The liver has significant anatomic variability. It develops from the foregut and is divided into lobes based on vascular and biliary anatomy. The caudate lobe is located posteriorly between the IVC and other lobes. It has complex vascular and biliary drainage patterns. The liver is commonly divided into segments based on Couinaud's or Brisbane's classifications to describe resection types. The caudate lobe specifically can be further divided into the Spiegel lobe, caudate process, and paracaval portion.
This document summarizes the surgical anatomy of the liver. It describes the topographic anatomy including the right, left, quadrate and caudate lobes. It then discusses Couinaud's segmental anatomy system which divides the liver into eight segments based on hepatic and portal venous branches. Finally, it provides details on the portal and hepatic veins, including their diameters, lengths, blood flow patterns and variations that are important for liver surgery.
The document summarizes Couinaud's classification of liver segmental anatomy. It divides the liver into eight functionally independent segments, each with its own vascular inflow and outflow and biliary drainage. The right hepatic vein divides the right lobe into anterior and posterior segments. The middle hepatic vein divides the liver into right and left lobes. The left hepatic vein divides the left lobe into medial and lateral segments. The portal vein divides the liver into upper and lower segments.
The document provides an overview of the segmental anatomy of the liver. It discusses:
- The historical understanding of liver anatomy dating back to ancient times.
- The location, lobes, surfaces, ligaments, and supports of the liver.
- Couinaud's functional division of the liver into eight segments based on vascular distribution.
- The three major hepatic veins and associated fissures that divide the liver into sectors and segments.
- Advances in liver surgery that have improved safety and allowed for more extensive resections.
1) The liver document provides an overview of the anatomy of the liver, its surfaces, ligaments, segments, vasculature including the hepatic veins, arteries and portal vein.
2) It describes the variations that can occur in the extrahepatic vasculature and the implications for surgery.
3) Surgical procedures like cholecystectomy and hepatectomy are discussed in the context of the relevant anatomy and how variations can impact the surgery.
This document defines and describes different types of internal hernias. It begins by defining an internal hernia as the protrusion of viscera through a normal or abnormal opening within the peritoneal cavity. It then lists common types of internal hernias such as paraduodenal, foramen of Winslow, and transmesenteric hernias. The document provides details on symptoms, diagnosis, and treatment for several specific types of internal hernias such as paraduodenal and transmesenteric hernias. It concludes by noting that high clinical suspicion and prompt surgical management are important for treating internal hernias.
The document discusses the anatomy and segmentation of the liver. It can be divided into three main lobes - right, left, and caudate. The right lobe can be further divided into anterior and posterior segments by the right intersegmental fissure. Similarly, the left lobe is divided into medial and lateral segments by the left intersegmental fissure. Couinaud classification divides the liver into 8 functionally independent segments based on vascular inflow, outflow and biliary drainage within each segment. Cross-sectional imaging can help identify the different liver segments by extrapolating lines along structures such as the falciform ligament, hepatic veins and portal veins.
Gall bladder & biliary tract anomalies and variantsSanal Kumar
This document describes the normal anatomy of the gallbladder and biliary tract, as well as common anatomical variations and anomalies. It discusses the normal divisions and structures of the gallbladder and cystic duct. It then covers several anomalies including agenesis of the gallbladder, gallbladder duplication, wandering gallbladder, gallbladder torsion, and variations in gallbladder shape. The document also discusses ectopic locations of the gallbladder and variations in cystic duct insertion and bile duct anatomy.
This document summarizes the surgical anatomy of the liver. It describes the topographic anatomy including the right, left, quadrate and caudate lobes. It then discusses Couinaud's segmental anatomy system which divides the liver into eight segments based on hepatic and portal venous branches. Finally, it provides details on the portal and hepatic veins, including their diameters, lengths, blood flow patterns and variations that are important for liver surgery.
The document summarizes Couinaud's classification of liver segmental anatomy. It divides the liver into eight functionally independent segments, each with its own vascular inflow and outflow and biliary drainage. The right hepatic vein divides the right lobe into anterior and posterior segments. The middle hepatic vein divides the liver into right and left lobes. The left hepatic vein divides the left lobe into medial and lateral segments. The portal vein divides the liver into upper and lower segments.
The document provides an overview of the segmental anatomy of the liver. It discusses:
- The historical understanding of liver anatomy dating back to ancient times.
- The location, lobes, surfaces, ligaments, and supports of the liver.
- Couinaud's functional division of the liver into eight segments based on vascular distribution.
- The three major hepatic veins and associated fissures that divide the liver into sectors and segments.
- Advances in liver surgery that have improved safety and allowed for more extensive resections.
1) The liver document provides an overview of the anatomy of the liver, its surfaces, ligaments, segments, vasculature including the hepatic veins, arteries and portal vein.
2) It describes the variations that can occur in the extrahepatic vasculature and the implications for surgery.
3) Surgical procedures like cholecystectomy and hepatectomy are discussed in the context of the relevant anatomy and how variations can impact the surgery.
This document defines and describes different types of internal hernias. It begins by defining an internal hernia as the protrusion of viscera through a normal or abnormal opening within the peritoneal cavity. It then lists common types of internal hernias such as paraduodenal, foramen of Winslow, and transmesenteric hernias. The document provides details on symptoms, diagnosis, and treatment for several specific types of internal hernias such as paraduodenal and transmesenteric hernias. It concludes by noting that high clinical suspicion and prompt surgical management are important for treating internal hernias.
The document discusses the anatomy and segmentation of the liver. It can be divided into three main lobes - right, left, and caudate. The right lobe can be further divided into anterior and posterior segments by the right intersegmental fissure. Similarly, the left lobe is divided into medial and lateral segments by the left intersegmental fissure. Couinaud classification divides the liver into 8 functionally independent segments based on vascular inflow, outflow and biliary drainage within each segment. Cross-sectional imaging can help identify the different liver segments by extrapolating lines along structures such as the falciform ligament, hepatic veins and portal veins.
Gall bladder & biliary tract anomalies and variantsSanal Kumar
This document describes the normal anatomy of the gallbladder and biliary tract, as well as common anatomical variations and anomalies. It discusses the normal divisions and structures of the gallbladder and cystic duct. It then covers several anomalies including agenesis of the gallbladder, gallbladder duplication, wandering gallbladder, gallbladder torsion, and variations in gallbladder shape. The document also discusses ectopic locations of the gallbladder and variations in cystic duct insertion and bile duct anatomy.
Bile is produced by the liver and stored and concentrated in the gallbladder before being released to aid digestion. The biliary tree consists of intrahepatic and extrahepatic ducts that drain bile from the liver to the gallbladder and duodenum. Developmental variations in branching patterns can occur and need to be recognized to avoid complications during surgery or imaging studies. Biliary disorders in children may be developmental, such as biliary atresia or choledochal cysts, or acquired, like inspissated bile plug syndrome. Gallbladder diseases include cholecystitis, porcelain gallbladder, and adenomyomatosis.
1) Transanal total mesorectal excision (TME) is a novel technique for resection of rectal cancers.
2) TME involves excising the rectum and the surrounding mesorectum in one block through the anus to minimize local recurrence.
3) This "down-to-up" transanal approach aims to improve on open TME by reducing morbidity and impairment of function compared to traditional surgery.
The document discusses liver anatomy, injuries, and management approaches. It provides details on:
1) The surface anatomy and blood supply of the liver.
2) Common causes and presentations of liver injuries including blunt trauma, penetrating trauma, and associated injuries.
3) Classification systems for grading liver injuries based on CT imaging findings.
4) Treatment approaches including non-operative management with observation for lower grade injuries or angioembolization for bleeding, and operative management using packing, Pringle maneuver, and resection for higher grade or unstable injuries.
Surgical anatomy of hepatobiliary system by biswajit dekaBiswajit Deka
This document summarizes a seminar on the surgical anatomy of the hepatobiliary system. It begins with an introduction to the liver, gallbladder, and biliary tree. It then discusses the historical background and some key figures. It provides facts about the liver and discusses its embryology and potential congenital anomalies. The remainder of the document details the gross anatomy of the liver including its lobes, ligaments, surfaces, and vascular structures. It then discusses the gallbladder, cystic duct, common bile duct, and variations. It concludes with the functions of the liver and biliary tree.
Gastrointestinal stromal tumors (GISTs) are rare sarcomas that arise from the gastrointestinal tract. Most commonly found in the stomach, they represent 0.2% of gastrointestinal tumors. While often asymptomatic, they can present with bleeding, pain, or obstruction. Diagnosis involves imaging such as endoscopy or CT scan followed by biopsy showing immunohistochemistry positive for CD117 in 95% of cases. Treatment involves surgical resection with clear margins although adjuvant therapy with imatinib is often used for higher risk tumors. Outcomes have improved greatly in the past two decades with 5-year survival rates now over 50% with appropriate treatment.
This document discusses various anomalies of the biliary tree that can occur during embryonic development, including choledochal cysts, anomalous pancreatobiliary junction, annular pancreas, and biliary atresia. It describes the embryology of the biliary system and pancreas. Common anomalies are discussed such as their presentation, diagnosis using imaging modalities, classification systems, and management approaches including various surgical procedures.
In this presentation, I have shown how to do open anterior resection both high and low varieties in a step-by-step manner with clear pictures as if reading an atlas of operative surgery.
This document discusses safe laparoscopic cholecystectomy and management of bile duct injuries. It begins with an overview of laparoscopic cholecystectomy and the increased risk of bile duct injury compared to open procedures. It then covers bile duct injury mechanisms, classifications, prevention techniques such as obtaining the critical view of safety, and management strategies whether the injury is recognized intraoperatively or postoperatively. The key messages are that obtaining the correct anatomical views and following established safety procedures can help prevent bile duct injuries, and injuries need to be promptly addressed either by repair or biliary reconstruction to reestablish bile flow.
The document provides an overview of the surgical anatomy of the liver. It discusses the historical background of liver transplantation and key facts about the liver. The liver's functions, embryology, blood supply, segments, ligaments, recesses, and surgical techniques like hepatectomy are summarized. A good knowledge of liver anatomy is essential for modern hepatic surgery.
The document describes the retroperitoneal space and structures contained within it. The retroperitoneal space lies between the peritoneum and posterior abdominal wall from the diaphragm to the pelvic floor. It contains various organs like the kidneys, ureters, parts of the colon, pancreas and more. The space is further divided into the anterior pararenal space, perirenal space, and posterior pararenal space by fascial planes. The document outlines the boundaries and structures of the retroperitoneal space.
Whipple's procedure - Indications, Steps, ComplicationsVikas V
The document describes the Whipple procedure, which was first performed by Dr. Allen Whipple in 1935. It involves removing the head of the pancreas, part of the small intestine, the gallbladder, and bile duct. The original procedure was done in two stages but is now typically done in one stage. The document outlines the key steps of the modern Whipple procedure, including mobilizing tissues, dividing vessels, transecting organs, and reconstructing the digestive and biliary systems with anastomoses. Vascular resection of veins like the splenic vein may sometimes be required as well.
The document provides information on the surgical anatomy of the kidney and ureter. It discusses the embryology, gross anatomy including orientation and position of the kidneys. It describes the microscopic anatomy including the nephron. It details the coverings of the kidney including the fibrous capsule, perinephric fat, Gerota's fascia and paranephric fat. It outlines the relations of the kidney to surrounding structures like ribs, diaphragm and pleura. It also discusses the blood supply, lymphatic drainage and nerve supply of the kidneys.
Bile duct injury is a rare but potentially devastating complication of cholecystectomy that can result in biliary peritonitis, sepsis, and cirrhosis. It is most commonly caused by misidentification of structures during laparoscopic cholecystectomy. Management involves controlling infection, delineating biliary anatomy, and reestablishing biliary drainage, usually through surgical hepaticojejunostomy. Prevention relies on identification of anatomical variations, achieving a "critical view of safety" before duct division, and open conversion if needed. Proper management requires a multidisciplinary approach between surgeons, radiologists, and gastroenterologists.
Surgical Anatomy of the Liver : Ηepatectomies - Dimitris P. KorkolisDimitris P. Korkolis
- The liver is the largest gland in the body and has a wide variety of functions
- Weight: 1/50 of body weight in adult & 1/20 of body weight in infant
- It is exocrine(bile) & endocrine organ(Albumin , prothrombin & fibrinogen)
Function of the liver :
- Secretion of bile & bile salt
- Metabolism of carbohydrate, fat and protein
- Formation of heparin & anticoagulant substances
- Detoxication
- Storage of glycogen and vitamins
- Activation of vita .D
Biliary stricture is an abnormal narrowing of the bile duct. The most common cause is injury during cholecystectomy, accounting for 80% of non-malignant strictures. Bile duct injury can cause inflammation, fibrosis, scarring, and cirrhosis. Surgical treatment depends on when the injury is recognized, with immediate repair during surgery or delayed repair weeks later being options. Roux-en-Y hepaticojejunostomy is a common repair method that involves a mucosa-to-mucosa anastomosis of the bile duct to the jejunum. Factors like multiple prior repairs, proximal strictures, and surgeon inexperience can lead to poor outcomes.
Acute mesenteric ischemia is a life-threatening condition caused by interrupted blood flow to the intestines. It has a high mortality rate of 60-80% if not treated promptly. The document discusses the definition, causes, clinical presentation, diagnostic tests and management of acute mesenteric ischemia. Key diagnostic tests include bloodwork, abdominal imaging like CT angiography and angiography. Treatment involves fluid resuscitation, antibiotics, stopping vasoconstrictors, and often emergency surgery to revascularize the intestines or resect non-viable bowel segments. Prompt diagnosis and treatment are critical given the rapid progression of intestinal tissue damage from ischemia.
The document discusses different procedures for inguinal lymph node dissection, including standard, modified, and radical dissection. It describes key aspects of modified inguinal lymphadenectomy such as a shorter skin incision and preservation of structures like the saphenous vein. Complications of inguinal node dissection are also outlined, ranging from minor issues like lymphocele and wound infection to major complications including debilitating lymphedema, flap necrosis, and blood clots. The document provides details on surgical techniques, postoperative care, and risks associated with dissection of lymph nodes in the groin area.
This document discusses the anatomy of peritoneal spaces. It defines the peritoneum and its two layers - parietal and visceral. It describes various peritoneal ligaments that connect organs, including the falciform, triangular, lesser and greater omentum. It outlines the major peritoneal spaces such as the supramesocolic, inframesocolic, pelvic and lesser sac spaces. It provides details on boundaries and locations of collections in each space. In summary, the document provides a comprehensive overview of the peritoneal anatomy and spaces in the abdomen and pelvis.
Primary retroperitoneal tumors are rare neoplasms that arise in the retroperitoneum and pelvis. Liposarcoma is the most common type of primary retroperitoneal tumor, while lymphoma is the most common retroperitoneal malignancy overall. These tumors often grow extensively before causing symptoms. Diagnostic imaging includes CT or MRI to evaluate the tumor characteristics and relationship to surrounding structures. Surgical resection with negative margins is the standard treatment for localized primary retroperitoneal sarcomas, while chemotherapy or radiation may be used in certain settings. Prognosis depends on tumor grade, stage, and ability to achieve a complete resection.
This document summarizes the surgical anatomy of the liver. It describes the location and surfaces of the liver, as well as its ligaments. It discusses the lobar anatomy based on Cantlie's line, which divides the liver into left and right lobes. It also describes the segmental anatomy according to Couinaud's system of 8 segments. Finally, it discusses classifications of liver anatomy including Bismuth's and the Brisbane classification.
1.Antomy and physiology of liver by worku.pptxGoldGetnet
The liver has complex anatomy and vasculature. It is divided into 4 lobes and 8 segments based on blood supply. The liver receives dual blood supply from the hepatic artery and portal vein. It has 3 major functions - metabolism, protein synthesis, and bile production. The bile duct drains bile from the liver into the small intestine.
Bile is produced by the liver and stored and concentrated in the gallbladder before being released to aid digestion. The biliary tree consists of intrahepatic and extrahepatic ducts that drain bile from the liver to the gallbladder and duodenum. Developmental variations in branching patterns can occur and need to be recognized to avoid complications during surgery or imaging studies. Biliary disorders in children may be developmental, such as biliary atresia or choledochal cysts, or acquired, like inspissated bile plug syndrome. Gallbladder diseases include cholecystitis, porcelain gallbladder, and adenomyomatosis.
1) Transanal total mesorectal excision (TME) is a novel technique for resection of rectal cancers.
2) TME involves excising the rectum and the surrounding mesorectum in one block through the anus to minimize local recurrence.
3) This "down-to-up" transanal approach aims to improve on open TME by reducing morbidity and impairment of function compared to traditional surgery.
The document discusses liver anatomy, injuries, and management approaches. It provides details on:
1) The surface anatomy and blood supply of the liver.
2) Common causes and presentations of liver injuries including blunt trauma, penetrating trauma, and associated injuries.
3) Classification systems for grading liver injuries based on CT imaging findings.
4) Treatment approaches including non-operative management with observation for lower grade injuries or angioembolization for bleeding, and operative management using packing, Pringle maneuver, and resection for higher grade or unstable injuries.
Surgical anatomy of hepatobiliary system by biswajit dekaBiswajit Deka
This document summarizes a seminar on the surgical anatomy of the hepatobiliary system. It begins with an introduction to the liver, gallbladder, and biliary tree. It then discusses the historical background and some key figures. It provides facts about the liver and discusses its embryology and potential congenital anomalies. The remainder of the document details the gross anatomy of the liver including its lobes, ligaments, surfaces, and vascular structures. It then discusses the gallbladder, cystic duct, common bile duct, and variations. It concludes with the functions of the liver and biliary tree.
Gastrointestinal stromal tumors (GISTs) are rare sarcomas that arise from the gastrointestinal tract. Most commonly found in the stomach, they represent 0.2% of gastrointestinal tumors. While often asymptomatic, they can present with bleeding, pain, or obstruction. Diagnosis involves imaging such as endoscopy or CT scan followed by biopsy showing immunohistochemistry positive for CD117 in 95% of cases. Treatment involves surgical resection with clear margins although adjuvant therapy with imatinib is often used for higher risk tumors. Outcomes have improved greatly in the past two decades with 5-year survival rates now over 50% with appropriate treatment.
This document discusses various anomalies of the biliary tree that can occur during embryonic development, including choledochal cysts, anomalous pancreatobiliary junction, annular pancreas, and biliary atresia. It describes the embryology of the biliary system and pancreas. Common anomalies are discussed such as their presentation, diagnosis using imaging modalities, classification systems, and management approaches including various surgical procedures.
In this presentation, I have shown how to do open anterior resection both high and low varieties in a step-by-step manner with clear pictures as if reading an atlas of operative surgery.
This document discusses safe laparoscopic cholecystectomy and management of bile duct injuries. It begins with an overview of laparoscopic cholecystectomy and the increased risk of bile duct injury compared to open procedures. It then covers bile duct injury mechanisms, classifications, prevention techniques such as obtaining the critical view of safety, and management strategies whether the injury is recognized intraoperatively or postoperatively. The key messages are that obtaining the correct anatomical views and following established safety procedures can help prevent bile duct injuries, and injuries need to be promptly addressed either by repair or biliary reconstruction to reestablish bile flow.
The document provides an overview of the surgical anatomy of the liver. It discusses the historical background of liver transplantation and key facts about the liver. The liver's functions, embryology, blood supply, segments, ligaments, recesses, and surgical techniques like hepatectomy are summarized. A good knowledge of liver anatomy is essential for modern hepatic surgery.
The document describes the retroperitoneal space and structures contained within it. The retroperitoneal space lies between the peritoneum and posterior abdominal wall from the diaphragm to the pelvic floor. It contains various organs like the kidneys, ureters, parts of the colon, pancreas and more. The space is further divided into the anterior pararenal space, perirenal space, and posterior pararenal space by fascial planes. The document outlines the boundaries and structures of the retroperitoneal space.
Whipple's procedure - Indications, Steps, ComplicationsVikas V
The document describes the Whipple procedure, which was first performed by Dr. Allen Whipple in 1935. It involves removing the head of the pancreas, part of the small intestine, the gallbladder, and bile duct. The original procedure was done in two stages but is now typically done in one stage. The document outlines the key steps of the modern Whipple procedure, including mobilizing tissues, dividing vessels, transecting organs, and reconstructing the digestive and biliary systems with anastomoses. Vascular resection of veins like the splenic vein may sometimes be required as well.
The document provides information on the surgical anatomy of the kidney and ureter. It discusses the embryology, gross anatomy including orientation and position of the kidneys. It describes the microscopic anatomy including the nephron. It details the coverings of the kidney including the fibrous capsule, perinephric fat, Gerota's fascia and paranephric fat. It outlines the relations of the kidney to surrounding structures like ribs, diaphragm and pleura. It also discusses the blood supply, lymphatic drainage and nerve supply of the kidneys.
Bile duct injury is a rare but potentially devastating complication of cholecystectomy that can result in biliary peritonitis, sepsis, and cirrhosis. It is most commonly caused by misidentification of structures during laparoscopic cholecystectomy. Management involves controlling infection, delineating biliary anatomy, and reestablishing biliary drainage, usually through surgical hepaticojejunostomy. Prevention relies on identification of anatomical variations, achieving a "critical view of safety" before duct division, and open conversion if needed. Proper management requires a multidisciplinary approach between surgeons, radiologists, and gastroenterologists.
Surgical Anatomy of the Liver : Ηepatectomies - Dimitris P. KorkolisDimitris P. Korkolis
- The liver is the largest gland in the body and has a wide variety of functions
- Weight: 1/50 of body weight in adult & 1/20 of body weight in infant
- It is exocrine(bile) & endocrine organ(Albumin , prothrombin & fibrinogen)
Function of the liver :
- Secretion of bile & bile salt
- Metabolism of carbohydrate, fat and protein
- Formation of heparin & anticoagulant substances
- Detoxication
- Storage of glycogen and vitamins
- Activation of vita .D
Biliary stricture is an abnormal narrowing of the bile duct. The most common cause is injury during cholecystectomy, accounting for 80% of non-malignant strictures. Bile duct injury can cause inflammation, fibrosis, scarring, and cirrhosis. Surgical treatment depends on when the injury is recognized, with immediate repair during surgery or delayed repair weeks later being options. Roux-en-Y hepaticojejunostomy is a common repair method that involves a mucosa-to-mucosa anastomosis of the bile duct to the jejunum. Factors like multiple prior repairs, proximal strictures, and surgeon inexperience can lead to poor outcomes.
Acute mesenteric ischemia is a life-threatening condition caused by interrupted blood flow to the intestines. It has a high mortality rate of 60-80% if not treated promptly. The document discusses the definition, causes, clinical presentation, diagnostic tests and management of acute mesenteric ischemia. Key diagnostic tests include bloodwork, abdominal imaging like CT angiography and angiography. Treatment involves fluid resuscitation, antibiotics, stopping vasoconstrictors, and often emergency surgery to revascularize the intestines or resect non-viable bowel segments. Prompt diagnosis and treatment are critical given the rapid progression of intestinal tissue damage from ischemia.
The document discusses different procedures for inguinal lymph node dissection, including standard, modified, and radical dissection. It describes key aspects of modified inguinal lymphadenectomy such as a shorter skin incision and preservation of structures like the saphenous vein. Complications of inguinal node dissection are also outlined, ranging from minor issues like lymphocele and wound infection to major complications including debilitating lymphedema, flap necrosis, and blood clots. The document provides details on surgical techniques, postoperative care, and risks associated with dissection of lymph nodes in the groin area.
This document discusses the anatomy of peritoneal spaces. It defines the peritoneum and its two layers - parietal and visceral. It describes various peritoneal ligaments that connect organs, including the falciform, triangular, lesser and greater omentum. It outlines the major peritoneal spaces such as the supramesocolic, inframesocolic, pelvic and lesser sac spaces. It provides details on boundaries and locations of collections in each space. In summary, the document provides a comprehensive overview of the peritoneal anatomy and spaces in the abdomen and pelvis.
Primary retroperitoneal tumors are rare neoplasms that arise in the retroperitoneum and pelvis. Liposarcoma is the most common type of primary retroperitoneal tumor, while lymphoma is the most common retroperitoneal malignancy overall. These tumors often grow extensively before causing symptoms. Diagnostic imaging includes CT or MRI to evaluate the tumor characteristics and relationship to surrounding structures. Surgical resection with negative margins is the standard treatment for localized primary retroperitoneal sarcomas, while chemotherapy or radiation may be used in certain settings. Prognosis depends on tumor grade, stage, and ability to achieve a complete resection.
This document summarizes the surgical anatomy of the liver. It describes the location and surfaces of the liver, as well as its ligaments. It discusses the lobar anatomy based on Cantlie's line, which divides the liver into left and right lobes. It also describes the segmental anatomy according to Couinaud's system of 8 segments. Finally, it discusses classifications of liver anatomy including Bismuth's and the Brisbane classification.
1.Antomy and physiology of liver by worku.pptxGoldGetnet
The liver has complex anatomy and vasculature. It is divided into 4 lobes and 8 segments based on blood supply. The liver receives dual blood supply from the hepatic artery and portal vein. It has 3 major functions - metabolism, protein synthesis, and bile production. The bile duct drains bile from the liver into the small intestine.
This document provides information on abdominal ultrasound indications and liver anatomy and segmentation. It discusses common reasons for abdominal ultrasound exams, including abdominal pain, jaundice, and liver or gallbladder abnormalities. It then details Couinaud's classification of liver segmentation, which divides the liver into eight functionally independent segments based on vascular supply and drainage. Each segment is examined using ultrasound, with descriptions of imaging views and anatomical landmarks to identify the different segments.
The document provides information about the liver and extrahepatic biliary apparatus. It describes the location, lobes, segments, blood supply, and lymphatic drainage of the liver. It also discusses the porta hepatis and relations of the liver. Additionally, it provides information about the gallbladder, cystic duct, and common bile duct. The objectives are to describe the anatomy and features of the liver and related structures.
The document provides detailed information on the anatomy of the liver based on CT imaging. It describes the liver's location, lobes and segments. It discusses the liver's vasculature including the hepatic artery, portal vein and hepatic veins. It also describes the bile ducts and variants. The document outlines the CT appearance of the liver in different phases following contrast administration and the technique for CT liver volumetry.
Brief description of hepatectomy with indications, procedure, pre operative, intra operative and post operative management of the patient. Also describes the various techniques and instrument available for liver resection.
Liver is the largest internal organ of the body weighing about 1500g in adults. It occupies the right hypochondrium and extends into the epigastrium and left hypochondrium .
The liver, gallbladder, and bile ducts make up the hepatobiliary system. The liver is the largest organ located in the right upper abdomen. It has two surfaces and receives 80% of its blood supply from the portal vein. The gallbladder stores and concentrates bile before it is released into the small intestine. Bile ducts drain bile from the liver and gallbladder and include the right and left hepatic ducts which join to form the common hepatic duct and eventually the common bile duct. Variations can occur in the anatomy of these structures. Ultrasound is useful for evaluating the normal anatomy and identifying any abnormalities.
The document provides information on the structure and functions of the liver and pancreas. It discusses the liver's location, lobes, ligaments, vascular and biliary supply. The liver receives blood from the hepatic portal vein and hepatic arteries. It secretes bile into canaliculi between hepatocytes. The bile ducts drain into the right and left hepatic ducts. The pancreas is also mentioned. The peritoneum and its derivatives are briefly introduced.
C:\documents and settings\user\desktop\gastrointestinal 0406 liverpdfMBBS IMS MSU
This document provides an overview of the anatomy of the gastrointestinal system, with a focus on the liver, gallbladder, and biliary system. It describes the structure and connections of the liver, including its lobes, ligaments, and vascular supply. It then discusses the gallbladder, its attachment to the liver, blood supply, and structure. Finally, it details the biliary system, including the branching of the hepatic ducts, formation of the common bile duct, and termination of the bile and pancreatic ducts in the duodenum.
The document summarizes CT anatomy of the liver in 3 sentences:
The liver is the largest abdominal organ, surrounded by Glisson's capsule. It has five surfaces and is divided into four sectors by structures forming an "H" on its inferior surface. The liver has eight functionally independent segments based on its vascular inflow, outflow and biliary drainage.
The document discusses the anatomy of the liver. It notes that the liver is the largest gland in the body, located in the right upper quadrant of the abdomen. It has both endocrine and exocrine functions, and performs many metabolic activities related to nutrition, hemostasis, and the immune system. The liver secretes bile and stores glycogen. It receives around 20% of its blood supply from the hepatic artery and 80% from the portal vein. The liver has 8 segments and is drained by the hepatic veins. It is supplied by both the sympathetic and parasympathetic nervous systems. The document outlines the liver's shape, size, blood supply, drainage and clinical applications.
The liver is the largest visceral organ located in the upper right quadrant of the abdominal cavity. It performs over 200 essential functions including nutrient storage, breakdown of red blood cells, bile secretion, and synthesis of proteins and cholesterol. The liver receives blood from the hepatic portal vein and hepatic artery and drains into the hepatic veins. It is divided into four lobes and has both a diaphragmatic and visceral surface. The gallbladder stores and concentrates bile produced by the liver. Cirrhosis is a condition where the liver develops scar tissue due to chronic damage.
Liver and extra hepatic biliary apparatus.pptxSundip Charmode
The document provides information about the liver including its shape, weight, position, surfaces, borders, lobes, ligaments, blood supply, lymphatic drainage and clinical significance. It discusses the gallbladder, cystic duct, common hepatic duct, and common bile duct which make up the extrahepatic biliary apparatus. The document describes the anatomy and relations of these structures in detail.
A patient presented with chronic hepatitis C, hematemesis, distended abdomen, and radiating veins. An ultrasound revealed a mass in the right lobe of the liver. The most likely diagnosis is hepatoma, or liver tumor. The document then provides an overview of liver anatomy, including its location, lobes, surfaces, supports, blood supply, and clinical correlations regarding conditions like cirrhosis, portal hypertension, and abscesses.
A patient presented with chronic hepatitis C, hematemesis, distended abdomen, and radiating veins. An ultrasound revealed a mass in the right lobe of the liver. The most likely diagnosis is hepatoma (liver tumor). The document then provides learning objectives and details on liver anatomy including location, lobes, surfaces, supports, blood supply, clinical correlations on liver injuries and diseases.
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.
The accessory organs of the digestive system include the salivary glands, liver, gallbladder and pancreas. The liver performs many vital functions including metabolic regulation, hematological regulation and bile production. It regulates nutrient levels, filters toxins, stores vitamins and produces plasma proteins and bile. The liver lobule is the basic functional unit, with hepatocytes arranged in plates around a central vein and sinusoids. Blood enters through the hepatic artery and portal vein and leaves through hepatic veins.
- Gallbladder polyps are common findings that require evaluation to determine if they are true polyps with malignant potential or pseudopolyps which are benign.
- Transabdominal ultrasound is usually the initial imaging study, while EUS may help in certain cases, though evidence is limited.
- Polyps greater than 10mm or those exhibiting certain high risk features like being sessile or in patients over 50 years old typically warrant cholecystectomy.
- For smaller polyps, follow up imaging is reasonable if they lack concerning characteristics, though risk of malignancy increases with size.
This document discusses surgical approaches for esophageal cancer. It covers:
- Esophageal anatomy, blood supply, lymph drainage
- Staging of esophageal cancer and criteria for resection
- Preoperative evaluation including imaging, biopsy, and laparoscopy
- Surgical procedures for cervical, thoracic, and esophagogastric junction cancers including transhiatal esophagectomy, Ivor-Lewis procedure, and tri-incisional esophagectomy
- Oncologic principles for lymphadenectomy and margins during resection
Benign liver tumors present diagnostic challenges due to overlap between lesions on imaging and clinical features. Hemangiomas are typically the only clearly diagnosed tumors without biopsy. Biopsy or laparoscopy are reasonable invasive approaches for diagnostic uncertainty. The predominant treatment is observation, except for adenomas which often require surgery due to malignant potential. Diagnostic uncertainty is an acceptable indication for surgical intervention.
Role of laparoscopic surgery in colorectal cancerDr Amit Dangi
Laparoscopic surgery for colorectal cancer has been studied extensively. Early studies showed potential short-term benefits of laparoscopy over open surgery but also raised concerns about port site tumor recurrence. Later randomized controlled trials demonstrated laparoscopy is oncologically equivalent to open surgery for colon cancer with some short-term recovery benefits. Studies of laparoscopy for rectal cancer found short-term benefits but higher rates of positive margins, though long-term oncologic outcomes were similar. New techniques like robotic surgery are being explored but have not proven more cost-effective than laparoscopy.
This document discusses the current evidence for D1 and D2 gastrectomy in treating gastric cancer. It begins by defining the lymph node stations and different levels of lymphadenectomy. It then reviews several key randomized controlled trials that compared D1 and D2 gastrectomy. While initial Western trials found higher morbidity and mortality with D2 without survival benefits, later long-term follow up and recent trials demonstrate lower recurrence rates and improved survival with D2 gastrectomy when performed safely. The consensus is that D2 gastrectomy with preservation of the spleen and pancreas can achieve radical treatment for gastric cancer with excellent outcomes when performed by experienced surgeons.
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Ventral rectopexy has gained worldwide acceptance for surgical correction of rectal prolapse and high-grade internal rectal intussusception. The technique is based on correcting the descent of the posterior and middle compartments combined with reinforcement of the vaginal septum and elevation of the pelvic floor. anterior mobilization of the distal rectum and mesh suspension performed during VR can correct full-thickness rectal prolapse, rectoceles, and internal rec- tal prolapse and can be combined with vaginal prolapse procedures, such as sacrocolpopexy, in patients with multicompartment pelvic floor defects.
This document discusses technical aspects of ileal pouch-anal anastomosis (IPAA). It describes the different types of pouches that can be constructed, including W and J pouches. It also discusses the surgical techniques for performing a laparoscopic IPAA, including port placement, mobilization of different parts of the colon, and creating the ileal-anal anastomosis. The document notes that a stapled anastomosis may have better outcomes than a hand sewn one. It also discusses topics like managing an emergency colectomy, the optimal site of the anastomosis, and techniques to lengthen the small bowel mesentery.
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POEM is a highly effective treatment for achalasia, providing long-term symptom relief in over 90% of patients. Studies have shown POEM to have similar efficacy to laparoscopic Heller myotomy with benefits including shorter procedure time, less pain, and shorter hospital stay. POEM allows for a longer myotomy and more complete treatment of achalasia compared to Heller myotomy and has been shown to be particularly effective for type 3 achalasia. While short-term complications are low, concerns remain around POEM's learning curve. Further research is still needed regarding its use in special cases like sigmoid achalasia and treatment failure patients.
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The document discusses metabolic surgery as a treatment for type 2 diabetes. It notes that gastric bypass surgery was found to result in diabetes remission in 78% of patients in early studies. This catalyzed research into the mechanisms by which bariatric surgery improves glucose control. Worldwide obesity and diabetes prevalence is increasing significantly. Metabolic surgery is the most effective means of substantial and durable weight loss, and results in better glycemic control and reduced cardiovascular risk factors compared to medical therapy alone. The mechanisms of diabetes improvement after surgery extend beyond just weight loss and include effects on incretin hormones, insulin secretion, and insulin sensitivity.
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The skin is the largest organ and its health plays a vital role among the other sense organs. The skin concerns like acne breakout, psoriasis, or anything similar along the lines, finding a qualified and experienced dermatologist becomes paramount.
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
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Mercurius is named after the roman god mercurius, the god of trade and science. The planet mercurius is named after the same god. Mercurius is sometimes called hydrargyrum, means ‘watery silver’. Its shine and colour are very similar to silver, but mercury is a fluid at room temperatures. The name quick silver is a translation of hydrargyrum, where the word quick describes its tendency to scatter away in all directions.
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There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
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Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
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In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
2. Anatomic variability is the rule rather than the
exception in liver surgery
• Embryology
• Peritoneal attachments
• Classifications
• Caudate lobe
• Bile duct anatomy
• Hepatic artery anatomy
• Hepatic venous anatomy
• Portal vein anatomy
• Plate system
3. Embryology
• Biliary system and liver originate from
the embryonic foregut as a diverticulum
at four weeks
• Liver diverticulum initially separates into
a caudal and cranial portion. The
caudal portion gives rise to the cystic
duct and gallbladder and the cranial
portion gives rise to the intrahepatic and
hilar bile ducts.
• The cranial endodermal diverticulum
extends into the septum transversum
mesenchyme promoting formation of
endothelium and blood cells. The
extrahepatic biliary system is initially
occluded with epithelial cells but later it
canalizes as cells degenerate
4.
5. Segmental anatomy
• 8 functionally indepedent segments with its own
vascular inflow, outflow and biliary drainage
• Middle hepatic vein divides the liver into right
and left hemiliver. This plane runs from the
inferior vena cava to the gallbladder fossa.
• Right hepatic vein divides the right lobe into
anterior and posterior segments.
• Left hepatic vein divides the left lobe into a
medial and lateral part.
• Portal vein divides the liver into upper and lower
segments
6. Cantlie’s line
• Couinaud divided the liver into a functional
left and right liver (in French 'gauche et
droite foie') by a main portal scissurae
containing the middle hepatic vein. This is
known as Cantlie's line.
• Cantlie's line runs from the middle of the
gallbladder fossa anteriorly to the inferior
vena cava posteriorly
7. Peritoneal attachments of Liver
• Include falciform ligament, the left triangular ligament , and
the coronary ligament with the right triangular ligament
•There are no right and left coronary ligaments, only the left
triangular and the complex of coronary and rt triangular
ligaments
• They represent the remnants of liver’s development in the
septum transversum
•Falciform ligament carries the obliterated left umbilical vein
& the round ligament. The coronary ligament carries the
hepatic veins and the retroperitoneal IVC . The left triangular
ligament may also contain large blood vessels
•Falciform ligament – main blood supply arises from left
inferior phrenic and middle hepatic arteries. Veins converge
into 2 branches and ultimately drain in to left inferior phrenic
vein
7
8. Peritoneal attachments of
Liver
•Liver is suspended mostly by
the fibrous attachments in the
bare area and by the attachment
of the hepatic veins to the IVC
•Double layer of parietal
peritoneum – continues to form
falciform ligament sagitally–
surrounds all except bare area
•left layer of falciform lig forms
the ant layer of left triangular lig
•Coronary lig has sup and inf
layers rather than anterior and
posterior layers which are united
laterally at angular extensions
forming the left and right
triangular ligaments. On the right
the two layers are widely
separated and they are named
coronary ligaments.
8
9. Bismuth's classification
• Similar to the Couinaud classification, although there are small differences.
It is popular in the United States, while Couinaud's classification is more
popular in Asia and Europe.
• According to Bismuth 3 hepatic veins divide the liver into 4 sectors, further
divided into segments. These sectors are termed portal sectors as each is
supplied by a portal pedicle in the centre.
• The separation line between sectors contain a hepatic vein. The hepatic
veins and portal pedicles are intertwined.
• The left portal scissura divides the left liver into two sectors: anterior and
posterior. Left anterior sector consists of two segments: segment IV, which
is the quadrate lobe and segment III, which is anterior part of anatomical left
lobe. These two segments are separated by the left hepatic fissure or
umbilical fissure.
• Left posterior sector consists of only one segment II. It is the posterior part
of left lobe.
10.
11. • Traditionally referred to as segment 1, the caudate lobe has been
divided into 2 segments: 1 and 9.
• Segment 1 refers to the Spiegel lobe, and segment 9 refers to the
paracaval portion and caudate process
• Reidel lobe refers to a ‘‘tongue-like projection of the anterior border
of the right lobe of the liver to the right of the gallbladder’’ below the
costal margin. It is not a true anatomic lobe, but is a normal variant
of segments 5 and 6
12. Brisbane 2000
• Liver anatomy is described in first-,
second-and third-order divisions.
• The third order divisions, or segments
(Sg), are referred to by Arabic numerals,
not Roman numerals.
13. Brisbane - I order
• First-order division divides the liver into the left and right hemiliver,
or left and right liver. The term lobe is not used because the division
between the right and left hemiliver is not an externally apparent
structure.
• The border, also referred to as a watershed, of the first-order
division is referred to as the midplane of the liver ( plane between
the IVCand the gallbladder fossa)
• Cantlie line is a misnomer, because the division between the
hemilivers is a three dimensional space, and therefore technically a
plane.
• The caudate lobe, also referred to as segment 1 is not included in
the first-order division.
• The terminology for surgical resection at the first-order division is
right or left hepatectomy or hemihepatectomy. To correctly classify
the resection, whether or not segment 1 was included in the
resection must be stipulated
15. Brisbane - II order
• Second-order division divides the liver into 4
sections based on the biliary and hepatic artery
anatomy.
• The right liver is divided into the right anterior
section (Sg 5,8) and the right posterior section
(Sg 6,7).
• The left liver is divided into the left medial
section (Sg 4) and the left lateral section (Sg
2,3). The terminology for resection is obtained
by adding -ectomy to the anatomic term (ie, left
lateral sectionectomy)
17. Addendum for
alternate second order division
• Based on portal vein anatomy rather than biliary and
arterial anatomy.
• Uses the term sector rather than section.
• The right lobe is divided as in the addendum system, but
given different names; segments 5 and 8 are referred to
as the right anterior sector or the right paramedian
sector, and segments 6 and 7 are referred to as the right
posterior sector or right lateral sector.
• Segments 3 and 4 are referred to as the left medial
sector or the left paramedian sector and segment 2 is
referred to as the left lateral sector or the left posterior
sector.
18. Brisbane – III order
• Third-order division refers to the individual
segments of the liver. The segments are
referred to as segment 1 to segment 9.
• Resection of a single segment is referred
to as a segmentectomy and resection of
any 2 contiguous segments is referred to
as a bisegmentectomy
20. • Resection of segments 4 to 8 ( Sg 1) is referred
to as a right trisectionectomy (preferred term) or
extended right hepatectomy or extended right
hemihepatectomy.
• Resection of segments 2 to 5 and 8 ( Sg 1) is
referred to as a left trisectionectomy (preferred
term) or extended left hepatectomy or extended
left hemihepatectomy.
21. Problems with Brisbane
• Does not address the nomenclature of resections that do not
encompass a complete segment, sometimes referred to as
wedge resections or partial segmentectomies.
• Does not define gray zones between resections; that is, is a
right hepatectomy that includes only a portion of segment 4
classified as a right hepatectomy or a right trisectionectomy?
22. Caudate Lobe:Anatomic Location
• Space below hilum
• Proximity to
confluences
• Anterior to IVC
• From the level of HV
as they enter IVC
• Inferior edge of liver
24. Caudate
• Caudate lobe itself can be divided into right, left, and
caudate process.
• Caudate lobe proper is located between the inferior vena
cava and the umbilical fissure
• Caudate process connects the caudate lobe to the right
hepatic lobe
• In 44%, 3 separate ducts drain each part. In 26% of
cases, the caudate process duct and the duct from the
right portion of the caudate form a common duct.
• In most cases, the caudate process duct drains into the
RHD (85%) and the left part of the caudate lobe drains
into the LHD (93%).
25. • The caudate lobe receives portal blood flow from both
the left and, to a lesser extent, the right portal systems
• Venous drainage occurs along its posterior aspect
directly into the IVC through multiple small branches of
variable size and location.
• Biliary drainage includes small tributaries to the right, but
is predominantly through the left hepatic duct.
• Isolated resection of segment 1 is technically demanding
because of its anatomical position posterior to the liver,
between the hepatic hilum and the inferior caval vein, in
close proximity to the middle and left hepatic vein
• Selective caudate segmentectomy can be done via an
anterior transhepatic approach or high dorsal resection
26. Anatomic Subclassification
• Papillary process or Spiegel lobe proper
– Protuberant portion to the left of IVC
– Seen through the hepatogastric ligament,
• Caudate Process
– Portion to the right of IVC
– Right border blends into the right hemiliver
• Paracaval portion
– Intimate contact with IVC
– Connects the Spiegel lobe to the caudate process
28. Segment IX ?
Couinaud 1994 used the term seg IX for an area on the dorsal sector
of the liver (caudate lobe) close to the IVC (paracaval portion)
The anatomy of the paracaval portion is the liver parenchyma ventral
to the hepatic IVC, between the Spiegel lobe and the right lobe,
adjacent to the middle hepatic vein ventrally. This portion was
classified by Couinaud as segment IX
•However in 2002 Couinaud and co-workers abandoned the concept
of seg IX as according to them no separate arteries, veins or ducts
can be identified for the right paracaval portion of the posterior liver
and because pedicles cross the proposed division between the right
and left caudate lobe
28
29. ANATOMY OF BILE DUCT
BRANCHES IN THE HILAR
AREA
Junction of anterior seg
duct and post seg duct to
form the RHD which in turn
joins the LHD at the hilar
confluence 53-72%
Post seg duct joining the
LHD 9-27%
Ant seg duct joins the hilar
conf forming 3 br type hilar
conf 7-14%
Ant seg duct joins the LHD
6-9% 29
32. • The classic biliary anatomy appears in about 58% of the population and
consists of the right hepatic duct and left hepatic duct draining the right and
left lobes of the liver, respectively (Fig 6).
• The right duct branches into the right posterior hepatic duct, draining
posterior segments VI and VII, and the right anterior hepatic duct, draining
anterior segments V and VIII.
• The right posterior duct, which has a horizontal course, usually runs
posterior to the right anterior duct, which is more vertically oriented, and
fuses with it from a medial approach to constitute a short right hepatic duct.
• Segmental tributaries draining segments II–IV form the left hepatic duct.
• The fusion of the right and left hepatic ducts gives rise to the common
hepatic duct. The caudate lobe usually drains to the origin of the left hepatic
duct, or to the right hepatic duct.
• The cystic duct usually drains into the lateral aspect of the common hepatic
duct below its origin
33. RHD
• Right posterior sectoral duct is generally
oriented in a horizontal direction as opposed to
the right anterior sectoral duct, which runs in a
vertical direction.
• The posterior sectoral duct is typically more
superior and longer than the anterior duct.
• In most cases, the anterior sectoral duct drains
segments 8 and 5; however, in 20% of cases,
segment 8 joins the right posterior sectoral duct
34. LHD
• Compared with the RHD, less anatomic variation of the
LHD.
• Significant variation in bile ducts draining the left medial
section
• Usually the sectoral branches from the lateral and medial
sections join each other within the umbilical fissure to
form the LHD.
• Orientation of the LHD and left portal vein are typically
horizontal at the hilum before entering the umbilical
recess where they lie in a more vertical direction. The
LHD courses horizontally at the base of segment 4
superior to the left portal vein. It then joins the RHD
anterior to the portal vein bifurcation to form the CHD
36. RHD
• Supraportal pattern
– Right posterior sectional bile duct ran dorsally and
cranially to the right or the right anterior portal vein
and joined with the distal bile duct at its cranial side
• Infraportal pattern
– Right posterior sectional bile duct ran ventrally and
caudally to the right or the right anterior portal vein
and drained into the distal bile duct at its caudal side
• Combined pattern
– Some parts of the right posterior sectional bile duct
entered the distal bile duct supraportally and the
remaining parts of the right posterior sectional bile
duct joined with the distal bile duct infraportally.
37. Supraportal pattern
• Type A
– Right posterior sectional bile duct joined with the right
anterior sectional bile duct, forming the right hepatic
duct
• Type B
– Right posterior sectional bile duct entered the
confluence of the right anterior sectional bile duct and
the left hepatic duct
• Type C
– Right posterior sectional bile duct drained into the left
hepatic duct
38. Infraportal pattern
• Type D
– Right posterior sectional bile duct joined with
the right anterior sectional bile duct, forming
the right hepatic duct
• Type E
– Right posterior sectional bile duct entered the
common hepatic duct
39. Combined pattern
• Type F
– A portion of the right posterior sectional bile duct
joined with the right anterior sectional bile duct
infraportally, becoming the right hepatic duct, and the
remaining parts of the right posterior sectional bile
duct entered the right hepatic duct supraportally
• Type G
– portion of the right posterior sectional bile duct joined
with the common hepatic duct infraportally and the
remaining parts entered the left hepatic duct
supraportally
41. Confluence Patterns of the LHD
• Type H
– Left medial sectional bile duct drained into the left lateral
sectional bile duct
• Type I
– Left medial sectional bile duct entered the confluence of the left
lateral anterior and posterior segmental bile ducts
• Type J
– Left medial sectional bile duct joined with the left lateral anterior
segmental bile duct
• Type K
– Left medial sectional bile duct entered the hepatic confluence
43. Clinical implication – Ductal
anatomy
• Right hepatic duct was absent in 26%.
• When harvesting a donor without a right hepatic duct,
two or more orifices of the bile ducts will be present in
plane of transection of the graft. Biliary reconstruction of
these variants is complicated and technically difficult. It is
essential that both stumps must be reconstructed when
they are present
• Particular care must be taken in harvesting the left liver
from a donor with a type C or G variant. As the right
posterior sectional bile duct will be divided from the left
hepatic duct in these cases, oversight or ligation of the
stump of the right posterior sectional bile duct will lead to
biliary leakage or obstruction in the donor.
44. Surgical Anatomy of the Left Lateral Segment as Applied to Living-Donor and
Split-Liver Transplantation
Four specific patterns of left biliary
anatomy:
•segment 2 and 3 bile ducts unite
close to the umbilical fissure to form
a single LLS duct that receives a
single segment 4 duct medially
(55%)
• segment 2 and 3 bile ducts unite
medial to the umbilical fissure with
two parallel segment 4 ducts joining
the single LLS duct to form the left
hepatic duct (30%)
• segment 3 duct that receives the
duct from segment 4 and joins
segment 2 close to the hepatic hilum
(10%)
• and segments 2 and 3 ducts unite
lateral to the umbilical fissure to form
a short LLS duct that immediately
receives the segment 4 duct forming
the left hepatic duct (5%)
44
45. Summary
• In LDLT, the biliary anatomy of the donor usually is
evaluated using intraoperative cholangiography
• The surgeon must make a snap decision as to the biliary
anatomy and its relationship to the line of transection.
• When the right posterior sectional bile duct drains into
the left hepatic duct, it runs supraportally; and when the
right posterior sectional bile duct enters the common
hepatic duct, it runs infraportally.
• Familiarity with the variations of the hepatic confluence,
especially types B, C, E, G, J’, and K, will decrease the
likelihood of surgical misadventure.
Masayuki Ohkubo,Masato Nagino,Junichi Kamiya, Surgical Anatomy of the Bile
Ducts at the Hepatic Hilum as Applied to Living Donor Liver Transplantation.
Ann Surg 2004;239: 82–86
47. CBD arterial supply
• Two major axial vessels along the lateral borders of the
supraduodenal CBD
– 3 o’clock and 9 o’clock arteries
• 8 small arteries with a diameter of 0.3 mm supplying the
supraduodenal CBD. These arteries arise from-
Below – 60%
posterior or anterior superior pancreaticoduodenal artery
gastroduodenal artery
retroportal artery
Above – 38%
right hepatic artery
cystic artery
left hepatic artery
Rarely – 2%
nonaxial supply from the common hepatic artery
48. • Hilar ducts
– Arterial branches from the right and left
hepatic arteries; form a rich network around
the ducts and are in continuity with the plexus
around the CBD
• Retropancreatic CBD
– multiple small branches from the posterior
superior pancreaticoduodenal artery
52. MHV
• Hepatic venous outflow of the median
sector(corresponding to Couinaud segments 5,
8 and 4) is drained mainly into the middle
hepatic vein
• As a result, preservation of MHV outflow
drainage plays an important role in LDLT with
the right lobe.
• However, inclusion of the MHV in the right lobe
graft and the necessity of MHV tributaries
reconstruction are still controversial
53. Right lobe graft - methods
• Two harvesting methods for right lobe grafts have been
proposed: an extended right lobe graft, in which the MHV
trunk is included in the grafts, and a modified right lobe
graft, in which only the MHV tributaries are included.
• Leaving the MHV with the remnant liver will place the
anterior segment (corresponding to segments 5 and 8) at
risk for congestion and this drainage problem can lead to
severe graft dysfunction and septic complications.
• In such cases, the reconstruction of MHV tributaries
have been recommended.
54. Deciding on MHV
• Kyoto group, using the three-dimensional
reconstructed images of the hepatic vascular anatomy,
divided the right lobe graft morphologically into two
types: one is a right hepatic vein dominant graft in which
the territory draining into the MHV is less than 40% of
the right lobe graft, and the other is a MHV dominant
graft.
• Their indication for a right lobe graft with or without the
MHV is based on dominancy of the hepatic vein, graft-to-
recipient weight ratio, and remnant liver volume
Kaneko T, Kaneko K, Sugimoto H et al. Intrahepatic anastomosis formation between the
hepatic veins in the graft liver of the living related liver transplantation: observation by
Doppler ultrasonography. Transplantation 2000;70:982-985.
55. MHV ?
• Sano et al reported that venous congestion in the right
liver graft can be assessed by temporary arterial
clamping and intraoperative Doppler ultrasonography.
They suggested the reconstruction of the hepatic vein or
its tributaries if the graft volume excluding the discolored
area under arterial clamping was estimated to be
insufficient for postoperative metabolic demand (the
remaining liver volume was less than 40% of the
standard liver volume).
• Kubota et al proposed if the congestive area of the liver
surface appeared after clamping of MHV tributaries and
the hepatic artery is larger than half of the surface of the
anterior segment, the vein should be reconstructed.
56. Preservation of MHV during
left hepatectomy
The key step is the accurate
identification of the intrahepatic
origin of the MHV, by IOUS
detection of the venous branches
originating from segments 4 (4b)
and 5
•It’s origin usually lies 2.5 to 3 cm
deep into the liver parenchyma.
•The parenchymal transection is
continued by following the
orientation of the main trunk of
the MHV up to the IVC, on the
left side of the vein securing and
cutting only the left branches,
which drain subsegments 4a and
4b. 56
57. Few techniques aiming to
preserve the MHV during left
hepatectomy
Classically, dissection of the
parenchyma is performed at
about 2 to3 mm to the left of
the main portal fissure,
dividing the left branches of
the MHV, which is kept
unseen.
The major drawback of this
technique is the risk of
accidental injury of the MHV.
Parenchymal dissection
along the MHV under visual
control reduces this risk and
also allows a better
oncological margin whenever
needed
57
58. Vessel diameter
• Other institutions concerned mainly about vessel
diameter.
• Gyu Lee et al indicated that when larger than 5
mm diameter, the reconstruction of MHV
drainage from the anterior segment is
recommended
• Mizuno et al suggested 7 mm as the
demarcation for reconstruction of MHV
tributaries.
59. IRHV
• Before transplantation, the size of the vein must be
determined as well as the distance between the main
right hepatic vein (at the confluence of the hepatic vein
with the inferior vena cava) and the drainage site of the
inferior right hepatic vein into the inferior vena cava.
• The size of the accessory inferior right hepatic vein is
important because it can affect the surgical approach. If
the cross-sectional diameter is greater than 5 mm, the
vessel has to be preserved and reanastomosed in the
recipient’s inferior vena cava; otherwise, it can result in a
congested graft and lead to organ rejection
60. IRHV
• The IRHVs are divided into superior, medial and inferior groups,
separately named the superior, medial and inferior right hepatic
veins according to the position of the IRHV entering the inferior vena
cava. The superior right hepatic vein mainly drains the superior part
of segment Ⅶ, and the medial right hepatic vein drains the middle
part of segment Ⅶ
•The smaller the diameter of the right hepatic vein, the larger the
diameter of the IRHV, and vice versa
•It is possible to perform anatomical resections removing the entire
right hepatic vein but sparing the right postero-inferior area. The
postero-inferior area of the right lobe can be preserved along with
the hypertrophic IRHV even if the entire major hepatic vein (MHV) is
resected
•The posteroinferior area of the right lobe can be preserved along
with the hypertrophic IRHV even if the entire main right hepatic vein
is resected during segmentectomy of Ⅶ and Ⅷ with right hepatic 60
62. Portal vein br in the hilar area
Because the portal vein
develops during the very
earliest part of the gestational
period, few variations are found
in the portal vein branches, and
variations in the anterior
segmental branches of the
portal vein (P5,P8) are very
rare. Three principal portal vein
branching patterns found in the
hilar area
→ common type – anterior
segmental br joining the
posterior seg br to form the
RPV 74-84%
→ the 3 br type in which the
anterior seg br joins the PV
conf 8-12%
→ Left br type in which
anterior seg br joins the LPV 9-
17%
62
64. • Failure to recognize PV trifurcation lead to loss of supply
to right anterior or right posterior segment. It needs
division on right side of trifurcation.
• Non division of main portal trunk with absence of
separate main left PV is absolute C/I to right lobe LDLT.
65. Biliary-Vascular Sheaths (PLATE)
• Fusion of the Glisson capsule with the
connective tissue sheaths surrounding the biliary
and vascular elements.
66.
67.
68. HILAR PLATE
• Is bounded above by S4a, on the right by the
Rouviere sulcus (a landmark demarcating the
division between S6 and S5) and the cystic
plate, and on the left it is continuous with the
umbilical plate.
• The anterior Glisson’s sheath generally runs
behind the junction between the cystic plate and
the hilar plate, and the posterior-inferior
Glisson’s sheath runs behind the Rouviere
sulcus.
69. CYSTIC PLATE
• The cystic plate is located in the gallbladder bed
and is continuous with the capsule of S5, S4a,
and the Glisson’s sheath of the anterior segment
of the liver.
70. UMBILICAL PLATE
• The umbilical plate is located along the inferior
edge of the ventral surface of the umbilical
fissure.
• It contains the ducts and blood vessels of S2,
S3, and S4, and is continuous with the round
ligament inferiorly.
71. LEFT DUCT EXPOSURE
• Its also called HEPP COUINAUD approach.(1st
to describe transfissural (intrahepatic) approach
through main fissure)
• For high biliary stricture in BDI and
cholangiocarcinoma. (dense adhesions)
• Length of left hepatic duct is reflected by the
length of the base of the quadrate lobe.
• It may be hazardous in case of atrophy-
hypertrophy liver lobes and deep hilus which
displaced upwards.
72. Cont…
• This approach is difficult if quadrate lobe is large
or carcinoma involving of left duct.
• it is ideal for repair of type El to E3 injuries.
(confluence is patent)
• Resection of segment 4 is very useful when the
liver is overhanging the upper ducts, as has
recently been advocated by Mercado et al. (type
E3)- confluence intact.
75. LOWERING
HILAR PLATE
• Biliary confluence and
left hepatic duct exposed
by lifting segment IV
upward after incision of
the Glisson capsule at its
base.
76. • The hilar plate is detached from the liver
parenchyma by dissecting in between the left portal
pedicle and liver tissue.
• The umbilical fissure and plate is the site of origin of
segmental and sectoral pedicles to the left liver.
Its anatomic landmarks are the falciform ligament
and the left longitudinal sulcus.
• The sulcus of Rouvière is an irregular fissure in
continuity with the right hilum.
Following this structure leads to the pedicles of
segments V and VI and further deeply and
posteriorly to the pedicles of segments VII and VIII.
77. EXPOSURE OF RIGHT DUCT
• Indicated in some cases of hilar
cholangiocarcinoma, the planned surgical
procedure—partial hepatectomy or segment III
duct bypass —seems impossible much more
hazardous and imprecise than that of the left.
78. Hepatectomy: the posterior intrahepatic
approach (launious)- RIGHT DUCT
• reliant upon early division of the hepatic pedicle
extrahepatically.
• This allows delineation of the line of resection for
hepatectomy and segmentectomy.
• approach is through the dorsal fissure between
segments IV and I, and segment VIII and the
new segment IX described by Couinauds.
79. • The main hepatic pedicle is clamped en masse and
incisions made into the liver capsule in two regions,
the first posterior to and the second anterior to the
hilus.
• anterior incision is made in front of the hilum and
through the liver capsule from the gallbladder bed to
the umbilical fissure.
• An identical incision is made posterior to the hilum,
the surgeon’s index finger is insinuated through this
incision, and liver tissue is blindly pushed away until
the superior surface of the confluence is reached.
80.
81. EXPOSURE OF ISOLATED RIGHT
DUCT IN BDI
• Right and left duct are in same coronal
plane.(the key to the dissection is to stay in the
coronal plane of the left hepatic duct.)
• To find the bile duct within the sheath of the right
portal pedicle, which also contains the portal
vein and hepatic artery, the cystic plate must be
detached from the anterior surface of the sheath
of the right portal pedicle.
• Base of segment 5 must be cored out to expose
right portal pedicle.