1. LIVER & BILIARY PASSAGES
Dr. Ahmed Fathalla Ibrahim

2. LIVER

3. 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

4. ANTERIOR SURFACE OF LIVER

5. 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)

6. POSTERIOR SURFACE OF LIVER

7. 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

8. INFERIOR SURFACE OF LIVER

9. INFERIOR SURFACE OF LIVER

10. 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)

11. 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

12. 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

13. 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

14. 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)

15. 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

16. 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

17. 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

18. 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

19. 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

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

21. 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

22. 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

23. BILIARY SYSTEM
BILIARY DUCTS
GALL BLADDER

24. BILIARY SYSTEM

25. COMMON BILE DUCT

26. 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

27. 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

28. 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

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

30. 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

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

32. 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