
the mesenchymal cells from the septum transversum. The liver diverticulum
initially separates into a caudal and cranial portion. The caudal portion
gives rise to the cystic duct and gallbladder and the cranial portion gives
rise to the intrahepatic and hilar bile ducts. As the cranial diverticulum
extends into the septum transversum mesenchyme, it promotes formation
of endothelium and blood cells from the mesenchymal cells. The endoder-
mal cells differentiate into cords of hepatic cells and also form the epithelial
lining of the intrahepatic bile ducts (Fig. 1) [2–4].
The ductal cells follow the development of the connective tissues around
the portal vein branches. This developmental process results in the similarity
seen between the portal vein branching pattern and the bile duct pattern. At

Fig. 1. Development of the liver, gallbladder, bile ducts, and pancreas. The liver bud begins to
expand into the ventral mesentery during the fourth week. (From Larsen W. Development of
the gastrointestinal tract. In: Larsen W, editor. Human embryology. Hong Kong (China):
Churchill Livingstone; 1997. p. 237; with permission.)
 BILIARY ANATOMY AND EMBRYOLOGY 1161

first, the bile duct precursors are discontinuous but eventually they join one
another and then connect with the extrahepatic bile ducts.
The extrahepatic biliary system is initially occluded with epithelial cells
but later it canalizes as cells degenerate. The stalk that connects the hepatic
and cystic ducts to the duodenum differentiates into the common bile duct
(CBD). Initially the duct is attached to the ventral aspect of the duodenum
but when the duodenum undergoes rotation later on in development, there
is repositioning of the CBD to the dorsal aspect of the duodenal wall [4].

Overview of the liver and the biliary system

Hepatocytes secrete bile into the bile canaliculi. Hepatocytes are sur-
rounded by canaliculi on all sides except for the side adjacent to a sinusoid.
The bile canaliculi are actually formed by the walls of the hepatocytes. Bile
that is secreted by the hepatocytes flows through the canaliculi toward the
center of the hepatic cords and drains into hepatic ductules that are lined
by epithelial cells. The ductules then coalesce and drain into successively
larger ducts. The segments of the liver are based on its biliary drainage.
In the late 1940s, Hjortsjö [5] proposed the idea that bile ducts follow a seg-
mental pattern. The liver terminology used in this article is based on the
Brisbane 2000 terminology of liver anatomy and resections [6].
The right and left lobes of the liver are defined by the Cantlie line, which
corresponds to an oblique line through the gallbladder fossa and the fossa of
the inferior vena cava. Healey and Schroy [7] examined 100 hepatic casts
and found that bile duct, hepatic artery, and portal vein branches never
crossed the Cantlie line. The right lobe is divided into anterior (segments 5
and 8) and posterior sections (segments 6 and 7) [6]. Each section is then di-
vided into superior (8 and 7) and inferior segments (5 and 6).
The left lobe is divided into medial (segment 4) and lateral (segments 2
and 3) sections, which are separated by the umbilical fissure. The bile ducts
draining each segment are considered third-order ducts. The sectoral bile
ducts are second-order ducts with the main right and left ducts referred to
as the first-order ducts [7]. The hepatic ducts course along the portal vein
and hepatic artery branches, which together constitute the portal triad
(see Fig. 1). The extrahepatic relationship of these structures can be variable
and is discussed later in this article.

Right lobe bile duct anatomy

The right hepatic duct (RHD) drains segments 5, 6, 7, and 8 of the liver.
In the most common configuration, the union of posterior (6 and 7) and an-
terior (5 and 8) sectoral ducts forms the RHD (Fig. 2A). There is significant
variation in the topographic configuration in which these sectoral ducts join
one another. In addition, frequently one of the right sectoral ducts may
1162 VAKILI & POMFRET

Fig. 2. Most common variations of the hepatic duct confluence. (A) Usual configuration of the
confluence, (B1, B2) triple confluence, (C1) right posterior sectoral duct (RP) draining into
LHD, (C2, D2) RP draining into CBD, (D1) RP draining into LHD more peripherally than
in C1, (E) absence of hepatic duct confluence.

drain into the left hepatic duct (LHD) (Fig. 2C1, D1). The right posterior
sectoral duct is generally oriented in a horizontal direction as opposed to
the right anterior sectoral duct, which runs in a vertical direction. The pos-
terior sectoral duct is typically more superior and longer than the anterior
 BILIARY ANATOMY AND EMBRYOLOGY 1163

duct (Fig. 3A). In most cases, the anterior sectoral duct drains segments 8
and 5; however, in 20% of cases, segment 8 joins the right posterior sectoral
duct [7]. In some instances, the anterior inferior duct (segment 5) may drain
into the RHD (Fig. 3B), right posterior sectoral duct (Fig. 3D), or the CBD
(Fig. 3C).
In a liver cast study, 34.5% of casts were found to have a subvesical duct,
which was located in the gallbladder fossa and usually drained into the an-
terior sectoral duct or the RHD [7]. In some cases it drained into more seg-
mental branches and in one case into the LHD. It was never shown to
communicate with the gallbladder and was not accompanied by a portal
vein branch.
The right sectoral branches coalesce anterior to the right portal vein
branch (Fig. 4A) [8]. The right posterior duct generally runs posterior to
the right portal vein or the anterior right portal vein before joining the right
ductal confluence cephalad to the right portal vein [9]. There is significant
variability at the confluence of the right hepatic bile ducts. When there is
a true RHD, the length of the duct may range from 2 to 25 mm with an
average length of 9 mm [7]. The absence of an RHD is a rare occurrence
that may occur during development because of the persistent presence of
the proximal portion of the left vitelline vein [10].

Left lobe bile duct anatomy

The left lobe is divided into left lateral and left medial sections that are
separated by the umbilical fissure. The left lateral section is further divided
into superior and inferior segments or segments 2 and 3, respectively
(Fig. 5). Compared with the RHD, there is less anatomic variation of the
LHD. There is significant variation in the anatomy of the bile ducts draining
the left medial section, however, which is divided into superior (4a) and in-
ferior (4b) segments. Usually the sectoral branches from the lateral and me-
dial sections join each other within the umbilical fissure to form the LHD.
The orientation of the LHD and left portal vein are typically horizontal
at the hilum before entering the umbilical recess where they lie in a more ver-
tical direction. The LHD courses horizontally at the base of segment 4 su-
perior to the left portal vein. It then joins the RHD anterior to the portal
vein bifurcation to form the common hepatic duct.
Segment 3 bile duct (B3) is usually larger than the segment 2 duct (B2)
and runs in a concave fashion. B2 has an oblique course toward the porta
hepatis and may join the B3 branch either posterior to the umbilical portion
of the left portal vein (42.7%), left of the fissure (41.7%), or to the right of
the fissure (15.6%) [11]. Fig. 5C illustrates a case in which B2 and B3 join to
the right of the umbilical fissure and relatively close to the confluence of the
main hepatic ducts. In most cases, the configuration of the B2 and B3 ducts
are similar to those in Fig. 5A and B.
1164 VAKILI & POMFRET

Fig. 3. Variations of the right intrahepatic segmental ductal system. (A) Anterior segments (B5
and B8) form the right anterior sectoral duct and join the posterior sectoral duct (formed by
B6 and B7) to form the RHD, (B) ectopic drainage of segment 5 (B5), (C) ectopic drainage
of B5 into CBD, (D) B5 draining into the right posterior duct, (E) long RHD, (F) absence of
right posterior duct, (G) drainage of B6 into common hepatic duct (CHD).
 BILIARY ANATOMY AND EMBRYOLOGY 1165

Fig. 4. Relationship of bile ducts, hepatic artery branches, and portal vein branches. (A) Right
hepatic artery (RHA) courses posterior to common bile duct (CBD), (B) RHA anterior to the
CBD, (C) right anterior bile duct (RAD) draining into LHD, (D) replaced RHA.

Segment 4 biliary drainage has a complex and variable pattern. Segment

4 is divided into a superior (4a) and inferior area (4b) with two ducts drain-
ing each area or subsegment. Healey and Schroy [7] categorized the drainage
pattern of segment 4 into four types. Type I (60%) had all ducts joining to
form a single medial sector duct (Fig. 6A). Type II (24%) had one of the
subsegmental ducts with a separate drainage. In type III (10%), the inferior
duct and superior duct had separate drainage sites (Fig. 6B), and in type IV
(6%), two subsegmental ducts had a common duct and two drained sepa-
rately into the LHD.
In the study by Onishi and colleagues [11] examining cadavers and liver
casts they further classified the confluence patterns of segment 4 bile ducts
(B4) based on the location of their drainage relative to the midpoint between
the confluence of B2 and B3 and the LHD and RHD. Most frequently
(54.6%), B4 joined the B2/B3 system on the peripheral side and in 35.5%
of cases it joined on the hilar side. Usually, B4 takes a J-shaped course be-
fore joining the LHD. In 9.9% of the cases, there is drainage into both the
peripheral and hilar sides of the B2/B3 systems [11]. It is extremely rare (1%)
for B4 to drain into B2 and it was never observed to cross to the left side of
the umbilical fissure [7]. During its horizontal course along the inferior por-
tion of segment 4, the LHD may receive small branches from the left medial
1166 VAKILI & POMFRET

Fig. 5. Variations of segment 2 (B2) and segment 3 (B3) bile ducts. (A–C) Usual configuration
with B2 and B3 joining each other at variable distances from the main confluence. (D) Non-
union of B2 and B3 with right posterior duct draining into B2.

segment. The average distance between B2/B3 confluence and the main he-
patic duct confluence is 3.25 cm with a range of 0.5 to 5.7 cm [11].
In our study, we found that B4 drainage had a single, common duct in
60% of cases (see Fig. 6A). In 12% of cases, we observed a separate drain-
age of the medial superior and inferior areas (see Fig. 6B). When the conflu-
ence of B2 and B3 is more toward the hilum as seen in 22% of the cases, B4
tends to join B3 (Fig. 6C). If B4a and B4b have separate drainages then B4b
may drain into B3 (Fig. 6D). In accordance with the observations of others,
we also found that on rare occasions (!2%) B4 may drain separately into
the common hepatic duct (CHD) (Fig. 6E) or very close to the main hepatic
ductal confluence (Fig. 6F).

Caudate lobe bile duct anatomy

The caudate lobe (segment 1) is divided into a caudate lobe proper, which
is located between the inferior vena cava and the umbilical fissure, and the
 BILIARY ANATOMY AND EMBRYOLOGY 1167

Fig. 6. Variations of segment 4 (B4) bile ducts. (A) Single B4 duct, (B) separate drainage of B4a
and B4b, (C) drainage of B4 into B3 (note B2 and B3 join close to the main confluence), (D)
separate drainages of B4a and B4b, and B4b drainage into B3, (E) absence of drainage of B4
into a true left system, (F) drainage of B4 into the main confluence.

caudate process, which connects the caudate lobe to the right hepatic lobe.
Based on the biliary drainage of the caudate lobe, it cannot be designated as
solely part of the either the right or the left lobe. The caudate lobe itself can
be divided into right, left, and caudate process. Healey and Schroy [7] noted
that in 44% of cases, three separate ducts drained each part of the caudate
1168 VAKILI & POMFRET

lobe. In 26% of cases, the caudate process duct and the duct from the right
portion of the caudate formed a common duct. In most cases, the caudate
process duct drains into the RHD (85%) and the left part of the caudate
lobe drains into the LHD (93%). Because of the position of the right portion
of the caudate lobe, it could drain into either the left or right systems.
Fig. 7 shows the commonly encountered drainage patterns of segment 1.
There may be small branches from the caudate lobe that may not be repre-
sented because of the resolution of the scan. The major branching patterns
that are more likely clinically relevant are similar to those described by
others [7].

Bile duct confluence and common hepatic duct anatomy

The left and right hepatic ducts merge to form the CHD. The bile duct
confluence is located in the hilar plate anterior to the portal vein. Extrahe-
patically, a sheath covers the bile duct and hepatic artery branches, which is
continuous with the hepatoduodenal ligament. Opening the connective tis-
sue of the hilar plate inferior to segment 4 of the liver exposes the LHD
and the confluence of hepatic duct. The intrahepatic portion of the bile ducts
is covered by the Glisson sheath except for the bile ducts of the left medial
section [10].
The formation of the CHD can be variable. The most commonly encoun-
tered confluence pattern is where RHD and LHD merge to form the CHD
(see Fig. 2A). Couinaud [1] reported this to be present in 57% of cases and
Healey and Schroy [7] reported a 72% incidence. In our study, we observed
this pattern in 57% of our cases.
The next most prevalent configuration is when the right posterior duct
joins the LHD (see Fig. 2C1). We found this to be the case in 19% of our
cases, which is comparable to Couinaud’s reported 16%. As can be seen
in Fig. 2D1, the right posterior duct may join the LHD more peripherally
in 5% of cases.
In 11% of our cases, the LHD and the right anterior and posterior ducts
formed a trifurcation. The relationship of the right posterior (RP) or right
anterior (RA) ducts to one another at the trifurcation may vary as illus-
trated in Fig. 2B1, B2. It is about three times more likely for the RP hepatic
duct to be superior to the RA duct (see Fig. 2B2).
Finally, 4.5% of our cohort had the RP hepatic duct join the CHD after the
RA and LHD had merged. The point at which the RP joins may be close to the
confluence of the RA and LHD (see Fig. 2C2) or more distal (see Fig. 2D2).

Common bile duct anatomy

The cystic duct drains into the common hepatic duct to form the CBD.
The CBD is situated anterior to the portal vein along the right edge of
 BILIARY ANATOMY AND EMBRYOLOGY 1169

Fig. 7. Variations of segment 1 (B1) bile ducts. (A) Drainage of B1 into the LHD, (B) drainage
of B1 into right posterior duct (RP), (C) B1 draining into RHD, (D) B1 draining into both the
RHD and LHD, (E) B1 drainage at the main confluence, (F) B1 drainage into B2 (note the
proximity of B2 and B3 union to the main confluence).

the lesser omentum. It courses caudad behind the first portion of the duode-
num then runs in an oblique fashion on the dorsal aspect of the pancreas in
the pancreatic groove. Most of the time, the CBD in the pancreatic groove is
covered by pancreatic tissue or embedded within pancreatic tissue and in
1170 VAKILI & POMFRET

12% of cases it has a posterior bare area [12]. CBD usually joins the pancre-
atic duct (70%) and they enter the second portion of the duodenum on its
posteromedial wall at the major papilla [13]. The union of the CBD and
the major pancreatic duct creates the ampulla of Vater. A sheath of circular
smooth muscle fibers surrounds the ampulla and the intraduodenal portion
of the CBD and the major pancreatic duct and is known as the sphincter of
Oddi [14]. In some cases, the pancreatic duct and the CBD do not join and
each enters the duodenum separately on the duodenal papilla. The site of
entrance of the CBD into the duodenum has been studied by several groups
and it was found that the CBD enters the descending portion of the duode-
num in greater than 80% of the cases. Other sites of entrance of the CBD are
the transverse duodenum and at the angle created by the junction between
the descending and transverse duodenum [14].
Anatomic studies have shown the external diameter of the suprapancre-
atic CBD to range from 5 to 13 mm with a mean diameter of 9 mm. The
internal diameter range is 4 to 12.5 mm with a mean diameter of 8 mm.
The external diameter seems to remain fairly constant from the hepatic con-
fluence to the papilla. The internal diameter decreases to a range of 1.5 to
7.5 mm with a mean of 4 mm near the duodenal papilla [12].
There are several anatomic variations in which sectoral ducts may enter
the CBD directly. One example is shown in Fig. 3C. Although rare, if not
recognized these variations can result in morbidity following biliary surgery.

Arterial blood supply of the biliary system

The extrahepatic bile ducts may receive their arterial blood supply from
several different major arteries. Northover and Terblanche [15] conducted
a resin cast study in human cadavers in which they described two major
axial vessels that ran along the lateral borders of the supraduodenal CBD.
They named these the 3 o’clock and 9 o’clock arteries. They reported an
average of 8 small arteries with a diameter of 0.3 mm supplying the supra-
duodenal CBD. These arteries arise from below (posterior or anterior supe-
rior pancreaticoduodenal artery, gastroduodenal artery, retroportal artery)
and above (right hepatic artery, cystic artery, left hepatic artery). In rare
cases, there is nonaxial supply from the common hepatic artery [15].
The hilar ducts receive numerous arterial branches from the right and left
hepatic arteries. These form a rich network around the ducts and are in con-
tinuity with the plexus around the CBD. In some cases, the 3 o’clock and
9 o’clock arteries may supply the hilar ducts. The retropancreatic portion
of the CBD is usually supplied by multiple small branches from the poste-
rior superior pancreaticoduodenal artery [15]. The various contributing ar-
teries form an arterial plexus within the wall of the bile duct before giving
rise to a capillary plexus. In the study by Northover and Terblanche [15],
no end-arteries to the CBD were noted.
 BILIARY ANATOMY AND EMBRYOLOGY 1171

Gunji and colleagues [16] used cadaver dissection and corrosion casts to
describe a communicating arcade between the right and left hepatic arteries.
They identified small branches from the communicating arcade that sup-
plied the hilar bile ducts. This arcade runs in the hilar plate and on the right
side may branch from the right hepatic artery or the anterior right hepatic
artery and on the left side it branches from the left hepatic artery or segment
4 artery. At the time of biliary surgery, attention to the preservation of the
blood supply to the bile ducts is imperative in the assurance of anastomotic
integrity and the prevention of strictures.

Venous drainage of the biliary system

A fine venous plexus that drains into marginal veins surrounds the sur-
faces of the extrahepatic and intrahepatic bile ducts [17]. The marginal veins
run in the 3 o’clock and 9 o’clock positions similar to the arterial vessels.
Inferiorly, the marginal veins drain into the pancreaticoduodenal venous
plexus. Superiorly, the marginal vessels have been shown to enter the he-
patic substance or join the hilar venous plexus, which eventually drains
into branches of the portal vein [18]. The intrahepatic bile duct venous
plexus drains into the adjacent portal vein. The veins of the gallbladder
do not follow arterial branches and have direct drainage into the liver [19].

Gallbladder and cystic duct anatomy

The gallbladder is a piriform sac that is situated in the cystic fossa on the
inferior and posterior aspect of the right lobe of the liver. On extremely rare
occasions, the gallbladder has been found on the left side of the liver or
intrahepatically where it is completely surrounded by liver tissue [20]. The
gallbladder is separated from the liver parenchyma by the cystic plate, which
is in continuity with the hilar plate. At times, it may be embedded deeply in
the liver or it may have a mesentery [8].
The gallbladder is about 4 cm wide and 7 to 10 cm long in most adults. It
is composed of a fundus, body, and neck. The fundus is the blind-ending
portion that projects below the inferior edge of the liver where it is in contact
with the anterior abdominal wall at the level of the ninth costal cartilage in
about 50% of cases [2]. The body is the largest part of the gallbladder and is
pointed up and to the left close to the right side of the porta. The body
decreases in width and forms the infundibulum as it becomes the neck of
the gallbladder with an average length of 5 to 7 mm. On the right side of
the neck, sometimes as a result of chronic dilatation, there may be a recess
that projects toward the duodenum called the Hartmann pouch.
The neck of the gallbladder is connected to the cystic duct, which is 3 to
4 cm long and courses inferiorly and to the left of the neck eventually joining
the common hepatic duct to form the CBD. The cystic duct has 5 to 12
1172 VAKILI & POMFRET

oblique folds, creating a spiral valve known as the valve of Heister [2]. In
greater than 70% of cases, the cystic duct joins the right lateral edge of
the common hepatic duct superior to the pancreas and about 2 cm inferior
to the RHD and LHD confluence [21]. In the study by Moosman and Coller
[21], the mean diameter of cystic duct was about 4 mm and its length ranged
from 4 to 65 mm with a mean length of 30 mm. They also found a short cys-
tic duct parallel to the CHD in 15% of cases and a long cystic duct in 4% of
cases. In 10% of cases, the cystic duct joined the CHD on its anterior or pos-
terior aspect. On rare occasions, the cystic duct may join the hepatic duct
near the confluence of the RHD and the LHD creating a trifurcation. The
union of the cystic duct with the CHD has been described as angular
(75%), parallel (20%), or spiral (5%) [22].
The blood supply of the gallbladder is by way of the cystic artery, which
usually branches from the right hepatic artery and courses superior to the
cystic duct. The cystic artery reaches the superior aspect of the neck of
the gallbladder where it divides into a superficial branch that runs on the
inferior aspect of the gallbladder and a deep branch that is on the superior
aspect between the gallbladder and the liver bed [2].
Some rare anatomic variations of the gallbladder include anomalies in its
form and number. Agenesis of the gallbladder [23], multiple gallbladders
[24], bilobed gallbladder [25], and double cystic duct [26] have been re-
ported. In cases of a double gallbladder, each gallbladder may have its
own cystic duct or the duct may join to form a common cystic duct before
joining the common hepatic duct [27]. When the entire gallbladder is cov-
ered by peritoneum resulting in a true mesentery, it has been referred to
as a floating gallbladder [28].

Relationship of extrahepatic bile ducts to vascular structures

An understanding of the relationship of various structures within the
porta hepatis is critical in performing safe dissections in this region. Fig. 4
illustrates the relationship between the bile ducts and portal vein and hepatic
artery branches. The CBD is invariably located slightly to the right and an-
terior to the portal vein. In most cases, the right hepatic artery that origi-
nates from the proper hepatic artery courses posterior to the CBD (see
Fig. 4A). In 22% of cases, it is situated anterior to the CBD (see
Fig. 4B). In 10% to 15% of cases, the blood supply to the right lobe of
the liver is by way of a replaced right hepatic artery, which arises from
the superior mesenteric artery and courses posterior to the portal vein
and the CBD (see Fig. 4D).
In some cases, the right hepatic artery may project beyond the CHD and
form a ‘‘knuckle,’’ which at times may run along the cystic duct and the gall-
bladder neck [19]. In this situation, the cystic artery is likely to be very short.
It is important to recognize this to avoid injury to the right hepatic artery
during cholecystectomy.
 BILIARY ANATOMY AND EMBRYOLOGY 1173

Summary
The anatomy of the biliary tree is variable and at times complex, thus
posing significant challenges for the diagnosis and treatment of its many
pathologic states. Over the past 60 years, there have been a great number
of pioneers who have elucidated our understanding of the complex liver
and biliary anatomy through cadaver dissections and cast studies. This
study used 3D reconstructions of CT images to analyze the biliary anatomy
of 178 patients who underwent imaging studies in preparation for living
donor hepatic lobectomy. Our results confirm earlier studies regarding the
anatomy of the biliary system. We have found that preoperative assessment
of the biliary and vascular anatomy by CT arteriography, venography, and
cholangiography is of significant benefit during complex liver and biliary
surgery.

Acknowledgment
We thank Carol Spencer, MSLS for her assistance in acquiring many of
the journal articles and books used in the preparation of this manuscript.

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