 This section will focus on the entire biliary system with all the clinical correlations. This is the gallbladder which is located in the gallbladder fossa on the under surface of the liver. Most of the gallbladder is covered by visceral peritoneum only on its outer surface. Only the portion which is projecting below the inferior margin of the liver that is the fundus of the gallbladder that is covered by peritoneum on all its surfaces. So this is the fundus of the gallbladder. This is the body of the gallbladder and then there is a doubtful portion known as the infundibulum and then we have the neck of the gallbladder going into the cystic duct. The gallbladder has been removed from the gallbladder fossa and then it was adduct here which connects the gallbladder with the liver and this is one of the rare situations this is called the cholecystohepatic duct. We have opened up the gallbladder just to show you a little bit of the mucosa and you can see that the mucosa of the gallbladder is slightly rough in appearance. One of the functions of the gallbladder mucosa is absorption. The gallbladder is supplied by a branch from the right hepatic artery and that branch is known as the cystic artery and we can see the cystic artery when I lift up the gallbladder we can see this is the cystic artery. That brings me to the next point and that is what is known as the cholecystohepatic triangle of callot. This triangle is formed by the cystic duct, the common hepatic duct and the liver. So this triangle is called the callot triangle and in that callot triangle we have the cystic artery. This is an important area we are doing cholecystohectomy. In the portal hepatic we have the right and the left hepatic ducts both of them unite to form the common hepatic duct where my instrument is pointing and the common hepatic duct then receives the cystic duct and after that that is known as the bile duct. The common bile duct CBD this runs in the free margin of the lesser omentum and it is running in the hepato-deodernal ligament and here it forms the anterior boundary of the epiploic foramen of Winslow so this is the common bile duct. This is the epiploic foramen of Winslow where my finger is gone in. The common bile duct runs on the right anterior aspect of the extra hepatic portal triad then it runs behind the first part of the deodernum and I am going to now lift up the deodernum and we can see that the common bile duct is running behind the first part of the deodernum it enters the head of the pancreas. I have split open the pancreas to show its course inside the head of the pancreas. Inside the head of the pancreas it unites with the main pancreatic duct of Winslow and termination of both these ducts there is a small sphincter and after the union both of them they have the small dilatation which is referred to as the hepato-pancreatic ampula and that also is covered by a sphincter which is known as a sphincter of OD and finally the combined opening opens in the second part of the deodernum at this point here which is known as the major deodernal papilla of Watter and this is located in the second part of deodernum known as D2. So this is the full extent of the biliary system. Let me mention some very important clinical correlations and hepato-pancreatic ampula there is a very special type of cancer which can occur in this region and that is known as a periampulary carcinoma and that can lead to intractable jaundice and for this periampulary carcinoma we do a very extensive procedure which is known as Vipul's pancreato deodenectomy that is the head of the pancreas and the sea loop of deodernum is excised and removed. Next we need to examine the common bile duct and the biliary system for that we pass an endoscope and we cannulate the common bile duct here at the papilla of Watter and we inject the dye. Once the dye is injected it outlines the pancreatic duct and it also outlines the common bile duct and the common hepatic ducts and we can see all the branches that procedure is known as endoscopic retrograde cholangio pancreatogram ERCP that tells us if there are any stones inside the common bile duct. Suppose a patient has got any obstruction narrowing of the sphincter or a stone impacted here then the patient has jaundice then we can do a sphincterotomy whereby we cut open the sphincter of OD and release the obstruction. The next important point is when we are looking at the common bile duct which we mentioned runs behind the first part of the deodernum if imaging study shows that this common bile duct is dilated more than 1 centimeter that is more than 10 millimeters then it is clinically significant then and that is especially done in the case of periampillary carcinoma which is inoperable then we need to relieve the patient of jaundice and there we do a unique procedure whereby we anastomose the common bile duct with the deodernum and that is known as colidocore deodernostomy that does not cure the patient but at least it relieves the jaundice and the itching. The next important clinical correlation is stone in the common bile duct which of course can be highlighted by the ERCP. Once we get a patient with a stone in the common bile duct then during colisostectomy we have to explore the common bile duct and after that we have to pass out what is known as a T-tube and 14 days later we inject a dye and we look at the common bile duct to see if there are any residual stones and if there are none we pull out the T-tube and that procedure is known as T-tube colangiogram. Galstones are one of the very common ailments in females the classical mnemonic is fat fertile fatty flatulent female of 40 and gallstone surgery of the gallbladder is also one of the most common surgeries performed in females. Galstones can be cholesterol stones, calcium stones, bilirubin stones, many types. Cholesterol stones are usually solitary, other stones are multiple. When a patient has got gallstones then the gallbladder becomes functionless because it is suffering from repeated attacks of cholecystitis. Then we have to remove the entire gallbladder and then we have to operate inside the callous triangle. We have to ligate the cystic duct, we have to ligate the branch of the right hepatic artery that is the cystic artery and we have to remove the gallbladder from the gallbladder bed. At that time if we have a situation like shown here if there is an accessory cholecystohepatic duct then this can be a potential site of leakage of bile and this bile can collect in this space here known as the hepatoreal space or the Morrison pouch. Similarly blood can also ooze from this gallbladder fossa and can collect here in the Morrison pouch. During cholecystectomy there may be accidental bleeding from the cystic artery or from one of the branches of the hepatic artery because anatomical variations are very common in the region of the callous triangle. In such a situation we do what is known as Pringles Melover. We put our finger in the lesser sac through the epiploid foramen of Winslow and my finger is behind the free margin of the lesser momentum and I put my thumb in front and thereby I effectively compress the hepatic artery and therefore stop the bleeding. Once the bleeding is reduced by compression on the hepatic artery then we can locate the site of bleeding and we can ligate it and this process is known as Hogarth Pringles Melover. A chronic gallstone located in the gallbladder can produce cholecystitis and adhesions with the surrounding structures namely the colon, transverse colon and the diodenum and can even lead to what is known as the cholecystodional fistula. Fundus of the gallbladder is projecting beyond the inferior margin of the liver and the fundus of the gallbladder is in contact with the anti-abdominal wall and this region of the abdominal wall is known as the linea semilunaris which is the right free margin of the rectus abdominis. So when we are examining the patient from below up and we are asking the patient to breathe deeply the moment our finger reaches this region and it hurts the patient suddenly holds her breath that catch in breath is referred to as Murphy's sign which is a very typical feature of polycystitis. Then we have a few other abnormalities pertaining to the common bile duct. Apart from gallstone there can be infection traveling from the diodenum and it can go ascent of common bile duct that is known as ascending cholangitis. Cholangitis is the inflammation of the common bile duct and that produces a very specific condition which is referred to as Sharco's triad when the patient has fluctuating jaundice, biliary pain and intermittent fever. This triad is suggestive of cholangitis ascending cholangitis. Then we can have cancer of the common bile duct which is known as cholangiocarcinoma and this cancer when it involves the bifurcation of the common hepatic duct into the right and the left hepatic duct that cancer is referred to as a clatskin tumor and finally in some Asian countries a particular type of helminth infection can involve the biliary system along with the liver and that is called asiatic cholangio hepatitis and that helminth is called clonarchis sinensis. So this is the phalseiform ligament and this is the attached margin to the liver and this is the free margin of the phasio-home ligament which contains these two structures. This is the round ligament of liver which is the obliterated umbilical vein and this is the parambilical vein. The parambilical vein connects with the left branch of the portal vein here and it connects with the umbilicus and to the superficial epigastric vein and this is the one which gets dilated in portal hypertension and produces what is known as the caput medica because this is a site of portal systemic anastomosis. So these are some of the common elements which involve the entire deliri system. Thank you very much for watching ladies and gentlemen if you have any questions or comments put them in the comment section below Dr. Sanjay Sanyal signing out have a nice day. So guys thanks for watching make sure like this video make sure you subscribe