LIVER & BILIARY PASSAGES Dr. Ahmed Fathalla Ibrahim

LIVER

LIVER DEFINITION: It is the largest gland in the body SURFACE ANATOMY: It occupies the whole right hypochondrium, a part of epigastrium & a part of left hypochondrium

ANTERIOR SURFACE OF LIVER

LIVER SURFACES: ANTERIOR: related to diaphragm & anterior abdominal wall. The diaphragm separates it from pleurae & lungs SUPERIOR: related to diaphragm separating it from pericardium & heart (in the middle) & pleurae & lungs (on each side)

POSTERIOR SURFACE OF LIVER

LIVER SURFACES: POSTERIOR: formed of (from right to left): Bare area: triangular area related to diaphragm. Its base is formed by groove for IVC; its sides are formed by upper & lower layers of coronary ligaments that meet at the apex to form the right triangular ligament Groove for IVC Caudate lobe: related to diaphragm, projects downwards to form a process separating IVC from porta hepatis & forming upper boundary of epiploic foramen Fissure for ligamentum venosum (obliterated ductus venosus) Esophageal notch

INFERIOR SURFACE OF LIVER

INFERIOR SURFACE OF LIVER

LIVER SURFACES: INFERIOR: Related to the following viscera: right kidney, right suprarenal gland, right colic flexure, 2nd part of duodenum, fundus & body of stomach Formed of (from right to left): Gall bladder fossa Quadrate lobe: related to pylorus, 1st part of duodenum & transverse colon Fissure for ligamentum teres (obliterated left umbilical vein)

LIVER ACCORDING TO ITS RELATIONS, THE LIVER IS DIVIDED INTO: DIAPHRAGMATIC SURFACE: includes superior, anterior & most of posterior surface VISCERAL SURFACE: includes inferior & a part of posterior surface

LIVER PORTA HEPATIS: It is the hilum of liver It lies in the inferior surface of liver Structures passing through it: right & left hepatic ducts, right & left branches of hepatic artery & portal vein (DAV, from before backwards)+ lymphatics, lymph nodes & autonomic fibers

LOBES OF LIVER ANATOMICAL DIVISION: The liver is divided into a smaller left & a larger right lobe by: Falciform ligament: anteriorly Fissure for ligamentum venosum: posteriorly Fisssure for ligametnum teres: inferiorly

LOBES OF LIVER FUNCTIONAL DIVISION: The liver is divided into a nearly equal left & right lobes by a plane passing through groove for IVC & gall bladder fossa. The caudate & quadrate lobes are included in the left lobe (because they are supplied by left branches of hepatic artery & portal vein)

LIGAMENTS OF LIVER PERITONEAL LIGAMENTS FALCIFORM LIGAMENT: a triangular fold formed of two layers (right & left) with: Anterior border: attached to diaphragm Posterior border: attached to anterior & superior surfaces of liver Lower free border: extending from liver to umbilicus & enclosing ligamentum teres & paraumbilical veins

LIGAMENTS OF LIVER PERITONEAL LIGMENTS LEFT TRIANGULAR LIGAMENT: to the left of falciform ligament, the peritoneum is reflected from the diaphragm to the upper surface of the liver to form the anterior layer of left triangular ligament (continuous with left layer of falciform ligament). The peritoneum then covers anterior, inferior & posterior surfaces & is reflected to the diaphragm to form the posterior layer of left triangular ligament

LIGAMENTS OF LIVER PERITONEAL LIGMENTS RIGHT TRIANGULAR LIGAMENT: to the right of falciform ligament, the peritoneum is reflected from the diaphragm to the upper surface of the liver to form the upper layer of coronary ligament (continuous with right layer of falciform ligament). The peritoneum then covers anterior & inferior surfaces then becomes reflected to the front of right kidney to form the lower layer of coronary ligament. The right extremity of both layers meet to form the right triangular ligament

LIGAMENTS OF LIVER PERITONEAL LIGMENTS LESSER OMENTUM: It is attached to the margins of porta hepatis & fissure for ligamentum venosum It extends to lesser curvature of stomach & upper border of 1st inch of 1st part of duodenum

LIGAMENTS OF LIVER LIGMENTUM M TERES: Represents the obliterated left umbilical vein that originally joins the branch of portal vein LIGAMENTUM VENOSUM: Represents the obliterated ductus venosus that originally connects IVC with left branch of portal vein

BARE AREAS OF LIVER TRIANGULAR DIAPHRAGMATIC AREA GROOVE FOR IVC GALL BALDDER FOSSA PORTA HEPATIS FISSURE FOR LIGAMENTUM VENOSUM

BLOOD SUPPLY OF LIVER HEPATIC ARTERY: brings oxygenated blood to the liver (30% blood reaching the liver) PORTAL VEIN: brings blood absorbed from GIT to the liver (70% blood reaching the liver) ALL BLOOD PASS TO HEPATIC SINUSOIDS Blood leave the liver through HEPATIC VEINS

LIVER LYMPHATIC DRAINAGE: Mainly into hepatic lymph nodes in porta hepatis. Efferent vessels pass to celiac lymph nodes NERVE SUPPLY: Hepatic plexus of autonomic fibers derived from celiac plexus SUPPORT: Hepatic veins (main support): suspend liver from IVC & have no extrahepatic course Peritoneal folds. Surrounding organs Tone of anterior abdominal wall

BILIARY SYSTEM BILIARY DUCTS GALL BLADDER

BILIARY SYSTEM

COMMON BILE DUCT

BILIARY DUCTS RIGHT & LEFT HEPATIC DUCTS: COMMON HEPATIC DUCT: Emerge from porta hepatis Drain bile from right & left lobes of liver Unite to form common hepatic duct COMMON HEPATIC DUCT: One and half inches in length Formed by the union of the 2 hepatic ducts Unite with the cystic duct to form the common bile duct

BILIARY DUCTS CYSTIC DUCT: One and half inches in length Connects the neck of gall bladder to common hepatic duct The mucous membrane of the duct as well as that of neck of gall bladder is raised forming the spiral valve. The valve keeps the lumen open

BILIARY DUCTS COMMON BILE DUCT: Formation: Formed by union of cystic & common hepatic duct Length: Three inches Course & relations: It descends: In the free margin of lesser omentum (to the right side of hepatic artery, anterior to portal vein) Behind 1st part of duodenum (to the right side of gastroduodenal artery, anterior to portal vein) Behind the head of pancreas, anterior to IVC Termination: usually join the main pancreatic duct forming the ampulla of Vater that opens into the lumen of 2nd part of duodenum through the major duodenal papilla

GALL BLADDER SHAPE: Pear-shaped sac SITE: Lies in gall bladder fossa of liver LENGTH: 3 – 4 inches CAPACITY: 30 – 50 ml

GALL BLADDER PARTS: Formed of 3 parts: Fundus: projects below inferior margin of liver, lies opposite the tip of right 9th costal cartilage, related anteriorly to anterior abdominal wall & posteriorly to transverse colon Body: related anteriorly to liver & posteriorly to 1st part of duodenum Neck: continuous with cystic duct has same relation as body

GALL BLADDER PERITONEAL COVERING: Fundus: completely covered by peritoneum Body & neck: only covered posteriorly FUNCTION: Stores & concentrates bile

SUPPLY OF BILIARY SYSTEM ARTERIES: Cystic branch of right hepatic artery VEINS: Cystic vein that drains into the right branch of portal vein LYMPH DRAINAGE: Cystic lymph nodes, then to hepatic & finally to celiac lymph nodes NERVES: autonomic fibers from celiac lymph nodes