Anatomy of

Liver, Biliary system & Portal vein

Dr Mohamad Aris Mohd Moklas (PhD) Department of Human Anatomy FPSK UPM aris@medic.upm.edu.my 03 8947 2330/2331/2783

LIVER
It is the largest gland in the body. Liver is a soft, dark brown highly vascular organ. It is readily torn in abdominal injuries causing severe intraabdominal bleeding. In adult it is approximately 2% of the body weight.

LIVER
Location Mainly present in right hypochondriac region . It also extends to epigastric region. Weight 1400 1800 gms in males. 1200 1400 gms in females.

Lobes of liver

Liver is divided into a large right lobe and a small left lobe by the attachment of falciform ligament , which extends from liver to the anterior abdominal wall.

Lobes of liver

Right lobe is further divided into quadrate lobe and caudate lobe.

Surfaces of liver
Five surfaces, anterior, posterior, superior, inferior and right surfaces.

A sharp inferior border separates the anterior from the inferior surface.

Relations of liver:
Peritoneal relations

&
Visceral relations

Relations of liver: Peritoneal relations Liver is covered by the visceral layer of peritoneum except the bare area of liver.

Relations of liver: Visceral relations Superiorly the liver is related to the diaphragm.

Relations of liver: Visceral relations Posteroinferior surface: (Posterior and inferior)

It is related to abdominal part of oesophagus, the stomach, the duodenum, the right colic flexure, the right kidney, right suprarenal and the gall bladder.

Relations of liver: Visceral relations Posteroinferior surface: (Posterior and inferior)

Groove

for Inferior vena cava lodges the upper part of I.V.C.

Abdominal part of oesophagus is related to the posterior surface of the left lobe. Bare area is related to the posterior surface of right lobe . Stomach is related to the inferior surface of the left lobe.

Right kidney and right colic flexure are related to the inferior surface of the right lobe .

Gall bladder fossa lodges the gall bladder on the inferior surface .

Left triangular ligament

Hepatic vein

Coronary ligaments

Bare area

Fissure for ligamentum venosum

Porta hepatis

Gastric

Renal

Fissure for ligamentum teres hepatis Falciform ligament

Quadrate lobe

Colic Ligamentum teres

Porta hepatis of liver (Hilum)

It is present on the posteroinferior surface and lies in between caudate and quadrate lobes.

Free edge of the lesser omentum is attached to its margins.

Porta hepatis of liver (Hilum)

Right and left hepatic ducts, right and left branches of hepatic artery and portal vein are passing through the porta hepatis.

Vascular segments of Liver

On the basis of blood supply and biliary drainage there are four main hepatic segments.

Left lateral (left lobe) Left medial (Left lobe) Right anterior (right lobe) Right posterior (right lobe)

Each of these main segments are further subdivided into upper and lower parts.

Peritoneal ligaments of liver 1. Falciform ligament It is a two- layered fold of peritoneum. It extends from the anterior abdominal wall to the anterior surface of liver. It contains the ligamentum teres, which is the remains of the umbilical vein.

The right layer of falciform ligament forms the upper layer of the coronary ligament and its left layer forms the upper layer of the left triangular ligament.

Peritoneal ligaments of liver

2. The lesser omentum It extends from the edges of the porta hepatis and passes to the lesser curvature of stomach.

Lesser omentum

Bare area of liver

This is the area of liver which is devoid of peritoneum.

Bare area of liver

To the right of the I.V.C the posterior part of the diaphragmatic surface is broad and a large part of it between the superior and inferior layers of the coronary ligament is not covered by peritoneum This is the bare area. Groove for I.V.C and the fossa for gall bladder are also devoid of peritoneum.

Blood supply

Hepatic artery, a branch of celiac artery. It divides into right and left terminal branches that enter the porta hepatis.

Veins Portal vein divides into right and left branches that enter the porta hepatis.

The hepatic veins emerge from the posterior surface of liver and drain into the I.V.C.

Blood vessels of liver

Nerve supply Sympathetic and parasympathetic from the celiac plexus. Lymphatic drainage The efferent vessels pass to the celiac nodes.

A few vessels from the bare area pass to the posterior mediastinal nodes.

Biliary system
It consists of the following structures.
Right and left hepatic ducts. Common hepatic duct. Gall bladder. Cystic duct. Common bile duct (bile duct).

Biliary system

Right and left hepatic ducts

Emerge from the right and left lobes of the liver in the porta hepatis. The hepatic ducts unite to form the common hepatic duct .

Common hepatic duct

It is about 4 cm long. It descends within the free margin of the lesser omentum. It is joined on the right side by the cystic duct from the gall bladder to form the bile duct.

Gall bladder

It is a pear-shaped sac. Lies on the undersurface of liver. Capacity 30 50 ml. It has three parts Fundus, body and neck. .

Fundus usually projects below the inferior margin of liver and comes in contact with the anterior abdominal wall .

Extrahepatic parts of the biliary system

The bile ducts and the Gall bladder

Surface marking of fundus of gall bladder: Fundus can be surface marked on the anterior abdominal wall at the level of the tip of the right 9th costal cartilage. The body of gall bladder lies in contact with the visceral surface of liver.

The neck is continuous with the cystic duct. The peritoneum completely surrounds the fundus of gall bladder.

Blood supply Cystic artery a branch of right hepatic artery. Veins Cystic vein which drains into portal vein.

Lymphatic drainage Drains into cystic lymph node. From here the lymph vessels pass to hepatic nodes and then to celiac nodes. Nerve supply Sympathetic and parasympathetic. Parasympathetic is the vagus nerve. Sympathetic and parasympathetic form the celiac plexus.

The pain fibres from the gall bladder and bile ducts ascend through the celiac plexus

Cystic duct

It is about 4 cm long.

It connects the neck of gall bladder to common hepatic duct to form the bile duct.

It descends in the free margin of lesser omentum.

Extrahepatic biliary apparatus

Bile duct (Common bile duct) It is about 8 cm long. It lies in the right free margin of lesser omentum.

Here it lies in front of the portal vein and on the right of hepatic artery.

Bile duct (Common bile duct)

It passes behind the first

part of the duodenum .

In the lower part of its course it is posterior to head of pancreas.

 The

bile duct is joined by the main pancreatic duct to form hepatopancreatic ampulla (ampulla of Vater).

 The

ampulla opens in the second part of the duodenum halfway down its length by means of a small papilla major duodenal papilla.
The terminal parts of both ducts and ampulla are surrounded by a sphincter of Oddi.

CLINICAL FEATURES
1.Errors in gall bladder surgery is due to the failure to appreciate the variations in the anatomy of biliary system. It is therefore important to identify all the three biliary ducts together with the cystic and hepatic arteries before dividing any structures and removing the gall bladder.

2.Haemorrhage during cholecystectomy can be controlled by compressing the hepatic artery between the finger and thumb when it lies in the anterior wall of the foramen of Winslow (epiploic foramen).

3.Stones in the common bile duct can usually be removed through an incision in the supraduodenal part of the common bile duct. 4. Biliary colic Spasmodic pain in abdomen relating to bile passage. Biliary colic is most intense when the calculus (stone) is impacted either at the cystic duct or at the lower end of the bile duct. Biliary colic referred pain is felt in the right upper quadrant or the epigastrium.

5.Liver biopsy Hepatic tissue may be obtained for diagnostic purposes by liver biopsy.

6.Rupture of liver Liver may be torn by a fractured rib.

7.Hepatomegaly Many diseases cause liver enlargement, or hepatomegaly.

8.Cirrhosis of liver Destruction of hepatocytes and replacement of them by fibrous tissue. 9.Liver transplantation A person with end stage liver disease may opt to have his liver removed to be replaced with a normal liver. 10. Imaging of the biliary tract Gall bladder and biliary tract can be demonstrated by ultrasound.

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Portal vein

Portal vein

Portal vein drains blood from abdominal part of the gastrointestinal tract, from the lower third of oesophagus to half way down the anal canal. It also drains blood from the spleen, pancreas and gall bladder.

The portal circulation begins as capillary plexus and ends by emptying blood into the sinusoids of liver.

The portal vein enters the liver through the porta hepatis. Blood from liver is collected by hepatic veins. Hepatic veins join the I.V.C.

Fig.20 The composition of the Portal system

Formation By the joining of superior mesenteric and splenic veins. Site of formation Posterior to neck of pancreas.

Length - 6 to 8 cm.

Formation of portal Vein

Relation of portal vein at its formation

Relations

At its formation, portal vein is posterior to neck of pancreas.

passes upwards posterior to first part of duodenum and enters the lesser omentum.

It

In lesser omentum it is related anteriorly to bile duct (right), and hepatic artery (left) . branches.

At the porta hepatis it divides into right and left

Relations of portal Vein

Portal Vein relations (In lesser omentum)

Portal Vein Tributaries: i. Splenic vein It receives the inferior mesenteric vein. ii. Superior mesenteric vein iii. Left gastric vein iv. Right gastric vein v. Cystic vein.

Tributaries of portal vein.

Portal- systemic anastomosis

Smaller communications exist between the portal and systemic veins and they become important when the direct route becomes blocked.

These sites are, 1. At the lower end of oesophagus The oesophageal tributaries of the left gastric vein (Portal tributary) anastomose with oesophageal veins (systemic tributary).

2. Superior rectal veins draining the upper part

of the anal canal (Portal tributary) anastomose with middle and inferior rectal veins (systemic tributaries).
3. Paraumbilical veins connect the left branch of portal vein with superficial veins of anterior abdominal wall (systemic tributaries).

Portal-systemic anastomosis

CLINICAL FEATURES
1. Portal hypertension

Liver cirrhosis obstruct the portal vein resulting in increased pressure in portal vein causing portal hypertension.
At the sites of portal caval anastomosis portal hypertension produces varicose veins. The veins may become so dilated that their walls rupture resulting in haemorrhage.

 Bleeding

from oesophageal varices, extremely dilated submucosal veins in oesophagus (at the distal end of the oesophagus) is often severe and may be fatal.
Oesophageal varices

3. Paraumbilical veins may become varicose and look like small snakes radiating under the skin around the umbilicus.
This condition is referred to as Caput

medusae .

Caput medusae

4.Collateral circulation through the portalsystemic communications forms haemorrhoids (piles) in the anal canal.

It may be responsible for repeated bleeding per rectum.

Haemorrhoids in anal canal