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

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.

Cystic duct and Heister's "valves"

The anatomy and physiology of the cystic duct have been relatively neglected by anatomists and the function of the spiral mucosal folds or "valves" of Heister, first described in 1732, remains obscure. The gross and microscopic anatomy of the cystic duct is reviewed together with results from laboratory investigations into the function of the cystic duct and its spirally arranged folds. The duct and spiral folds contain muscle fibers responsive to pharmacologic, hormonal, and neural stimuli. There is, however, no convincing evidence of a discrete muscular sphincter within the duct. Although the cystic duct is unlikely to play a major role in gallbladder filling and emptying, it appears to function as more than a passive conduit. Coordinated, graded muscular activity in the cystic duct in response to hormonal and neural stimuli may facilitate gallbladder emptying. The principal function of the internal spiral folds that are found in man and other animals may be to preserve patency of this narrow, tortuous tube rather than to regulate bile flow.

[Structural basis of peripheral innervation mechanisms in the walls of the biliary tract]

Several types of giant neurons exist in the extrahepatic bile ducts in the dog. The intrinsic innervation of the ducts wall has the characteristics as follows: 1) within the nerve, fascicless axons and nerve terminals come into a different relation to the glial cytoplasm; 2) two categories of the nerve terminals are identified by their glial accompaniment--"closed" and "open" types; 3) separation of the nerve terminals containing synaptic vesicles from the several effector elements is usually about several thousand A and with no synapses; typical synaptic complexes were identified between nerve terminals and neurons, although not as commonly as would have been expected considering the large amount of nerve terminals surrounding some of the neurons; 4) within the interstitial space the terminals are often of the "open" type. The morphological data suggest that the peripheral vegetative fibers may form transitional provisional "functional" nerve endings.

Reoperation for amputation neuroma of the cystic duct

Two cases of amputation neuroma of the cystic duct are reported. In both instances, significant symptoms were totally relieved by excision of the neuroma. Review of the literature reveals at least twenty similar cases with the same results. Emphasis is placed on the importance of considering this diagnosis in postcholecystectomy patients after all the usual causes of right upper quadrant symptoms have been ruled out.

[Development of the neural and tissue components of the excretory ducts of the liver, pancreas and Odd's sphincter in human embryogeny]

The development of pancreatic, hepatic, cystic, common bile ducts, the Oddi's sphincter and their nervous apparatus were studied during prenatal human ontogenesis of fetuses and newborns. The process of formation of the nervous apparatus corresponds to the development of tissue structures of the ducts and the sphincter. The distinctions in the organization of nervous elements which are noted in adult humans are laid in the process of embryogenesis. These distinctions are especially pronounced in the structure of nervous plexuses and receptory endings. The nervous apparatus of the Oddi's sphincter region has a complex arrangement. This is the site of concentration of nerve nodules and receptory endings as well as abundant nervous connections between plexuses of the pancreatic head, duodenum and orifice zones of the both ducts. The receptors in nerve nodules and pericellular apparatuses on the bodies of ganglionic neurons were revealed.

An acetylcholinesterase method for in toto staining of peripheral nerves

Stomach, small intestine, uterus, urinary bladder, vagina, mesentery, mesometrium and joint capsule of rats, gall bladder, cystic duct and bile duct of dogs and uteri of young children are stained in toto.

PROCEDURE

Tissue is perfused with saline containing hyaluronidase, then pinned on a flat layer of Paraplast and fixed for 24 hr in cold sucrose formol solution. Stomach, urinary bladder and gall bladder are also fixed in toto. Rinse for 2 days in cold 0.22 M sucrose in a sodium cacodylate buffer pH 7.2. Incubate in medium consisting of 60 mM acetate-buffer pH 5.0 or pH 5.6 (for human material only), 2 mM acetylthiocholine iodide, 15 mM Na citrate, 3 mM Cu sulphate, 0.5 mM K3Fe(CN)6, 5 times 10-4 M iso-OMPA, 1% Triton X 100 at 37C. Rinse in doubly distilled water. Dehydrate in glycerine/water mixtures of increasing glycerine content. Store in glycerine or delaminate under dissecting microscope. Delaminated specimens are mounted on gelatinized object glasses, cleared in xylene and coverslipped with Malinol. Specimens stored in glycerine can be studied microscopically. Stained specimens can also be embedded in Paraplast and sections can be studied after counterstaining.