This document discusses the surgical anatomy of the liver and biliary tree. It begins with a description of liver embryology, including how the hepatic diverticulum and primordium form from the transverse septum and later differentiate into the mature liver and gallbladder. It then discusses the development of the biliary duct system and liver parenchyma. Key surgical landmarks, vasculature, variations, anomalies, and pathological conditions of the biliary tract are outlined, including biliary atresia and choledochal cysts. The classifications, diagnoses, and surgical treatments of these conditions are summarized.

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.

9. Surgical Landmarks

10. Lines

11. Segments

12. Couinaud

13. Ant.& Post. Segments

14. Artery

15. Portal Vein

16. Hepatic veins

17. Biliary

18. Anomalies Of Biliary Tract

19. Duplication Of Gall Bladder

20. Anomalies Of The Cystic
Duct

25. Gall Bladder

26. Biliary Atresia
“B.A”

27. • Incidence
–1 : 15,000 live birth
• Sex
–F > M

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

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

32. Diagnosis Of B.A.
• HIDA scan iminodiacetic acid
• U/S.
• Operative cholangiography

33. HIDA Scan

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 .

36. Atretic Gall Bladder

37. Cirrhotic Liver

38. Obliterated & Fibrotic
Biliary system

40. Kasai Porto-Enterostomy

41. Follow Up
• I.V. Antibiotics for 3-6 months .
• Liver assessment .
• Colour of stools.
• HIDA at 6 months .
• Treatment of cholangitis ,

42. Post-Operative HIDA

43. Post Operative
Complications Of B.A.
• Cholangitis
• Portal hypertension
• Liver failure

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 .

45. Normal Ampulla

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 .

47. Classification

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 .

49. Radiology
• Abdominal US .
• CT Scan .
• MRCP .
• HIDA ( rarely ) .
• ERCP ( Dangerous for pancreatitis).

50. US

51. CT Scan

52. MRCP

53. Surgical Treatment
• Intra-operative Cholangiography.
• Cyst Excision ( malignant
transformation ) .
• Roux-en-Y hepatico -jejunostomy .
• The limb should be about 50 cm to
prevent ascending cholangitis .
• Hepatico-duodenosotomy.
• Liver biopsy in delayed cases .

54. Intra-Oprative
Cholangiography

56. Cyst

58. Cyst Excision

60. Hepatico-Duodenostomy

61. Post-Operative
• Intestinal Aseptic for long time .
• US & HIDA follow up .
• Liver assessment for delayed cases .