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Hepatobiliary anatomy
The document provides an overview of hepatobiliary anatomy including the liver, gallbladder, bile ducts, pancreas, and spleen. It describes the location, structure, vasculature, innervation, and variations of each organ. Key points include that the liver is the largest organ located under the diaphragm, the gallbladder stores and concentrates bile, and the pancreas has both exocrine and endocrine functions including insulin and enzyme production. Anatomical variations are also discussed for each structure.
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Hepatobiliary anatomy
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- 2. The Liver • Largestorgan in the body • Weighs about 1.5kg • Located under diaphragm and protected by the rib cage. • Covered by Glisson’s capsule
- 3. Surgical Anatomy Morphological-Surfaces • Posterior •Anterio-superior • Inferior
- 4. Picture of surfacesof the liver
- 5. Anatomy Morphological-ligaments • Ligaments/Peritoneal Attachments •Falciform ligament • Anterior and posterior coronary ligaments • Right triangular ligament-coronary layers • Left triangular Ligament-falciform layers • Round ligament-umbilical vein • Fibrous ligamentum venosum- • Hepatoduodenal Ligament-portal triad
- 6. Picture of portaltriad
- 7. Surgical Anatomy Morphological-segments • AnatomicLobes: Right and left lobe based on Cantle's Line. • Segmental Anatomy based on vascular supply and ductal distribution (I-VIII) by Couniad • Sectoral Anatomy based on hepatic vein anatomy( Left lateral, left medial, right anterior and right posterior) by Bismuth.
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- 9. Surgical Anatomy Morphological-sectors • Caudate(I) Three parts ; 1. Spiegal lobe 2. Paracval Portion 3. Caudate Process • Segment II & III form lateral sector of left lobe
- 10. Surgical Anatomy Morphological-sectors • SegmentIV: has IVa cephalad and IVb caudally • Segment V-VIII V and VIII form right anterior sector VI &VII form right posterior sector
- 11. Picture of Surgicalresections
- 12. Vascular Supply Arterial andVenous • Dual supply 75 % portal venin and 25 % hepatic artery. • Venous and biliary drainage
- 13. Picture of vascularsupply
- 14. Vascular Supply Arterial andVenous • Hepatic proper artery is branch from celiac trunk (splenic and left gastric). • Its run to the left side in porta hepatis and divides into right and left in 67% of people. • Variations seen in 24% of population 1. Replaced RHA 11-21% from SMA 2. Replaced LHA 4-10% from left gastric artery 3. Replaced R & LHA 1-2% 4. Replaced CHA
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- 17. Vascular Supply Arterial andVenous • Portal Vein, formed behind neck of pancreas by SMV and SV. • 5-8cm long and +/- 1 cm in diameter. • Normal Pressure 3-5mmHg. • Runs in Portal triad deep to the duct, • Bifurcate into right(V-VIII) and left(II-IV) portal veins. • Variations: trifurcation/Aberrant from left PV.
- 19. Vascular Supply Hepatic Veinsand IVC • Three in numbers 1. Right hepatic Vein (RHV) drains; V-VIII. 2. Middle Hepatic Vein (MHV) drains IV, V and VIII. LHV and MHV form trunk in 95%. 3. LHV drains II and III. 4. Caudate drains directly to IVC 5. Small veins to IVC • Inferior Accessory right hepatic vein 15-20%
- 21. Ductal anatomy Classfications • IntrahepaticBile ducts 1. Canaliculi 2. Segmental bile ducts 3. Sectoral bile ducts a. Right posterior sectoral duct RPSD (VI&VII) b. Right anterior sectoral duct RASD (V&VIII) c. Left lateral sectoral duct LLSD (II & III) d. Left medial sectoral duct LMSD (Iva & Ivb) 3. LHD and RHD
- 23. Ductal anatomy Classfications • Extrahepaticbile ducts 1. CHD formed by left and right HDs 2. Cystic duct 3. CBD: CHD and cystic duct
- 24. Ductal anatomy Variations-30-40% • Bifurcation57% • Trifurcation 12%; Right anterior, right posterior and LHDs • RPSD drains into CHD in 16% or RASD into CHD in 4%. • RPSD into LHD in 5% or RASD into LHD in 1%. • Absence of CHD confluence in 3% • Absence of RHD in 2%.
- 25. Innervation of theLiver • Parasympathetic –vagus • Sympathetic from; 1. T7-10 2. Greater thoracic nerve 3. Caeliac ganglia 4. Splanchnic nerves Form anterior and posterior hepatic plexuses of nerves.
- 27. Lymphatic Drianage • Lymphis formed at perisinusoidal space of Dise and periportal cleft of Mall. • Caudal drainage via Calot’s triangle node, CBD nodes, Hepatic artery nodes, retropancreatic nodes and last at celiac nodes • Cephalad; cardiophrenic nodes
- 29. Surgical Anatomy Microscopic Anatomy •Functional unit is Lobule; central terminal hepatic venule surrounded by 4-6 portal triads • Blood flow from triad to terminal hepatic venule. • Bile is formed by hepatocytes and drain into canaliculi and then to bile ducts • Between terminal portal triad and central hepatic venule are 3 zones,
- 31. Surgical Anatomy Microscopic Anatomy •Zone I (Periportal): increase O2 and blood supply. • Zone II (intermediate): equivocal supply • Zone III( Perivenular): decrease o2 supply
- 32. Physiology of theliver • Metabolism. • Synthetic Function- Alb/Coagulations factors/complements, • Bilirubin metabolism • Bile formation- primary/secondary bile acids • Drug Metabolism • Storage
- 33. Assessment of Liverfunction • Laboratory: LFT/Clotting factors; abn include 1. Liver injury-raised AST/ALT 2. Abnormal Synthetic function-low Alb, raised INR and decreased Vit-k dependant factors. 3. Cholestasis-bilirubin and fractionation, ALP and GGT. • Scoring Systems; Child-Pugh score, OKUDA and MELD score.
- 34. Assessment of Liverfunction • Child-Pugh prognostic indicator • Class A; 5-6 10% MR • Class B; 7-9 30% MR • Class C; 10-15 75-80% MR Variables Points 1 2 3 Bilirubin <2 mg 2-3 >3 Albumin >3.5g/dl 2.8-3.5 <2.8 INR <1.7 1.7-2.2 >2.2 Ascites None Mild Severe Encephalopathy None Mild Severe
- 35. Assessment of Liverfunction • Model of End-stage Liver Disease Scoring (MELD) prognostic for organ donor • Uses Bilirubin/Creatinine/INR/sodium 1. Score <10; elective surgery 2. 10-15 cautious surgery 3. > 15 no elective surgery
- 36. Assessment of Liverfunction • OKUDA Staging Systems; staging and prognosis in HCC. • Stage I; no positives • Stage II; < 2 positives • Stage III; .3 positives Criteria Positive Negative Tumour Size >50% <50% Ascites Present Absent Albumin <3g/dl > 3g Bilirubin >3mg <3mg/dl
- 37. Assessment of Liverfunction • Functional Assessment; Clearance test/Tolerance Test. 1. Indocyanine Green Clearance (ICG) 15% or more of dye is retained mean impairment. 2. T-99 galactosyl-Human Serum albumin (GSA) 3. Monoethylglycine-xylidide lidocaine (MEGx) for liver cirrhosis.
- 38. Assessment of Liverfunction • Volumetric CT or U/S.
- 39. Gallbladder and BiliaryTree Surgical Anatomy • Pear-shaped organ located gallbaldder fossa • 7-10cm long • Parts; Fundus/Body/Infundibulum/Neck. • Histology: Columnar cells/mucus cells at the neck/infundibulum • Layers: Mucosa, Lamina propria, no Submucosa or muscularis mucosa, smooth muscle, circular, longitudinal and oblique
- 41. Gallbladder and BiliaryTree Surgical Anatomy • Blood supply : Cystic artery frpm RHA in 90% and LHA in 10%. Cystic drain into PV • Lymphatics drainage via Cystic nodes. • Innervation: sympathetic T7-9 and vagus nerves.
- 42. Extra-hepatic Biliary Ducts SurgicalAnatomy • CHD; 1-4cm long and 4mm in diameter. • Cystic duct; variable length, union parallel or spiral to CHD. • CBD: 7-11cm long, 5-10 mm in diameter and has three parts; 1. Supraduodenal- hepatoduodenal ligament 2. Retroduodenal; 1st part of D1. 3. Pancreatic Portionbehind HOP.
- 43. Extra-hepatic Biliary Tracts SurgicalAnatomy • CBD and PD join in three configurations; 1. 70% outside duodenal wall ? APBJ anomalies 2. 20% in the wall of duodenum. 3. 10% separate opening • CBD histology-columnar epithelium • Blood supply; proximal RHA & Cystic artery distally GDA and SMA forming networks from 3-9 O’clock
- 44. Extra-hepatic Biliary Tracts Anomalies •Gallbladder anomalies; 1. Abn position- Intra-hepatic 2. Rudmentary 3. Duplication 4. Small duct of Lushka-biloma 5. Accessory RHD 5%
- 45. Extra-hepatic Biliary Tracts Anomalies •Hepatic artery anomalies; 1. Two RHA; CHA and SMA in 5% 2. Replaced RHA from SMA 3. Abnormal Course; parallel to cystic duct
- 46. Extra-hepatic Biliary Tracts Anomalies •Cystic Artery anomalies 1. Normal anatomy from RHA in 90% 2. Both SMA and RHA (replaced /accessory) in 10%. 3. Two cystic arteries; RHA & CHA 4. Two cystic arteries; RHA & LHA 5. Abnormal Course; parallel/spiral 6. Two cystic arteries from RHA
- 48. Extra-hepatic Biliary Tracts Anomalies •Cystic Duct Anomalies 1. Abnormal union with CHD; high or low. 2. Adherent to CHD 3. Drainage to RHD 4. Abnormal Course; spiral anterior or posterior 5. Absence cystic duct.
- 50. Pancreas Surgical Anatomy • Pan=all,creas=flesh • Topographic; retroperitoneal in C-loop of duodenum. • Weighs;75-100grams • Length; 15-20cm
- 51. Pancreas Parts • Head; anteriorTV colon and IVC posteriorly. • Neck; PV and SMA/V. • Body; SA/V. • Tail; helium of the spleen.
- 52. Picture of thepancreas and parts
- 53. Pancreas Vascular anatomy • GDA;Anterior and Posterior superior PDA. • SMA; Inferior PDA • Splenic artery branches; a. Dorsal pancreatic artery b. Greater pancreatic artery c. Caudal pancreatic artery • Venous drainage via SMV/SV into PV.
- 56. Pancreas Lymphatic drainage • Head:via Subpyloric, portal, mesenteric, mesocolic and aortocaval nodes. • Body and Tail: Caeliac, aorto-caval, mesenteric and mesocolic group of nodes.
- 57. Pancreas Ductal Anatomy • Embyrological;ventral and dorsal buds fuse. • Ventral analge gives to Uncinate process and inferior part of HOP. • Dorsal analge gives to HOP, body and tail. • Duct from ventral analge remains as main PD and opens on to major ampulla of Vater • Duct from dorsal analge remain as santorini and opens on to minor papilla.
- 59. Pancreas Neuroanatomy • Autonomic Nervoussystem. a. Sympathetic (inhibitory); greater, lesser and least splanchnic nerves. b. Parasympathetic(excitatory); caeliac branch • Somatic fibres (afferent).
- 61. Pancreas Composition • Exocrine 85% •Extracellular matrix; 10% • Blood Vessels and ducts; 3-4% • Endocrine 1-2% • 20% of gland is required for normal function.
- 62. Pancreas Histology • Exocrine- acinar/ductalcells a. Acinar cells; enzymes b. Ductal water and electrolytes • Endocrine cells a. Alpha cells-glucagon b. Beta cells insulin c. Sigma cells-somatostatin etc.
- 63. Pancreas Embyrological Anomalies • Pancreasdivisum; failure of ductal fusion. Treated by minor papillotomy. • Ectopic/Accessory pancreas; resection/bypass. • Annular Pancreas; bypass or duodeno- jejenostomy. • Developmental Pancreatic Cysts; congenital/duplication/dermoid cysts.
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- 65. Spleen Surgical anatomy • Embyrogenesis;outgrowth from dorsal mesogastrium at 5th week gestation. • Topographic; postero-lateral in LUQ • Weighs; 150grams • Length; 7-11cm • Blood supply from Splenic artery an short gastric arteries. Venous drainage via SV.
- 67. Spleen Anomalies • Asplenia-autosomal recessive •Splenic hypolasia- autosomal dorminant • Polysplenia • Wandering spleen-ligament anomalies. • Splenic cysts • Accessory spleen x 7 sites: hilium/pedicle/tail of pancreas/splenocolic ligament/greater omentum/mesentery/left ovary.
- 68. Spleen Histology and physiology •Filtration of senescent RBCs. • Extra-medullary hemopoiesis • Host defense-opsinization.