Call Girl Bangalore Nandini 7001305949 Independent Escort Service Bangalore
Liver& biliary
1. Surgical Anatomy Of Liver
And Biliary Tree
Alaa Fayez Hamza
MD FRCS FAAP(Hon.)
2. Liver Embryology
• The transverse septum (septum
transversum) arises at an embryonic
junctional site. The junctional region
externally is where the ectoderm of the
amnion meets the endoderm of the yolk sac.
The junctional region internally is where the
foregut meets the midgut. The mesenchymal
structure of the transverse septum
provides a support within which both blood
vessels and the liver begin to form. This
structure grows rapidly.
3. • The transverse septum then differentiates
to form the hepatic diverticulum and the
hepatic primordium, these two structures
together will go on to form different
components of the mature liver and gall
bladder.
• The rapidly developing liver forms a visible
surface bulge on the embryo directly under
the heart bulge.
4. Embryology
• At 4 wks of gestation, the biliary duct
system originate from hepatic
diverticulum of the foregut &
differentiate into
–Cranial component : Prox E.H.B.D &
most of the I.H.B.D
–Caudal component : G.B, cystic duct
C.B.D
5. Parenchyma
• By Day 24, the hepatic diverticulum is
growing into the transverse septum that,
at this stage, contains the vitelline
and umbilical veins.
• As the hepatic bud appears, the
hepatic and cardiac mesenchyme
become segregated.
6. • The second and third inductions occur
when the hepatic mesenchyme
stimulates the cells of the endodermal
cords to differentiate into hepatocytes,
and simultaneously the endodermal
hepatocytes stimulate the mesenchyme
to form the endothelial cells of the liver
sinusoids.
7. • Growth of the liver makes it bulge out of
the transverse septum so that the liver
becomes a truly abdominal organ lying
in the ventral mesentery. The bare area
of the liver and diaphragm remains as
an indication of the origin of the liver
from the transverse septum. The
asymmetry of the organ increases.
8. • The intrahepatic bile ducts were long
assumed to develop by extension of the
extrahepatic ducts. It is now believed that the
ducts differentiate from hepatic cells and join
the extrahepatic duct system secondarily. The
ducts appear first at the hilum and spread
peripherally. Bile may appear as early as the
third month and is often in the intestine by the
fifth month. By the ninth week, the liver
embraces as much as 10% of body volume.
Its relative size decreases to 5% by term.
28. Types Of B.A.
• Type I (10%) correctable
– Patent cranial diverticulum
– Obliterated caudal diverticulum
• Type II : Non correctable
– Obliterated cranial diverticulum
– Patent caudal diverticulum
• Type III Non correctable
– Both cranial and caudal diverticulae are
obliterated
29.
30. Etiology Of B.A.
• Congenital : Failure of E.H.B.D to
develop patency
• Acquired : Sclerotic process
starts in E.H.B.D
–Reovirus type 3
–Fetal vascular accident
–Pancreatico - biliary malunion
31. Clinical Picture Of B.A.
• At birth Normal
• Progressive jaundice
• Stools : Acholic
• Urine : Dark with bile
• Failure to thrive
• Liver & spleen enlarged
34. Treatment Of B.A.
• Correctable:
–Roux en Y intest. anast. to prox B.D.
• Non correctable:
–Hepatic Porto - enterostomy (Kasai’s
operation)
• Liver transplantation
35. Prognostic factors
• Surgery below 45 days .
• Neonatal forms .
• Liver condition before surgery .
• Post-operative cholangitis .
• 25% will have normal life .
44. Choledochal Cyst
• Congenital dilatation
of the CBD .
• 1: 13000 hospital
admission or 1:2
million live birth.
• 2/3 from japan .
• 2/3 Are females .
46. Etiology Of Choledochal Cyst
• Congenital abnormal insertion of the
pancreatic duct into the common bile
duct resulting in reflux of trypsin and
other pancreatic enzymes into the
common bile duct (CBD).
• Stenosis of the distal duct at the level of
duodenum or failure of canalization of
the distal part Of the CBD .
48. Diagnosis
• Ante-natal Diagnosis.
• Triad of Pain, jaundice and palpable
mass is only in 1/3 of cases .
• Infantile form with jaundice ,older by
recurrent abdominal pains and colics.
• Rarely by stones in adults or intermittent
jaundice .
• Hyperbilirubinemia of the direct type .
