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Liver, biliary system, pancreas and spleen

  1. 1. Anatomy of the liver, pancreas and portal system Surgical case discussion Antonio Manzelli MD MSc PhD Upper GI and HPB Consultant
  2. 2. Embryology of the digestive glands  Liver, gallbladder and pancreas develop from endodermal diverticulae that bud from the duodenum in the 4th to 6th weeks  Liver sprouts first and expands in ventral mesentery  Cystic diverticulum also in ventral mesentery  Pancreas arises from a dorsal and ventral bud.  Ventral pancreatic bud migrates posteriorly to fuse with the dorsal bud.  Main duct of ventral bud becomes the main pancreatic duct.
  3. 3. Liver  Largest gland in the body (1.5 Kg)  Lies in right upper quadrant.  Underlies the thoracic cage.  Conforms to right dome of diaphragm  Connected to the diaphragm by the falciform and coronary ligaments
  4. 4. Liver Functions  Exocrine (digestive) functions: 1. Synthesizes and secrets bile salts 2. Secrets into the bile a bicarbonate-rich solution  Endocrine functions: 1. Secrets insulin-like growth factor I (IGF-I) 2. Contributes to the activation of vitamin D 3. Metabolizes hormones 4. Secretes cytokines involved in immune defenses
  5. 5. Liver Functions  Clotting functions: -Produces many of the plasma clotting factors  Plasma protein -Synthesizes and secretes plasma albumin
  6. 6. Liver Functions Organic metabolism  Converts plasma glucose into glycogen  Converts plasma amino acids to fatty acids  Synthesizes triacylglycerols and secrets them as lipoproteins  Produces glucose from glycogen (glycogenolysis)  Converts fatty acids to keones during fasting  Produces urea
  7. 7. Liver Functions Cholesterol metabolism 1. Synthesizes cholesterol and releases it into the blood 2. Secretes plasma cholesterol into the bile 3. Converts plasma cholesterol into bile salts  Excretory function: 1. Secrets bilirubin and other bile pigments into the bile 2. Destroys old erythrocytes
  8. 8. At laparotomy the liver is divided by the umbilical fissure and falciform ligament into a larger ‘right’ lobe and a smaller ‘left’ lobe
  9. 9. Liver - relations  Surfaces separated by inferior border of liver and coronary ligament posteriorly  Bare area between the reflections of coronary ligaments in direct contact with diaphragm and not covered by peritoneum  Diaphragmatic surface  Smooth and convex  Separated from diaphragm by subphrenic recess
  10. 10. Liver – relations (2)  Visceral (posteroinferior) surface  Lies in contact with oesophagus, stomach and lesser omentum on the left  Duodenum in midline  Right kidney, adrenal and hepatic flexure of the colon on the right  H-shaped arrangement of structures  Crossbar formed by porta hepatis (portal vein, hepatic artery, hepatic ducts, nerve plexus and lymph vessels  Left: ligamentum teres (remnant of left umbilical v.) and ligamentum venosum (remnant of ductus venosum)
  11. 11. Liver - old lobar anatomy  Right and left lobes divided by plane through the IVC and gallbladder fossa  Caudate lobe  Lies posteriorly between lig. venosum and IVC fossa  Porta hepatis inferiorly  Tail-like caudate process connects to right lobe and separates portal vein from IVC  Quadrate lobe  Anteroinferior between GB bed and lig. teres  Porta hepatis superiorly  Caudate and quadrate lobe considered to be part of left lobe  Reidel’s lobe (not a true lobe)  Lower border of the right lobe lateral to the GB may project downwards for a considerable distance as a broad or bulbous process  Occurs in 5-10% of females and rarely in males
  12. 12. Liver - segmental anatomy (Couinaud system)  Knowledge of segments important in the assessment of location and extent of hepatic pathology as surgery is performed in segmental fashion and distribution of disease determines whether lesions are resectable.  The hepatic veins divide the liver into 4 divisions  A horizontal plane through the portal vein divides the 4 divisions into superior and inferior segments  Segments numbered in clockwise direction starting at caudate lobe (segment 1)
  13. 13. R ant / R Post Left medial / Left lateral
  14. 14. Liver - vascular anatomy  Double blood supply from hepatic artery (30%) and portal vein (70%)  Arterial supply by common hepatic artery branch of coeliac artery.  Gives off right gastric and gastroduodenal arteries before reaching the liver in the free edge of the lesser omentum.  Divides into left and right hepatic arteries before entering the liver at the porta.  Variants of right hepatic artery below  Portal vein formed posterior to neck of pancreas by union of SMV and splenic vein
  15. 15. In approximately 25% of individuals, the right hepatic artery arises partially or completely from the superior mesenteric artery (A, C, E), and in a similar proportion of patients, the left hepatic artery may be partially or completely replaced by a branch arising from the left gastric artery and coursing through the gastrohepatic omentum to enter the liver at the base of the umbilical fissure (D, F). Rarely, the right or left hepatic arteries originate independently from the celiac trunk or branch after a very short common hepatic artery origin from the celiac (B, C). The gastroduodenal artery may originate from the right hepatic artery (B, C).
  16. 16. The portal vein is formed behind the neck of the pancreas by confluence of the superior mesenteric and splenic veins
  17. 17. Biliary and vascular anatomy of the left liver. Note the position of segment III duct above the corresponding vein and its relationship to the recessus of Rex. Biliary and vascular anatomy of the right liver. Note the horizontal course of the posterior sectoral duct and the vertical course of the anterior sectoral duct.
  18. 18. Liver - vascular anatomy (2)  Right and left lobes functionally independent and defined by arterial distribution  Each supplied by left and right portal v., left or right hepatic arteries and drained by left or right hepatic duct (portal triad)  Quadrate lobe supplied by left hepatic artery  Caudate lobe supplied by both
  19. 19. Liver - hepatic veins  Hepatic veins are intersegmental and do not run with the structures of the portal triad  Right, middle and left hepatic veins drain corresponding thirds of the liver  Middle hepatic vein lies in the principal plane between right and left lobes  Left hepatic vein lies between medial and lateral segments of the left lobe  Right hepatic vein lies between anterior and posterior segments of the right lobe  All drain into the IVC without an extrahepatic course  Inferior group of small veins from right lobe also drains into IVC
  20. 20. Liver – Lymph drainage and innervation  Lymph drainage  Superficial and most deep lymph vessels converge at the porta and end in the hepatic lymph nodes (eg. Cystic LN near GB neck or LN of omental foramen)  Hepatic LN’s drain into coeliac LN’s around the coeliac trunk, then thoracic duct  Some deep lymph vessels follow hepatic veins to IVC foramen in diaphragm and end in middle phrenic LN’s  Innervation  Sympathetic and parasympathetic supply from the hepatic plexus, a derivative of coeliac plexus (formed from fibres of left and right vagus and right phrenic nerves)
  21. 21. Terminology of Liver Anatomy and Resections: The Brisbane 2000 Terminology In 1998 at its meeting in Berne, Switzerland, the Scientific Committee of the International Hepato-Pancreato-Biliary Association (IHPBA) established a Terminology Committee to deal with the confusion in terminology of hepatic anatomy and liver Resections. The terminology was published in the official journal of the IHPBA in 2000. The terminology shown below is based on the hepatic artery and bile duct. A terminology based on the division of the portal vein was added as an addendum.
  22. 22. Primary and secondary, benign and malignant liver Tumors / Liver cysts / Liver abcess and pyogenic disease / Hydatic disease Liver resections Laparoscopic Liver Resection Cryosurgery Radiofrequency Ablation of Liver Tumors Selective Hepatic Intra-arterial Chemotherapy Unroofing and Resection for Benign Non-Parasitic Liver Cysts Pericystectomy for Infectious Liver Cyst Orthotopic Liver Transplantation Partial Cadaveric Liver Transplantation: Donor Procedure and Implantation, Right Living Donor Hemihepatectomy Living Donor Liver Transplantation: Left Hemiliver Donor Procedure and Implantation
  23. 23. Portal Hypertension Distal Splenorenal Shunt Low-Diameter Mesocaval Shunt Interposition Portacaval Shunt Portacaval Shunts: Side-To-Side and End-To-Side Gastroesophageal Devascularization: Sugiura Type Procedures
  24. 24. Gallbladder and cystic duct  Pear shaped sac lies to the right of the quadrate lobe in GB fossa on the visceral surface of liver  Concentrates and stores bile secreted by the liver  Cholecystokinin produced by intestinal mucosa during digestion, passes to GB and causes it to contract and release bile  Fundus, body and neck  Mucosal membrane arranged into spiral folds (valves of Heister) at GB neck and cystic duct
  25. 25. Gallbladder - relations  Anterosuperiorly  GB fossa of liver  Fundus projects from inferior border of liver, located at tip of 9th costal cartilage in MCL where lateral edge of rectus abdominis meets costal margin  Posteroinferiorly  Neck: lesser omentum. Omental (epiploic) foramen lies immediately to the left.  Body: D1  Fundus: transverse colon
  26. 26. Gallbladder – blood supply  Arterial supply  cystic artery  Venous drainage  directly into liver or via a cystic vein
  27. 27. Biliary Tree  Bile is secreted by hepatocytes into bile canuliculi which drain into interlobular bile ducts. Progressively larger ducts formed.  Left and right hepatic ducts emerge from porta and merge to form common hepatic duct (4cm)  Joined on the right by the cystic duct from the GB to form the common bile duct (8- 10cm long, 5-6mm diameter)  Runs in free edge of lesser omentum, passes posterior to D1 and head of pancreas  Comes in contact with pancreatic duct on the left side of D2  Usually unite in the duodenal wall to form hepatopancreatic ampulla (of Vater)  Ampulla opens into descending part of duodenum at summit of major duodenal papilla, 8-10cam from pylorus
  28. 28. Biliary Duct – blood supply  Arterial supply  Proximally: cystic artery  Middle: right hepatic artery  Distally: posterior superior pancreaticduodenal a.  Venous drainage  Proximally: drainage directly into liver  Distally: posterior superior pancreaticduodenal v.  Lymph drainage  Cystic LN, node of omental foramen, hepatic LN’s
  29. 29. Biliary Tree - variants  Accessory hepatic ducts may arise in the liver and join the right hepatic duct, common hepatic duct, common bile duct, cystic duct or GB  Right and left hepatic ducts may fail to unite giving a double duct  Cystic duct  Absent  Joins common hepatic duct on the left rather than the right  Joins the right hepatic duct or an accessory duct  Joins the common hepatic duct anywhere between the porta and the duodenum (low and high union)
  30. 30. Variants in union of CBD and pancreatic duct
  31. 31. Biliary Tract and Gallbladder Laparoscopic Cholecystectomy, Open Cholecystectomy and Cholecystostomy Resection of Gallbladder Cancer, Including Surgical Staging Exploration of the Common Bile Duct: The Laparoscopic Approach Bile Duct Resection Resection of the Mid Common Bile Duct Intrahepatic Biliodigestive Anastomosis Without Indwelling Stent The Ligamentum Teres Approach and Other Approaches to the Intrahepatic Ducts for Palliative Bypass Choledochojejunostomy and Cholecystojejunostomy Choledochoduodenostomy Reconstruction of Bile Duct Injuries Operative Treatment of Choledochal Cysts
  32. 32. Pancreas  Retroperitoneal organ lies transversely and slightly obliquely at L1-L2 level  Transverse mesocolon attached to anterior margin  Exocrine (pancreatic enzymes) and endocrine functions (glucagon and insulin)  Head, neck, body and tail
  33. 33. Pancreas - Relations  Head  Lies in curvature of duodenum  Anterior to IVC, aorta, right renal vessels and left renal vein  Uncinate process projects posteriorly and to the left and lies posterior to superior mesenteric vessels  CBD passes posteriorly in a groove or embedded within  Neck  Anterior to the union of splenic vein and SMV to form the portal vein  Body  Curves over vertebrae and great vessels  Anterior to the aorta and lies between the coeliac trunk and the SMA  Splenic vein passes posterior  Tail  lies in the splenorenal ligament  Usually contacts the hilum of the spleen
  34. 34. A, The head of the pancreas is globular with an extension, the uncinate process, which curves behind the superior mesenteric vessels. The uncinate process may finish even before it embraces the superior mesenteric vein (a), or it may pass completely behind between the aorta and the left of the patient's superior mesenteric artery (b, c). All variations are commonly seen. Posteriorly, the head of the pancreas lies in juxtaposition to the IVC at the level of the entry of the left and right renal veins. The head of the pancreas forms a narrow neck in front of the superior mesenteric and splenic vein confluence. The neck joins to the body of the gland, which forms a narrow tail. B, The common bile duct (CBD) passes through the pancreas either directly in the substance of the gland or initially with a posterior groove. C, The duct of Wirsung courses from left to right within the pancreas, curves downward approaching the CBD, and runs parallel with but separated from it by the transampullary septum to enter the duodenum 7 to 10 cm distal to the pylorus at the papilla of Vater after traversing the sphincter of Oddi. An accessory duct (duct of Santorini) runs more proximally in the head of the pancreas and usually terminates in the duodenum at an accessory papilla. Multiple variations of the ductal system occur depending on the extent of development of the accessory duct of Santorini, such that rarely the accessory duct can enter the duodenum inferior to the main duct. It can be in communication with the main duct directly (i), or it can occur in duplicate version known as pancreas divisum (ii). The duct of Santorini drains the body and tail of the organ, and the duct of Wirsung drains the head and the uncinate process.
  35. 35. Pancreatic Duct Schematic representation of the sphincter of Oddi: notch (a); biliary sphincter (b); transampullary septum (c); pancreatic sphincter (d); membranous septum of Boyden (e); common sphincter (f); smooth muscle of duodenal wall (g).
  36. 36. NERVE SUPPLY TO THE LIVER AND PANCREAS Note the distribution of sympathetic and parasympathetic nerves to the liver and pancreas from the celiac ganglion mainly in association with major arteries.
  37. 37. Stylized representation of the major nerves serving the pancreas.
  38. 38. Nerve supply to the extrahepatic bile tree.
  39. 39. Pancreas - Embryology  Arises from the junction of the primitive foregut and midgut as a larger dorsal division and a smaller ventral bud  Ventral bud swings posteriorly to unite with the inferior aspect of the dorsal bud trapping the superior mesenteric between divisions  Ventral bud forms the uncinate process  Duct of the ventral bud forms the proximal end of the main pancreatic duct; the distal end of the dorsal pancreatic duct forms the remainder.
  40. 40. Pancreas – blood supply  Arterial supply  Head: superior pancreaticoduodenal a. (from gastroduodenal artery) and inferior pancreaticoduodenal a. (from SMA)  Body and tail: branches from splenic artery  Venous drainage  Mostly splenic v., but also portal v. and SMV
  41. 41. Pancreatic operation – Primary and secondary, benign and malignant pancreatic tumors / cystic lesions / pancreatic psedeudocyst / acute and chronic pancreatitis Drainage of Pancreatic Pseudocysts Denervation: Pain Management Enteric Ductal Drainage for Chronic Pancreatitis Resection for Neoplasms of the Pancreas Enteric Drainage of Pancreatic Fistulas with Onlay Roux-en-Y Sphincteroplasty for Pancreas Divisum Sphincterotomy/Sphincteroplasty for Papillary Dysfunction: Stenosing Papillitis Pancreatic Enucleation Transduodenal Resection of Periampullary Villous Neoplasms Pancreas Transplantation Chronic Pancreatitis Exploration of the Gastrinoma Triangle Laparoscopic Staging of Periampullary Distal Pancreatectomy

Editor's Notes

  • Left umbilical v. carries blood from placenta to foetus. Ductus venosum shunts blood form the left umbilical vein to the IVC in the foetus bypassing the liver.
  • Even older anatomy Falciform ligament anteriorly and lig. teres and venosum on visceral surface Caudate and quadrate lobe considered to be part of right lobe
  • Hepatic a. carries oxygenated blood and conducted to central v of each liver lobule Portal v carries venous blood containing products of digestion absorbed from the GI tract.
  • Areas drained by hepatic ducts are the same as those supplied by the accompanying portal v. and hepatic a. Choledochal sphincter surrounds the bile duct as it penetrates the duodenal wall Hepatopancreatic sphincter (sphincter of Oddi) at distal end of hepatopancreatic ampulla controls release of both bile and pancreatic fluid
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