The Funneling or Pouching Effects of Gallstones on Gallbladder wall: Personal Surgical Anatomical Perspective
The Harmann’s pouch is well documented and is usually seen during cholecystectomy in cases of Chronic calcular cholecystitis with lage gallstones in the neck of the gallbladder leading to what is called Hartmann’s pouch which is well known; and with long standing stones in this pouch, it will increase in size and by the weight of the stones with their increase in size, the pouch gradually increases in size and will form a fossa adjacent to the right side (or the right posterolateral aspect) of the CBD and CHD, this fossa is seen in cases of large stones impacted in the Hartmann’s pouch and may be referred to as Hartmann’s fossa. During Laparoscopic cholecystectomy dissection of Hartmann’s pouch should be done meticulously from adhesions in this fossa avoiding bleeding and preserving the CBD and CHD and the adjacent duodenal wall. Longstanding impaction of large stones in the Hartmann’s pouch may lead to Obstruction of the cystic duct with empyema of the gallbladder or may lead to Mirizzi syndrome.
On the other hand, in cases of small stones in the gallbladder extending to the neck of the gallbladder, we have observed, during Laparoscopic cholecystectomy, that there is what we refer to it as Funneling of the gallbladder in the region of the neck of the gallbladder extending to the body of the gallbladder and may be extending also to the cystic duct, as seen in the first illustration, and in the MRCP images, and in the first video.
Funneling of the gallbladder in cases of small stones is likely to lead to migration of stones to the cystic duct, Cystic duct-CBD junction and CBD.
Conclusion and Summary :
The effects of small gallstones on the gallbladder wall are different than large gallstones. Large gallstones has been reported to be associated with Harmann’s pouch, due to their pouching effects. Small stones on the otherhand tend to have Funneling effects on the gallbladder. These Funneling or Pouching effects have their surgical relevance during Laparoscopic cholecystectomy and should be taken into consideration to do safe Laparoscopic cholecystectomy and to achieve the best results.
