Surgical anatomy of innervation of the gallbladder in humans and Suncus murinus with special reference to morphological understanding of gallstone formation after gastrectomy

Abstract

Aim: To clarify the innervation of human gallbladder, with special reference to morphological understanding of gallstone formation after gastrectomy.

Methods: The liver, gallbladder and surrounding structures were immersed in a 10 mg/L solution of alizarin red S in ethanol to stain the peripheral nerves in cadavers (n=10). Innervation in the areas was completely dissected under a binocular microscope. Similarly, innervation in the same areas of 10 Suncus murinus (S. murinus) was examined employing whole mount immunohistochemistry.

Results: Innervation of the gallbladder occurred predominantly through two routes. One was from the anterior hepatic plexus, the innervation occurred along the cystic arteries and duct. Invariably this route passed through the hepatoduodenal ligament. The other route was from the posterior hepatic plexus, the innervation occurred along the cystic duct ventrally. This route also passed through the hepatoduodenal ligament dorsally. Similar results were obtained in S. murinus.

Conclusion: The route from the anterior hepatic plexus via the cystic artery and/or duct is crucial for preserving gallbladder innervation. Lymph node dissection specifically in the hepatoduodenal ligament may affect the incidence of gallstones after gastrectomy. Furthermore, the route from the posterior hepatic plexus via the common bile duct and the cystic duct to the gallbladder should not be disregarded. Preservation of the plexus may attenuate the incidence of gallstone formation after gastrectomy.

Figure 1

Innervation of the gallbladder (GB) from the ventral aspect (A) in a cadaver and a schematic representation of it (B). The branches innervating the GB originate from the anterior hepatic plexus, and run along the cystic duct (CD) and the cystic artery (CA). The hepatic divisions (*) of the vagus join in the anterior hepatic plexus in the proper hepatic artery (PHA). Arrows indicate nerve branches. CBD: common bile duct; CHA: common hepatic artery; D: duodenum; GDA: gastroduodenal artery; L: liver; RGA: right gastric artery.

Figure 2

Innervation of the gallbladder (GB) from the dorsal aspect (A) in a cadaver and a schematic representation of it (B). The branches innervating the GB arise from the posterior hepatic plexus, and run along the cystic duct (CD). Ao: aorta; CA: cystic artery; CBD: common bile duct; CeA: celiac artery; CHA: common hepatic artery; D: duodenum; IVC: inferior vena cave; L: liver; PHA: proper hepatic artery; PSPDA: posterior superior pancreatoduodenal artery; PV: portal vein; RCeG: right celiac ganglion; SMA: superior mesenteric artery.

Figure 3

Innervation of the gallbladder (GB) in S. murinus revealed on whole-mount immunostaining (A) and high magnification of the boxed areas (B and C). Arrows indicate the stained/labeled nerve branches or bundles. CBD: common bile duct; CeT: celiac trunk; Es: esophagus; GDA: gastroduodenal artery; LGA/V: left gastric artery/vein; RGA: right gastric artery; St: stomach. Scale bar = 2 mm in A.