Cystohepatic Triangle of Calot

The Cystohepatic Triangle is formed between the right side by the cystic duct, on the left side by common hepatic duct, and above by inferior surface of the liver. It is a downward-facing triangle between the cystic and common hepatic ducts. The triangle comprises of the right hepatic artery, cystic artery, and cystic lymph node of Lund. Majority of the aberrant segmental right hepatic ducts and arteries are generally struck in this triangle. The accessory hepatic ducts terminate either into the gallbladder or in the common hepatic duct or even into the bile duct, and are responsible for oozing of bile from the wound after cholecystectomy.

The surgeon find out find the pedicle of gallbladder and its ligation in cholecystectomy with the help of the identification of this cystohepatic triangle. The mistakes in gallbladder surgery frequently happen from failure to recognize the common versions of the extrahepatic biliary system. This takes place particularly when the right hepatic artery in this triangle presents a caterpillarlike loop termed Moynihan’s hump, which may be mistakenly clamped, ligated together with cystic pedicle, and wound leading to profuse bleeding.

The cystic node of Lund (a solitary node) present in the apical part of the triangle gets the majority of the lymph from gallbladder and is always seen enlarged in cholecystitis.

Clinical Significance

Cholecystitis

The cholecystitis is the inflammation of the gallbladder. It can be acute or chronic.

Acute Cholecystitis

• It happens normally in adult women and is distinguished by (i) abrupt pain in the hypochondrium referred to the inferior angle of the right scapula or to the tip of right shoulder, (ii) vomiting, and (iii) favorable Murphy’s indication- if the finger is pressed under the right costal margin in the tip of the 9th costal cartilage when the patient is requested to take a deep breath, she/he feels sharp pain and winces with a” grab” in the breath as the diseased gallbladder meets the examining finger.

The indications of cholecystitis are aggravated on taking oily meals since the gallbladder contracts to pour the bile into the duodenum when fat reaches the duodenum. Fat in the duodenum causes liberation of a localized hormone cholecystokinin-pancreozymin (CCK-PZ), which reaches the gallbladder via the blood stream and arouses its contraction.

Chronic Cholecystitis

Chronic cholecystitis normally results in creation of stones in the gallbladder (cholelithiasis): It normally takes place usually in fat, fertile, flatulous female of forty (5F).

Referred Pain of Gallbladder

In acute cholecystitis, the inflammation of the gallbladder might cause annoyance of the subdiaphragmatic parietal peritoneum, that is supplied in part by the phrenic nerve (C3, C4, and C5 spinal sections). This may result in referred pain over the tip of the right shoulder for being supplied by the supraclavicular nerves (C3 and C4 spinal sections).

Biliary Colic

It’s normally caused by the spasm of smooth muscle of the gallbladder wall in an effort to expel the gallstone. It’s sporadic and is most extreme when stone (calculus) is influenced either at the terminal end of cystic duct or at the lower end of the bile duct since the smooth muscle everywhere in the biliary duct system issparse with the exception of at the terminal portions of the cystic and bile ducts. The afferent fibres from the gallbladder goes into the thoracic sections of spinal cord (T7 T9), therefore referred pain is felt in the right upper quadrant or epigastrium (T7 T9) dermatomes.

Obstacle of Cbd

The obstruction of CBD typically happens because of gallstones, pancreatic carcinoma, or enlarged neoplastic hepatic lymph nodes. It causes obstruction to bile flow, which results in jaundice.

Courvoisier’s Law

This law says that the obstructive jaundice with distended and palpable gallbladder is most likely because of extrinsic obstruction of CBD (example, carcinoma of head of pancreas). On the contrary, obstructive jaundice with non-distended, non-palpable gallbladder is a result of an intrinsic impediment of CBD (example, impaction by gallstones) because in this case preceding cholecystitis makes the gallbladder fibrotic and got.