A 38-year-old woman is admitted to the hospital with signs of cholecystitis and gallbladder stones. During cholangiography, the catheter is inserted with difficulty into the gallbladder. Which of the following structures is most likely to interfere with the passage of the catheter into the cystic duct?
The gallbladder consists of a fundus, body, and neck. The fundus is the rounded, blind end that comes in contact with the transverse colon. The body is the major part and rests on the upper part of the duodenum and transverse colon. The neck is the narrowest part and gives rise to the cystic duct. This duct contains the spiral valve (of Heister), which is a redundant mucosal fold that maintains patency of the duct. This is not actually a valve and does not determine the direction of flow of bile. This could potentially be a point of constriction that could present difficulty with insertion of a catheter. The cystic duct comes into contact only with the cystic artery and is not particularly tortuous. The hepatoduodenal ligament is the thickened free edge of the lesser omentum, and it conducts the portal triad (portal vein, hepatic artery, and bile duct) and encloses structures that pass through the porta hepatis. This ligament is unlikely to compress the cystic duct. Though the cystic duct is in close relation to the portal vein and the hepatic artery, the most likely cause of difficulty would be potential constriction by the spiral valve.
Cystic duct compression by a hepatic artery
Spiral valve (of Heister)
Tortuosity of the cystic duct
Adhesions from the hepatoduodenal ligament
Abdomen & Pelvis