this is power point discussion on anatomy of liver, gall bladder and bile ducts

1. Surgical Anatomy of Liver and
Biliary Tree
Kassaw D. (Assistant professor of Surgery,
HPB Fellow)
Meskerem, 2015 E.C
SPHMMC

2. Outline
• Introduction
• Surface anatomy
• Segmental /functional anatomy
• Intrahepatic biliary tract
• Vascular system
• Lymphatics and innervation
• References
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3. Introduction
• Liver is the largest internal organ, about 2% of adult body
weight.
• Dual blood supply and intimate relationship with the bile
ducts.
• Frequent occurrence of anatomic variants
• Discordance between its external morphology and internal
segmentation
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4. Surface Anatomy
• Most of the liver bulk lies to the right of the midline,
• Extends as a wedge to the left of the midline
• Up to the 4th ICS on the right and to the 5th ICS on the left.
• Covered by Glisson’s capsule, extension of visceral
peritoneum.
• It covers the entire organ except the bare area (contact site
with IVC, right hemidiaphragm and GB fossa with the liver
hilum (porta hepatis)).
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5. Surface anatomy …
• The shape of the liver is molded by the adjacent organs.
 Surfaces
• Diaphragmatic surface
– Anterosuperior surface
– Posterior surface
• Inferior or visceral surface
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6. Surface anatomy …
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7. Surface anatomy …
• Peritoneal reflections and ligaments
– Coronary ligament
– Triangular ligament
– Falciform ligament
– Ligamentum teres (round ligament)
– Ligamentum venosum
– Hepatoduodenal and hepatogastric ligaments
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8. Surface anatomy …
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9. Surface anatomy …
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10. Surface anatomy ….
 Plate /sheath system of the liver
• Fibrous condensations of Glisson’s capsule
• Four fibrous plates on the surface of the liver
– hilar, cystic, umbilical and arantian
 Incising between the base of Sg4 and the hilar plate -
‘lowering the hilar plate’- left hepatic duct (extrahepatic)
 Cholecystectomy
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11. Surface anatomy ….
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Plate system …

12. Surface anatomy …
• Clinical importance
 Liver mobilization
 Round ligament – left portal pedicle(Sg 3 bypass)
 Ligamentum venosum - left hepatic vein
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13. Incision and exposure
• Different incisions,
– Inverted -T (Mercedes) incision,
– Bilateral subcostal (chevron) incision,
– Right/left subcostal (Kocher/Kehr) incisions
– Makuuchi incision (J incision)
– Inverted L (Rio Branco incision)
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14. Segmental/Functional Anatomy
• Composed of segments, sections/sectors and hemiliver/lobe
supplied by independent a portal triad
• Traditionally four anatomical lobes: right, left, quadrate and
caudate
• Couinaud –based on portal vein bifurcation and origin of
hepatic veins ( eight segments)
• The International Hepato-Pancreato- Biliary Association
(IHPBA)- based on hepatic artery and bile duct
ramifications
• Right liver/right hemiliver and Left liver/left hemiliver
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15. Segmental anatomy…
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16. Segments by CT scan
N.B: At levels of HVs, PV
bifurcation and below hilus
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17. Resectional terminology
• First order division - lobes
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18. Resectional terminology …
• Second order division – intersectional planes
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19. Resectional terminology …
• Alternative nomenclature for second order division
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20. Resectional terminology …
• Third order division – intersegmental planes
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21. Caudate lobe
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22. Intrahepatic Duct system
• 50% have the normal biliary anatomy
• Follow the hepatic artery and portal vein
• Right and the left hepatic ducts drain the respective hemilivers
 Caudate lobe
• 78% right and left hepatic ducts
• 15% only left hepatic ductal system
• 7% only right hepatic system
• Right hepatic duct is short and joins the left hepatic at
confluence lying in front of the right portal vein
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23. Intrahepatic Duct system …
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24. Intrahepatic Duct system ….
 Right hepatic duct- right posterior and anterior sectional bile
ducts
• Two major anomalies-insertion to the left bile duct and lower
to the biliary tree
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25. Intrahepatic Duct system ….
• Hjortsjo’s crook
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26. Intrahepatic Duct system ….
 Left hepatic duct-
the left medial and
lateral sectional duct
• Longer extrahepatic
course than the right
bile duct
• Normal variant
present in only 30%
of individuals
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27. • Ducts of Luschka
• 20% to 50% of cases
• Joins either the common hepatic duct or the right hepatic duct
• Does not drain any specific liver territory, never communicates
with the gallbladder
• Injury may occur during cholecystectomy
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28. Variations
Variations in hepatic duct confluence
Variations in intrahepatic
ducts
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29. Variations …
• Ectopic drainage of
intrahepatic ducts in to GB
and CD
Variations in GB CD anatomy
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30. Vascular supply
• Hepatic artery
• 20-25% of blood supply
• 30-50% of the liver ’s oxygen requirement
• Exclusive blood supply to the intrahepatic bile ducts through
the peribiliary plexus
• 2–3 cm along the left side of the common bile duct
• Right hepatic artery immediately passing behind the common
hepatic duct
• Four sectional arteries arise from the right and left arteries 1–2
cm from the liver
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31. Vascular supply …
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32. Variations
• In approximately 25% of individuals, the right hepatic artery
arises from the superior mesenteric artery
• In 25% of individuals, left hepatic artery may arise from left
gastric artery
• Rarely, the right or left hepatic arteries originate independently
from the celiac trunk
• Gastroduodenal artery - from the right hepatic artery
• Hepatic artery trifurcation
• Aberrant vs Replaced vs Accessory
• An artery on right side supply always right side but arteries
found on the left side may supply either side of the liver
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33. Vascular supply …
Variations in hepatic arteries
Variations in cystic artery
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34. Vascular supply …
 Clinical importance
• Gastrectomy
• Pancreatico-duodenectomy
• Donor hepatectomy
• Right trisectionectomy for hilar
cholangiocarcinoma(advantage)
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35. Vascular supply …
• Occlusion of hepatic artery
– Inferior phrenic arteries
– Gastroduodenal artery
– Intrahepatic trans lobar and trans segmental anastomosis
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36. Vascular supply …
• Portal vein
• Venous outflow from the entire prehepatic splanchnic vascular bed
• 75%-80% of the total blood flow
• 90 mL/min per 100 g of liver weight
• Originates with the confluence of the superior mesenteric and
splenic veins behind the pancreas
• The right portal vein correspond to those of the hepatic artery and
bile duct unlike the left
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37. Portal vein …
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38. Portal vein …
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39. Portal vein …
 Ligation or occlusion
• Intersegmental communication
• Reduction in portal blood flow increases hepatic artery blood
flow
• Atrophy of the liver
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40. Vascular supply …
• Hepatic vein
• The systemic drainage tract of the entire splanchnic circulation
• Three large hepatic veins
• Hepatic veins lie in the planes between the lobes and segments
• Have a thin wall with no capsular covering
• Land marks to guide anatomical resection
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41. Vascular supply …
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42. Vascular supply …
• Right inferior hepatic vein( accessory)
• The most common variation-10%
• Resection of Sg 7 and 8 without compromising Sg 5 & 6
• Provide adequate drainage if tumor involves the right hepatic
vein
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43. Lymphatics
• 25% to 50% of lymph flow through the thoracic duct
• Superficial
– Xiphosternal , lateroaortic and pericaval, LNs of the hepatic
pedicle
• Deep
– Drains to hepatoduodenal nodes at the hilum and along the
hepatic artery and portal vein
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44. Lymphatics…
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45. Innervation
• From branches of the celiac ganglion
 Parasympathetic - vagus nerve
 Sympathetic- greater thoracic splanchnic nerve( T7- T10)
• Right phrenic nerve – referred pain
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46. References
• Blumgart's surgery of the liver, biliary tract and pancreas, 5th
edition
• A Companion to Specialist Surgical Practice, hepatobiliary and
pancreatic surgery, 6th edition
• Fischer ’s mastery of surgery, 6th edition
• Mastery techniques in surgery, hepatobiliary and pancreatic
surgery
• John E. Skandalakis, Panajiotis N. Skandalakis: Surgical
Anatomy and Technique A Pocket Manual Third Edition
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47. THANK YOU!
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