Liver,gb, Biliary Tree

Liver, Gallbladder and Biliary Tree Dr. Aldwin A. Yaneza Dept of Anatomy

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LIVER -

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Largest gland Approx 1500 g, ¼ of BW Lies in R upper and L upper quadrants [mainly on right] Inferior to diaphragm Function: 1] stores glycogen 2] secretes BILE

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SURFACES 

A. Diaphragmatic 

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Smooth and dome shaped Recesses 

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Subphrenic – bet diaphragm & liver Hepatorenal – bet liver and R kidney

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Ligaments of liver Bare area of liver – not covered–with peritoneum  Ligaments 1] Coronary – superior 2] Triangular – lateral 3] Falciform – anterior, middle 4] Round – inferior, remnant of umbilical vein 

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SURFACES 

B. Visceral 

 -

Covered w/ peritoneum except at bed of gallbladder and porta hepatis Relations R side of stomach – gastric/pyloric area 1st part duodenum – duodenal area Lesser omentum Gallbladder R colic flexure – colic area R kidney/suprarenal gl – renal/ suprarenal` area

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Visceral surface 

Structures:  

IVC Portal triad   

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Hepatic artery Portal Vein Hepatic duct

Caudate lobe Quadrate lobe

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FUNCTIONAL PARTS 

Functionally independent R/ L lobes 

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Each lobe with own   

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Can donate one lobe to relative Blood supply Venous drainage Biliary drainage

Division into R – L lobes  

GB fossa inferiorly and IVC fossa superiorly Facilform lig [ old terminology]

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Current [func’l] terminology

L liver = caudate and quadrate lobe + L lobe R liver = R lobe

OLD terminology Falciform lig – divides it into R and L 8

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Functional parts

Round ligament [L. ligamentum teres] 

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Remnant of umbilical vein that carried oxygenated blood from placenta to fetus

Porta Hepatis  

Transverse fissure on visceral surface of liver bet caudate and quadrate lobes Passage for portal triad    

1] Portal vein 2] Hepatic artery 3] Hepatic duct Others – hepatic nerve plexus, lymph

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Portal v

Hepatic art Hepatic duct 10

Peritoneal Relations 

Lesser omentum - fr liver to lesser curve of stomach and 1st part of duodenum - parts: 

Hepatoduodenal lig 

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Extends bet porta hepatis and duodenum Encloses portal triad 

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Hepatic duct, hep. artery, portal vein

Hepatogastric lig 

Extends bet liver and lesser curve of stomach

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Vessels and nerves

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Liver receives blood from 2 sources  

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1] Portal vein [ 70 % ] 2] Hepatic artery [ 30 %]

Venous drainage 

Hepatic vein  

Formed by union of central veins of liver Drains into IVC

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Blood supply of liver 

1. PORTAL VEIN  Formed by union of superior mesenteric vein [SMV] and splenic vein  Ascends anterior to IVC, has R - L branches  Carries poorly oxygenated but nutrient rich blood fr GIT to liver  70%

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Blood supply of liver 

2. HEPATIC artery  

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Br of celiac art Div into R and L hepatic art Carries well oxygenated blood from aorta to liver 30%

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SEGMENTS 

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Horizontal plane thru R lobe and lateral division of L lobe plus caudate lobe Divides liver into 8 vascular segments Based on divisions of the hepatic artery and portal vein and hepatic ducts Each segment:  

Supplied by br of hepatic art. and Portal V. Drained by branch of hepatic duct

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I-back Posterior

IVa

II

superior

III VII

VIII IVb

V VI Posterior inferior

P A Me La 18

Division  

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Anatomic[2] – Falciform lig Functional[2] – L lobe is quadrate +caudate + L anatomic lobe Surgical[4] - R/ L Lateral and Medial div Segments [8] - Couinauds

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P A Me La

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Segments    

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I - Caudate II - Lateral superior III - Lateral inferior IVa - Medial superior IVb – Medial inferior V - Anterior inferior VI - Posterior inferior VII – Posterior superior VIII - Anterior superior

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The Couinaud classification of liver anatomy divides the liver into eight functionally indepedent segments. Each segment = own vascular inflow, outflow and biliary drainage. In the centre of each segment - branch of the portal vein, hepatic artery and bile duct. In the periphery of each segment = vascular outflow through the hepatic veins. 22

4A

4B

Segments numbering There are 8 liver segments. Segment 4 is sometimes divided into segment 4a and 4b according to Bismuth. The numbering of the segments is in a clockwise manner (figure). Segment 1 (caudate lobe) is located posteriorly. It is not visible on a frontal view. 23

Lymphatics  

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Major lymph producing organ Occur as superficial lymphatics in Glisson’s capsule and as deep lymphatics in connective tissue that accomp the p.triad Anterior superf lymph  hepatic LN  celiac LN  chyle cistern [dilated sac of t. duct] Posterior superf lymph  phrenic LN  posterior mediastinal LN  thoracic duct

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Nerve Supply 

Hepatic Nerve Plexus Largest derivative of celiac plexus  Accomp branches of p. triad to liver  Consists of sympathetic and parasym fibers  Function: Vasoconstriction 

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Variations in LIVER

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IRON MAN

Robert Downey Jr

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The Dark Knight ,2008 29

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GALLBLADDER and BILIARY DUCTS Bile Produced by hepatocytes  Yellow fluid  Stored in GB  Passes to via bile ducts duodenum  Emulsifies fat 

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Gallbladder

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I. General Information A. Location: 1. Epigastric region 2. R hypochondriac 3. inferior surface of liver 4. Between quadrate and right lobes B. Pear-shaped, hollow structure thin walled greenish 33

General Information, con’t.

C. Fundus slants inferiorly, to the right D. Attached to liver by loose (areolar) connective tissue E. Peritoneum covers free surfaces

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Introduction, continued …

F. Normal measurements: 7-10 cm long 4 - 6 cm diameter 30 – 60 cc bile G. Function:Stores and concentrates bile

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II. Detailed Anatomy A. Fundus of GB:

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Parts

Gallbladder

Fundus -wide end -Projects fr inferior border of liver  Body -Main part -Contacts the R part of transverse colon and 1st part of duodenum 

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Body -Contacts the R part of transverse colon and 1st part of duodenum - Chronic cholecystitis[inflammation], body forms connection with 1] colon – cholecystocolonic fistula 2] duodenum – cholecystoduodenal fistula

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Gallbladder

Neck -Narrow,tapered -Continuous w/ cystic duct -Mucosa thrown into spiral fold [valve of Heister] -Serves as guide to omental bursa Cystic duct - 2- 4 cm long - Joins common hepatic duct to form common bile duct -mucous membrane thrown into spiral fold

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Gallbladder 

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Arterial supply  Cystic art [fr R hepatic artery] Venous drainage  Cystic vein [drains into R branch of portal vein] Lymphatic drainage  Hepatic LN Nerve supply  Celiac plexus [symp]  Vagus n [parasymp] 40

The Gallbladder and Biliary System with Pancreas

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Detailed Anatomy, con’t….

O. Lymphatic drainage of GB 1. Enlarged – [+]malignancy 2. Cystic node at neck of GB a. Cystic node of Calot b. Behind is cystic artery c. Guide for laparoscopic surgeons

3. Other lymph vessels also drain into hepatic nodes 42

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Lymph Nodes 

N1   

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Choledochal Hilar Cystic duct

N2   

Peripancreatic Retroduodenal Portal, celiac, or superior mesenteric vessels

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Biliary Ducts

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Hepatic ducts- drain the liver  

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Common hepatic ductswhen R and L hd unite 

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R Hep duct – R lobe L Hep duct – L Lobe

4 cm, in lesser omentum

Common bile duct - after giving off cystic duct on right

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Harry Potter and the Half blood Prince 48

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Transformer 2: Revenge of the Fallen

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    

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Common Bile Duct [ CBD ] 8-10 cm long 5-6 mm diameter in lesser omentum Passes behind 1st part of duodenum Unites w/ main pancreatic duct to form hepatopancreatic ampulla Opens into descending or 2nd part of duodenum

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CBD 

Arterial supply   

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Venous drainage 

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Proximal part – cystic a Middle part – R hepatic a Distal part – posterior superior pancreaticoduodenal a Posterior superior pancreaticoduodenal vein

Lymphatic   

Cystic LN Hepatic LN Celiac LN

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III. Gallbladder Diseases

A. Cholelithiasis & Cholecystitis 1. Cholecystitis = inflammation of GB 2. Cholelithiasis = Stone(s) in GB

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Cholelithiasis

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GB shows likely sites of stone formation/depositi on

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Gallbladder Diseases, continued …

B. GB Carcinoma a. US useful in diagnosis b. mass producing thickening and irregularity in wall c. Calculi found frequently 57

Gallbladder Diseases, continued …

C. Polyps of GB a. Intraluminal echogenic projections b. Do not change position with patient c. Must be differentiated from stones

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Gallbladder diseases, continued …

D. Viscid Bile, “sludge” a. Due to intermittent obstruction of CBD or cystic duct b. Seen in patients with bile stasis c. Produces linear, echogenic interface within GB 59

Cystic artery 

Ligated during surgical removal of gallbladder [cholecystectomy]

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Variations in Anatomy of Cystic Duct

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Anatomy /Histology 

Mucosa Smooth muscle Serosa

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Attachment to liver

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Tumors can extend directly into liver

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Laparoscopic Cholecystectomy

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Identify the gallbladder

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Triangle of CALOT = area formed by the cystic duct, hepatic duct and edge of liver. The cystic artery will be located in this triangle

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Isolate and ligate the cystic artery

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Isolate and ligate the cystic duct

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Clinical correlation: Calculous cholecystitis Diet high in fat produces cholesterol stones inside GB  After eating GB contracts, it expels stone w/c lodges at cystic duct  Trigger inflammation of GB [cholecystitis]  Pain at RUQ  Diagnosed by: -History, PE and ultrasound 

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Empyema of gallbladder Longstanding impaction of stone at cystic duct  Remaining bile cannot exit the GB because of impacted stone  Bacteria will set in  Abscess forms inside GB  GB enlarges, wall thickens Clinical :  Fever, RUQ pain, palpable GB at RUQ  Common among diabetics and noncompliant patients 

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Ruptured Cholecystitis

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National Kidney Institute,East Ave FEU Medical Center,Fairview

The end

Aldwin A. Yaneza,MD General and Laparoscopic Surgery

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SET A

SET B

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Gallbladder

Pear shaped sac Along R edge of quadrate lobe of liver in depression called gallbladder fossa,V Hangs by stem = cystic duct Rounded fundus projects beyond inferior margin of liver Thin walled greenish Covered on its posterior and inferior surfaces by peritoneum Concentrates and stores bile secreted by liver Holds 30-60 ml of bile

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END

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Quiz  

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Set A Tabulate the 7 differences between the jejunum and ileum Draw and label the 8 surgical segments Draw and label the biliary tree/ tract

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Set B Draw and label the 8 Couinauds segments Tabulate the 7 differences between the jejunum and ileum Draw and label parts of gallbladder

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