SURGICAL ANATOMY AND EMBRYOLOGY

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AMPULLA OF VATER
Anatomic, Embryologic, and Surgical Aspects
Claude Avisse, MD, Jean-Bernard Flament, MD,
and Jean-Franqois Delattre, MD

The ampulla of Vater (i.e., the hepatopancreatic ampulla) corresponds anatomically with the dilated junction of the common bile duct and the main
pancreatic duct of Wirsung before their opening into the duodenum. This ampullary appearance is inconstant, and its existence is disputed by some investigators.
Considered more widely and realistically from the surgical viewpoint, the
ampulla of Vater constitutes the junction of the biliary, pancreatic, and digestive
tracts (Fig. 1).It corresponds to an anatomic and functional region that comprises
(1)the junction of the common bile duct and pancreatic duct; (2) surrounded by
the sphincteric system of Oddi; (3) traversing a dehiscence of the duodenal wall
(fenestra choledochae); and (4) terminating at the greater duodenal papilla (or
great caruncle), covered by the duodenal mucosa. The ampulla of Vater is the
site of tumors, often with a threatening prognosis and the surgical treatment of
which may be consequently difficult. It is also commonly the site of disorders
specific to or caused by the neighboring organs that affect biliopancreatic emptying. The understanding of these disorders has benefited from peroperative
manometric studies and from endoscopy. Numerous anatomic, embryologic,
pathophysiologic, and pathologic studies of the ampulla of Vater have been
performed. This article reviews only important and practical points of these studies.
CHOLEDOCHOPANCREATIC JUNCTION

The junction of the main pancreatic duct and the common bile duct and
their opening at the greater duodenal papilla (Fig. 2) occurs in three ways6: (1)

From the Department of Anatomy, University of Reims; and Department of Digestive

Surgery, HBpital Robert DebrC, Reims, France

SURGICAL CLINICS OF NORTH AMERICA

VOLUME 80 * NUMBER 1 FEBRUARY 2000

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Figure 1. Junction of the biliaty, pancreatic, and digestive tracts (peroperative cholangiogram).

a common duct, 1 mm to 8 mm in length, in 60% of cases; (2) a doublebarreled opening at the apex of the papilla in 38% of cases; and (3) separate
duodenal openings for the two canals in 2% of cases. In 1720, Vater6 noted this
junctional arrangement of the bile and pancreatic ducts; after having ligated the
papillary orifice and injecting water into the common bile duct, he noted a reflux
of fluid into the duct of Wirsung, which became expanded at the duodenal wall
as a tubercle, which he called the diverticulum of the bile. The studies of Soemmering6in 1801 and of Bernard6in 1856 established this concept of a common duct
dilated into an ampulla, the so-called ampulla of Vater. Of 50 anatomic specimens
studied, Papalmitiades and Rettori7found such a common duct in only 31 cases
(62%), and observed a dilatation of this common duct, justifying the term ampulla
in only 2 cases (4%), so the existence of this structure is disputed, and many
investigators consider it as merely an artifact of anatomic dissection.
The site of duodenal implantation of this ductal junction and the association
of the main pancreatic duct of Wirsung with the common bile duct are important
to consider. In 75% of cases, the greater duodenal papilla, with the two ducts, is
implanted in the descending portion of the duodenum (see Fig. 2) at the junction
of its posterior and medial aspects, high up but usually at its midportion. The
terminal pancreatic duct is always inferior and anterior to the common bile duct
(Fig. 3A). In 25% of cases, the implantation of the greater duodenal papilla is
low, especially at the horizontal portion of the duodenum (Fig. 3B), to the right
of the superior mesenteric vascular axis; the pancreatic duct is verticalized
parallel to the left border of the common bile duct (Fig. 4).
For surgeons, the high position of the papilla can be appreciated on intraop-

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Figure 2. Choledochopancreatic junction (intraoperative cholangiogram). A, Common duct.

6, Double-barreled opening. C,Separate duodenal opening.

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TOP

LEFT

Figure 3. Implantation of the ductal junction and relation of the main pancreatic duct (P) to
the common bile duct (C) through the papilla in the descending portion (A) and in the
horizontal portion of the duodenum (B). Incision for sphincterotomy (arrow).

erative cholangiography. With the duodenum closed, the precise location of the
position of the papilla calls for the insertion of a probe into the common bile
duct, palpated through the duodenal wall. Duodenopancreatic stripping (i.e.,
the Kocher maneuver) makes the biliary-digestive confluence, normally situated
deeply in the subhepatic region, superficial and easily palpable.

Figure 4. Greater duodenal papilla in the horizontal portion of the duodenum. The pancreatic duct is verticalized, parallel to the left border of the common bile duct.

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SPHINCTERIC SYSTEM OF ODD1

The existence of a sphincter at the termination of the common bile duct was
demonstrated by Oddi in 1887 as a smooth muscle sphincter, causing the passage
of the bile to be intermittent. The anatomic and embryologic research of
Schwegler and Boyden12 and Rettori9 indicated the independent origin of the
sphincter in association with the duodenal musculature. Schwegler and BoydenI2
showed that this muscular system differentiates separately from the duodenal
muscle in the mesenchyme that surrounds the ducts and that it becomes integrated with the duodenal wall only secondarily.
According to Papalmitiades and R e t t ~ r i the
, ~ three elements constituting
this sphincteric system are (Fig. 5A):
A common sphincter-6 mm in length, composed of thick, circular, semicircular, and longitudinal fibers and interspersed with numerous glands
that are the origin of potentially malignant vaterian tumors
A specific common bile duct sphincter-10 mm in length, one third of
which is outside of the duodenal wall, intraluminal
A specific sphincter of the pancreatic duct-6 mm in length, of which
only one fourth is extramural

According to Barraya et a1,2 these sphincters can be divided into three zones
(Fig. 5B): (1) a superior occlusive sphincter; ( 2 ) a middle sphincter defining an
infundibulum, which can be easily dilated; and (3) an inferior sphincter, which
participates in the formation of the papilla. This sphincteric complex is situated
in a dehiscence of the duodenal wall, the duodenal window.
From these concepts can be derived the existence of an extramural, intraduodenal, or intraluminal zone of the sphincter, which alone should be involved in
a possible sphincterotomy.

Figure 5. A, The sphincteric system of Oddi, according to Papalmitiades and Rettori.

Duodenal wall (1). Specific sphincter of common bile duct (2). Specific sphincter of pancreatic duct (3). Common sphincter (4). 6, The sphincteric system of Oddi, according to
Barraya. Superior occlusive sphincter (1 and 2). Middle sphincter (3 and 4). Inferior
sphincter (5). lnfundibulum (6).

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DUODENAL WINDOW
Classic descriptions of the duodenal window show the presence of an
interruption of the duodenal muscle fibers at the point of penetration of the
common bile duct and the main pancreatic duct into the duodenal wall. The
muscular orifice that Schwegler and BoydenI2called the duodenal window (fenestra
choledochae) was described in detail by Papalmitiades and R e t t ~ r iThe
. ~ duodenal
window is a quadrilateral orifice, typically with sides of 5 mm to 7 mm. Its
anterior and posterior borders correspond with the spindle-shaped separation
of the superficially situated longitudinal muscle fibers of the duodenal wall. Its
superior and inferior borders correspond with a separation of the deeply situated
circular fibers. The window is situated on the posterior slope of the medial
border of the duodenum, and its margins are united with the sphincteric block
by a system of muscle fibers, the nomenclature and description of which vary
among investigators. The duodenal wall surrounding the sphincteric apparatus
must be respected" 6, during sphincterotomies and localized excisions of the
papilla; a procedure that is too extensive risks opening the digestive lumen into
the pericholedochal and retropancreatic cellular spaces and may cause severe
vascular damage, so, except for carcinologic imperatives, the excision of tumors
of the ampulla of Vater often requires a sacrifice: cephalic duodenopancreatectomy.
The association of the ductal termination with the duodenal wall (see Figs.
2 and 4) is important surgically and functionally.10The common bile duct
approaches the duodenal wall, forming an acute angle of approximately 25" to
309 open upward when the papilla is located in the descending duodenum. The
terminal intraparietal part of the duct has a zigzag course between the duodenal
muscle fibers, which prevents reflux of the duodenal contents toward the biliary
tract regardless of the variations of intraduodenal pressure.
The main pancreatic duct, closer to horizontal, forms an angle of 60" with
the duodenal wall in the frontal plane. It receives the common bile duct at its
upper border and right side. In practice, the pancreatic duct is always situated
below and in front of the common bile duct.
Muscle fibers (Fig. 6) coming from the margins of the duodenal window
tether the termination of the biliary and pancreatic ducts to the duodenal wall.
The authors borrow the description and nomenclature of these fibers from
Papalmitiades and Rett~ri.~,Superficially, the C1 fibers originating from the
longitudinal muscle layer at the anterior and posterior borders of the papilla
join the common bile duct and pancreatic duct. The C2 fibers, given off by the
circular muscle layer, arise from the lower border of the duodenal window and
disappear over the pancreatic duct. The C4 fibers, also arising from the circular
muscle layer, arise from the upper border of the window and disappear at the
common bile duct.
Deeply, the C5 fibers, originating from the circular muscle layer at the upper
border of the window, dissipate obliquely at the papilla. The C3 fibers, given off
by the circular muscle layer at the inferior border of the window, have a special
arrangement: The fibers coming from in front disappear over the anterior and
inferior aspects of the papilla, whereas posteriorly they turn downward and are
lost at the lower pole of the papilla. The lesser density of the tethering fibers
behind the papilla gives rise to a weak point where mucosal hernias may
develop: the mucosal diverticula of the duodenal window (Fig. 7). In the authors'
experience? l1 these acquired diverticula are common in elderly patients; they
may lead to dysfunction of the sphincter of Oddi and may have a major role
in the development of biliary calculi, cholangitis, or pancreatitis. Lastly, the

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Ch

207

Ch \
\

FL

FL

--

c, ,

.w

W'

FC

FC

'

c,

Figure 6. A-D, The tethering fibers (Cl-C5) of the greater duodenal papilla (P) and the
weak point for development of mucosal diverticula. Ch =common bile duct; W = main
pancreatic duct; FC = circular fibers; FL = longitudinal fibers.

intermingling of the musculature of the duodenum and the sphincter of Oddi

makes the physiology of biliopancreatic emptying complex; inflammation of the
sphincter and biliary dyskinesia are well known but still ill defined clinical entities.
DUODENAL MUCOSA AND THE PAPILLA

The duodenal mucosa and the greater duodenal papilla (see Fig. 3; Fig. 8),
with the orifices of the common bile duct and the main pancreatic duct, can be
examined by endoscopy or surgically after duodenotomy. The papilla presents
as a polypoid prominence 5 mm to 10 mm in length and 5 mm in width, hidden
by transverse, circular, duodenal folds. The smoothing out of these folds allows
for the identification of the papilla, which is surmounted by a transverse fold,

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Figure 7. A and 6, Juxtaposed duodenal diverticulum. C and D, Interposed duodenal

diverticulum.

or "hood." Above is a depression related to the invagination of the duodenal

mucosa in the choledochal window. Below, one or more typically well-developed
longitudinal folds-the "restraints" of the papilla-hold the papilla downward
and form an essential landmark because they are the only vertical structures in
the duodenal mucosa. The apex of the papilla is usually occupied by a single
orifice by which the biliopancreatic secretions empty into the duodenum. This
orifice is evidence of the existence of a common channel situated in the prolongation of the main pancreatic duct, whereas the common bile duct joins it by a
curve with an infero-left concavity. When two orifices are present, the biliary
opening is always dorsal and cranial in relation to the main pancreatic duct. The
main pancreatic duct is thus usually easily identifiable and can be catheterized
during a surgical sphincterotomy.
For surgeons, access to the papilla for sphincterotomy or local tumoral
excision requires a duodenopancreatic stripping (i.e., the Kocher maneuver), the
identification as already described; a duodenotomy of the outer aspect of the

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Figure 8. The greater duodenal papilla. Papilla (1). Transverse fold (2).Longitudinal fold
(3). Orifice of mucosal diverticulum (4).

organ, preferably horizontal for vascular reasons; and smoothing out of the
transverse folds. The only anatomic anomaly or variation of any importance is
the presence of a lesser duodenal papilla (i.e., a small caruncle), which is always
situated several centimeters above the greater papilla and drains only pancreatic
secretions. The patent accessory pancreatic duct of Santorini sometimes drains
the entire dorsal pancreas in cases of a pancreas divisum, in which the dorsal
and ventral pancreatic channels have failed to fuse., l o

VASCULARIZATION

The arterial vascularization of the choledochopancreaticoduodenal junction,

and more globally of the entire duodenopancreatic block, has been described
precisely in numerous publications, from which the authors extract the main
points3, lo Three arterial supplies participate in this vascularization (Fig. 9):

Posterior and superior pancreaticoduodenal arch (Fig. 10A)-Gives off

several rows of branches to the common bile duct, which form a vessel
parallel to the posterior border of the papilla
Ventral commissural arch (or vertical intrapancreatic arch of Evrard)Gives off branches distributed to the duodenal wall in front of the terminal
bile duct; one branch, traversing the duodenal wall near the upper border
of the window, is arranged along the anterior border of the ,papilla; these
two anterior and posterior axes are joined at the tip of the papilla by a
finely anastomosed submucosal plexus (hence the hemorrhagic nature of
juxtapapillary tumors)
Anterior and inferior pancreaticoduodenal arch (Fig. 10B)-Gives
off

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5
J
Figure 9. Arterial vascularization of the papilla. Posterior and superior pancreaticoduodenal
arch (1). Ventral cornmissural arch (2). Anterior and inferior pancreaticoduodenal arch (3).
Gastroduodenal artery (4). Superior mesenteric artery (5).

some branches ramifying at the lower border of the duodenal window

and participating in the juxtapapillary submucosal network
The small caliber of these vessels results in little concern with regard to the
risk for hemorrhage on sphincterotomy. The same is not true if the margins of
the duodenal window are transgressed because vessels of greater caliber appear
here, explaining the risk for hemorrhage in local excisions. Lastly, the vessels of
the duodenal wall have a horizontal direction and are distributed in anterior
and posterior territories, the frontier zone of which is situated on the outer
aspect. At this site, a duodenotomy should be performed, preferably horizontally.
The lymphatic drainage of the papilla is common to that of the right
pancreas, and three sectors may be recognized5,6,
Anterior and superior cephalic territory-The lymphatic pathways travel
in the right retropancreatic process to reach the right interceliomesenteric
lymph nodes
Inferior cephalic territory-Drains to the right interceliomesenteric nodes
bilaterally suprarenal and infrarenal, still in the right retropancreatic
process
Posterior and superior cephalic territory-Drains toward the retrocholedochal lymph nodes and then relays to the interaorticocaval nodes; numerous variations exist, with the possibility of long collectors draining the
lymph of the duodenum or pancreas directly to the juxta-aortic nodes or

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Figure 10. Posterior and superior (A) and anterior and inferior (B) pancreaticoduodenal

arches.

even the left lumbar trunk or thoracic duct; the rapid invasion of remote
nodal regions justifies the consideration of cephalic duodenopancreatectomy as the procedure of choice for malignant tumors of the vaterian region
SUMMARY

The region of the ampulla of Vater constitutes a complex anatomic and

functional entity, the biliopancreaticoduodenal confluence, of which the essentials of this rapid review are the:
Variation in site of implantation of the greater duodenal papilla, whereas
the relations between the common bile duct and the main pancreatic duct
are relatively constant
Presence at this site of a weak point in the duodenal wall, commonly the
site of mucosal diverticula

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Interdependence of the parietal duodenal mucosa and the sphincteric

system of Oddi
Existence of an extramural zone of this sphincter, which should be the
only one involved in sphincterotomy
Danger of wide excisions of the papilla, which, apart from the risk for
hemorrhage, cause a breach of the digestive barrier
The ampulla of Vater corresponds to the dilated junction of the common
bile duct and main pancreatic duct, if present. The ampulla is an extensive
anatomic and functional region that includes not only the choledochopancreatic
junction but also the sphincter of Oddi, the whole traversing the duodenal wall
to open at the greater duodenal papilla. The chief anatomic features of this
biliopancreaticoduodenal junction have been reviewed, forming the basis of
techniques of surgical or endoscopic sphincterotomies and localized excisions of
vaterian tumors.
References
1. Adda G, Hannoun L, Loygue J: Development of the human pancreas: Variations and
pathology. A tentative classification. Anatomica Clinica 5275, 1984
2. Barraya L, Pujol-Soler R, Yvergneaux P: La region oddienne: Anatomie millimetrique.
La Presse Med 79:2527, 1971
3. Donatini B: A systemic study of the vascularisation of the pancreas. Surg Radiol Anat
12:173, 1990
4. Flament JB, Palot JP, Delattre JF, et al: Les diverticules muqueux de la fenOtre duodenale. Approche anatomique et physiopathologique. Chirurgie 113:395, 1987
5. Hidden G, Hureau J: Les grandes voies lymphatiques des visceres digestifs abdominaux chez ladulte. Anat Clin 1:167, 1979
6. Marchal G, Hureau J: Les tumeurs oddiennes. Rapport de 1A.F.C. Paris, Masson, 1978
7. Papalmitiades M, Rettori R Architecture musculaire de la jonction choledoco-pancreatico-duodenale. Acta Anat 30:575, 1957
8. Pissas A: Anatornoclinical and anatomosurgical essay on the lymphatic circulation of
the pancreas. Surg Radiol Anat 6955, 1984
9. Rettori R: Etude morphologique du systeme musculaire de la jonction choledocopancrkatico-duodenale et bases anatomiques de la section du sphincter dOddi. Presse
Med 64:1208, 1956
10. Richelme H, Bourgeon A, Ferrari C, et al: Bases anatomiques de la sphincterotomie
oddienne. Anat Clin 1:177, 1978
11. Rives J, Lardennois B, Flament JB: Les diverticules muqueux de la fenOtre duodenale
et leurs consequences bilio-pancreatiques. J Chir 102541, 1971
12. Schwegler RA, Boyden E A The development of the pars intestinalis of the common
bile duct in the human foetus, with special reference to the origin of the ampulla of
Vater and the sphincter of Oddi. Anat Rec 67441, 1937

Address reprint requests to

Claude Avisse, MD
Department of Digestive Surgery
HBpital Robert Debre
Rue du General Koenig
51092 Reims Cedex
France