SURGICAL ANATOMY OF LIVER

1. SURGICAL ANATOMY OF
LIVER
MODERATORS PRESENTED
BY
DR. S. NAGAMUNEIAH.,M.S PROF DR. P.KARTHIK,
DR. SABITHA., M.S, ASST PROF 2ND YEAR PG.

2. HISTORICAL BACKGROUND
HEROPHILUS OF CHALCEDON (334-280 B.C.) First anatomical description of liver
THOMAS STARZL: Performed first successful human ORTHOTOPIC liver transplant in
1968
HENRI BISMUTH: Performed first HETEROTOPIC liver transplant in humans in 1980
J. CANTLIE 1897 Confirmed rex's findings. rex's lobular plane of division later named
cantlie's line.

3. FEW FACTS : LIVER
Second largest organ of body after skin.
Average weight : 1.5kg ( 2 % of total body weight) Largest gland.
Position – b/w 5th ICS & costal margin.
Blood flow : 1500 ml/min (25% of CO).
Blood supply : 1/3rd hepatic artery(20%) , 2/3rd portal vein(80%).

4. FUNCTION OF THE LIVER
Secretion of bile (salt and pigments)
Metabolism of carbohydrate, fat and protein.
Formation of heparin & anticoagulant substances.
Detoxication.
Storage of glycogen and vitamins.
Activation of vitamin D.

5. EMBRYOLOGY
4TH WEEK OF DEVELOPMENT
 Projection from ventral wall of distal end of
foregut.
Cranial bud - liver
Caudal bud - gallbladder,
extrahepatic biliary tree
Ventral pancreas

6. EMBRYOLOGY
 Bile ducts develop from hepatocytes,
Originating at hilum
 Biliary lumen recanalize 7th week
 Liver begins to secrete bile 12th week

7. CONGENITAL ANOMALIES
TRANSPOSITION OF LIVER
 RIEDEL’S LOBE
 ACCESSORY AND ECTOPIC LOBE OF LIVER
 MESENCHYMAL HAMARTOMA
 INTRAHEPATIC BILIARY ATRESIA
 CONGENITAL CYST
 CONGENITAL HEPATIC FIBROSIS
 VASCULAR MALFORMATION

9. ANATOMY
 POSITION
Between 5th intercostal space and
costal margin extends across midline
 GLISSON’S CAPSULE
Visceral Peritoneal

10. BARE AREA OF LIVER

11. LIGAMENTS OF LIVER
1.Falciform ligament
2.Right & left coronary ligament
3.Right & left triangular ligaments
4.Gastrohepatic ligament
5.Hepatoduodenal ligament
6.Ligamentum venosum

12. HEPATODUODENAL LIGAMENT
‘PRINGLE’ MANOEUVRE

13. THE LIGAMENTUM
VENOSUM
 Fibrous band that is the remains of the
ductus venosus
 Ligament of aranthius
 It is attached to the left branch of the portal
vein and ascends in a fissure on the visceral
surface of the liver to be attached above to
the inferior vena cava

14. BLOOD SUPPLY OF THE LIVER

15. HEPATIC ARTERY
Cautions
 Only 55-65% of population has
“normal” hepatic arterial anatomy
 Aberrant R hepatic artery may be
mistaken for cystic artery
 Cystic artery may originate from the
Gastroduodenal artery, the left hepatic
artery, or the common hepatic artery

16. PORTAL VEIN
80% of hepatic bloodflow
1-3cm diameter
5-8cm length
4-5mm hg

17. NERVE SUPPLY OF LIVER

18. LIVER HISTOLOGY
 Lobules >> roughly hexagonal
structures consisting of
hepatocytes. Radiate outward from
a central vein.
 At each of the six corners of a
lobule is a Portal triad (
p.Arteriole,p.Venule & bile duct)
 Between the hepatocytes are the
liver sinusoids.

19. HEPATIC MICROCIRCULATION

20. BILIARY SYSTEM
TRIANGLE OF CALOT
 Cystic duct, common hepatic duct, and
hilum of liver.
 Dissected during cholecystectomy.
 Contents- cystic duct and artery, lymph
node of Lund

21. BILIARY ANOMALIES

22. HEPATIC VEINS
 Short extrahepatic segment
Right
Middle -usually joins left
Left
 Direct communication to IVC from segment
I (caudate)

23. LYMPHATICS
SUPERFICIAL
CAVAL,
HEPATIC
PARACARDIAC,
COELIAC
DEEP
IVC, HEPATIC
NODES

24. HEPATIC RECESSES
 ANATOMICAL SPACES BETWEEN THE LIVER AND SURROUNDING
STRUCTURES.
 INFECTION MAY COLLECT IN THESE AREAS, FORMING AN
ABSCESS.
SUBPHRENIC SPACES – BETWEEN THE DIAPHRAGM AND THE
ANTERIOR AND SUPERIOR ASPECTS OF THE LIVER.
DIVIDED INTO A RIGHT AND LEFT BY
FALCIFORM LIGAMENT.
SUBHEPATIC SPACE – PERITONEAL SPACE IS LOCATED BETWEEN
THE INFERIOR SURFACE OF THE LIVER AND THE TRANSVERSE
COLON.

25. MORISON’S POUCH
 A POTENTIAL SPACE BETWEEN VISCERAL
SURFACE OF THE LIVER AND THE RIGHT KIDNEY.
 DEEPEST PART OF THE PERITONEAL CAVITY
WHEN SUPINE (LYING FLAT),
 THEREFORE PATHOLOGICAL ABDOMINAL FLUID
SUCH AS BLOOD OR ASCITES IS MOST LIKELY TO
COLLECT IN THIS REGION IN A BEDRIDDEN
PATIENT.

26. TOPOGRAPHIC ANATOMY
 RIGHT
 LEFT
 QUADRATE
 CAUDATE

27. LOBAR ANATOMY
(AMERICAN SYSTEM)
 Right and left lobe determined by cantlie’s
line (portal fissure)
 Gallbladder fossa to IVC

28. •CLAUDE
COUINAUD
1922 - 2008

29. SEGMENTAL ANATOMY
(COUINAUD SYSTEM)
BASED ON HEPATIC VEINS
 CAUDATE LOBE
SEGMENT I
 LEFT LOBE
SEGMENTS II – IV
 RIGHT LOBE
SEGMENTS V-VIII

30. SEGMENTS OF LIVER

31. RISE AND DEMISE OF SEGMENT IX
 FOR SEVERAL YEARS COUINAUD AND HIS COLLEAGUES, AS WELL AS SEVERAL
OTHER INVESTIGATORS, REFERRED TO AN AREA OF THE DORSAL SECTOR OF THE
LIVER CLOSE TO THE IVC AS "SEGMENT IX."
BUT THE EXISTENCE OF THIS SEGMENT WAS SHORT-LIVED WHEN, IN 2002,
COUINAUD AND HIS ASSOCIATES PUBLISHED THE FOLLOWING
CONCLUSION:
BECAUSE NO SEPARATE VEINS, ARTERIES, OR DUCTS CAN BE DEFINED FOR THE
RIGHT PARACAVAL PORTION OF THE POSTERIOR LIVER AND BECAUSE PEDICLES
CROSS THE PROPOSED DIVISION BETWEEN THE RIGHT AND LEFT CAUDATE,
THE CONCEPT OF SEGMENT IX IS ABANDONED.

32. ΗEPATECTOMY
 Liver tissue has remarkable powers of
regeneration and major resection are well
tolerated.
 To preserve the viability of the liver
following surgery, resection follow parellel
to hepatic veins and leaving portal traid.
 Segmental or non segmentaal

33. DIVISION OF HEPATECTOMY
FIRST ORDER DIVISION
Based on LOBES (R OR L)
SECOND ORDER DIVISION
Based on BILE DUCT and HEPATIC ARTERY
THIRD ORDER DIVISION
Based on SEGMENTS (1 to 8)
FOUTH ORDER DIVISION (alternative to 2nd order division)
Based on PORTAL VEIN

38. 8
8
8
8

43. A GOOD KNOWLEDGE OF THE ANATOMY IS A
PREREQUISITE FOR MODERN SURGERY OF THE LIVER.
H.BISMUTH