FAR

EASTERN UNIVERSITY – NICANOR REYES MEDICAL FOUNDATION

GROSS A HSB
James Taclin C. Bañez, MD, FPCS, FPSGS, FPALES
LIVER and BILIARY APPARATUS

LIVER LIGAMENTS
• Largest gland Inside the abdomen, a ligament is a structure that suspends
• Location: Although there are some parts of the liver in the something.
left side, bulk of it is at the right hypochondriac area and Falciform ligament
somehow in the epigastric region. • Falci comes from the Latin word falx, meaning sickle.
• It has grossly four lobes based on the division by the • Attached to the undersurface of the diaphragm.
falciform ligament: left, quadrate, caudate, and right lobes Coronary ligament
• Each lobe has lobules contains hepatocytes surround • Coronary – means something that goes around
sinusoids feed into central vein • This ligament goes around the bare area that actually
• Highly vascularized attaches it to the diaphragm.
• Pyramidal shape • Upper layer is formed by the reflection of the peritoneum
• 1/50 of body weight from the upper margin of the bare area
• 1.0 – 2.5 kg • Lower layer is reflected from the lower margin of the bare
• Male – 1.4 – 1.8kg area
• Female - 1.2 – 1.4kg Triangular ligaments
• Right triangular ligament is situated at the right extremity
Right lobe of the bare area.
• Highest point – 5th rib; 1cm below the nipple • Left triangular ligament connects the posterior part of the
Left lobe upper surface of the left lobe to the diaphragm.
• 6th rib; 2cm below the nipple Round ligament (Ligamentum teres)
*Lower border at tip of 9th right costal cartilage and descend • At the end of the falciform ligament
2.5cm below the rib in erect position. • Fibrous cord resulting from the obliteration of the
*Midline lower border between xiphoid and umbilicus umbilical vein.

FUNCTION (LIVER)
• Secretion of bile
• Synthesis of serum protein and lipids
• Participates in the elimination of sensecent cells and
particular matter from the bloodstream
• Process the products of digestion and most endogenous
and exogenous substances, like toxin and drugs that enter
the circulation.

SURFACES
• The liver has superior, inferior, and posterior surfaces. The
anterior surface is almost just a flat surface, therefore not
included in this discussion. IMPRESSIONS
Superior surface Since the liver is in an area between the thorax above and the
abdomen below, there are a lot of structures giving their
• Is convex, and fits under the vault of the diaphragm.
impressions on it.
• The diaphragm separates the liver from the lower part of
the lungs and pleura, the heart and pericardium. • Gastric impression – anterosuperior surface of the
stomach
• It is completely covered by peritoneum except along the
line of attachment of the falciform ligament. • Colic impression – produced by the right colic flexure
Inferior surface • Renal impression – occupied by the upper part of the
right kidney
• This is where majority of the structures can be found
because it is already in the abdominal area. • Duodenal impression – descending portion of the
duodenum
• Is uneven, concave, directed downward

• Almost completely invested by peritoneum except where
FOSSAE
the gall bladder is attached to the liver and at the porta
A fossa is a cavity in which structures insert into.
hepatis.
• Left sagittal fossa – separates the right and left lobe
• Porta hepatis – where the portal triad enters the liver
Posterior surface • Porta or transverse fissure – extending transversely
across the undersurface of the left portion of the right lobe.
• Large part of its extent is not covered by peritoneum and
It separates the quadrate lobe in front from the caudate
is in direct contact with the diaphragm.
lobe and process behind.
• This is where the bare area can be found. It is an area
• Fossa for the gall bladder – oblong fossa, placed on the
where the diaphragm covers the liver.
undersurface of the right lobe where the gallbladder is
• Left of the inferior vena cava is the caudate lobe, on the
attached.
right, the caudate process.
• Fossa for the inferior vena cava – is a short deep

depression of the liver surrounding the vena cava.


SOURCES:
• Outline and illustrations from Dr. Bañez discussion and presentation
• Supplement text from previous transcriptions and Snell



FAR EASTERN UNIVERSITY – NICANOR REYES MEDICAL FOUNDATION
GROSS A HSB
James Taclin C. Bañez, MD, FPCS, FPSGS, FPALES
LIVER and BILIARY APPARATUS

PHYSIOLOGIC DIVISION

COUINAUD SEGMENTS HEPATIC BLOOD SUPPLY (LIVER)
• Nine segments Hepatic portal vein (75%)
• Each segment has its own hepatic artery, portal vein, and • direct input from small intestine
hepatic duct. Because of this, it is possible to resect only a
• It originates from the esophagus, stomach, small intestine,
certain segment of the liver, and will still render the organ and most of the large intestines.
functional. Resecting somewhere aside from these
segments will cause the liver to just bleed. Hepatic artery (25%)
• direct links to heart
• The bulk of the blood going to the liver comes from the
portal vein (2⁄3) that is why even if you cut the hepatic
artery the liver can still survive because only a third of the
blood supply comes from the hepatic artery proper.

CANTLIE’S LINE
• is a vertical plane that divides the liver into left and right
lobes creating the principal plane used for hepatectomy.
• It extends from the inferior vena cava posteriorly to the
middle of the gallbladder fossa anteriorly.
• It divides the liver into functional left and right segments,
whereas the falciform ligament only grossly divides the VENOUS DRAINAGE (LIVER)
liver into left and right lobes. Hepatocytes are irregularly shaped cells found in the liver.
• Each of these segments has a hepatic artery, portal vein, They radiate outward from a central vein. In a liver lobule,
and a hepatic bile duct. they form a series of irregular plates arranged like wheel
spokes.
• Blood leaving the liver returns to the systemic circulation
via the hepatic veins that open into inferior vena cava.
• There are only three hepatic veins.
• Since they are attached to the liver, these veins are patent.
Unlike most veins that are collapsible, if you cut the
inferior vena cava at the level of the liver, three holes will
be seen corresponding to the left, central, and right
hepatic veins.
SOURCES:
• Outline and illustrations from Dr. Bañez discussion and presentation
• Supplement text from previous transcriptions and Snell



FAR EASTERN UNIVERSITY – NICANOR REYES MEDICAL FOUNDATION
GROSS A HSB
James Taclin C. Bañez, MD, FPCS, FPSGS, FPALES
LIVER and BILIARY APPARATUS

• Veins draining the small intestines (i.e. superior DESCRIPTION

mesenteric vein, inferior mesenteric vein) and the • Pear-shaped, hollow structure
splenic vein do not drain directly into the inferior vena • Fundus slants inferiorly, to the right
cava. The inferior mesenteric vein ascends to meet with • Body and neck directed towards porta hepatis because of
the splenic. These then meet with the superior mesenteric the cystic duct going to the porta
vein to form the portal vein. Because the contents of the • Attached to liver by loose (areolar) connective tissue
small intestine are dirty, there is a need for these to be • Peritoneum covers free surfaces because other surfaces
filtered and cleaned in the liver before draining into the are attached to the liver
inferior vena cava, and eventually to the heart. • Normal measurements (anything beyond these
measurements is indicative of a probable mass, probable
infectious process that is inflamed, or a probable
obstruction):
• 7-10 cm long
• ≈ 6 cm. diameter
• 30-35 cc volume

PARTS
• Fundus – may be palpable
• Body
BILE (LIVER)
• Infundibulum - tapering portion
• The liver secretes bile into the bile canaliculi. These are
of gallbladder, opposite the
narrow channels between sheets of hepatocytes.
fundus, where the body of the
• Bile then passes into bile ductules of the triads and drain
gallbladder narrows to the neck
into the left and right hepatic ducts.
(from which the cystic duct
• Once they have merged, this forms the common hepatic
proceeds).
duct. Once this joins the cystic duct (gall bladder), this is
• Neck – continuous with cystic
now known as the common bile duct.
duct, characterized by a tortous
SUMMARY:
spiral valve of Heister
Bile ductules (LIVER) → L/R hepatic ducts → common hepatic
• Hartmann’s pouch – found at the infundibulum of gall
duct → cystic duct (GALLBLADDER) → common bile duct
bladder (lies between body and neck of gall bladder) and

is not always present but a normal variation
NERVE SUPPLY (LIVER)
Hepatic plexus • Cystic Duct – Extends from neck of gall bladder to common
hepatic duct; Joins with common hepatic duct inferior to
• Originates from the celiac plexus
porta hepatis; Spiral valve may extend into neck of gall
• Sympathetic stimulation causes constriction of hepatic
bladder
artery and portal vein
• Common bile duct – Hepatic artery on left and portal vein
Vagal stimulation
posterior; Descends in free margin of lesser omentum


GALLBLADDER / BILIARY APPARATUS
BILE (GALLBLADDER)
• Location: epigastric and the right hypochondriac region
• neck → cystic duct.
• Found on the inferior surface of liver and between the
• cystic duct + common hepatic duct →common bile duct.
quadrate and right lobes.
• Common bile duct is 10-15 cm long and courses through
• In thin individuals and if it is large, the gall bladder can be
the lesser omentum.
palpated.
• Combined duct empties into the duodenum at the ampulla
of Vater
• The sphincter of Oddi guards the duct and regulates the
bile flow. When the sphincter is closed, the bile is stored in
the gall bladder. When opened, the bile empties into the
duodenum to aid in fat emulsification.

ARTERIAL BLOOD SUPPLY (BILIARY TREE)
Cystic artery
• Cholecyst – relating to the gall bladder • Arises (≈ 60% of the time) from the right hepatic artery.
• Cholecystitis – inflammation of the gall bladder Sometimes it arises directly from the common hepatic
• Murphy’s sign – when there is pain when the right upper quadrant is artery.
pressed; named after Benjamin Murphy who first described the • Passes posterior to hepatic duct then divides into multiple
hypersensitivity to deep palpation in the subcostal area when a patient
with gallbladder disease takes a deep breath.
branches covering the gall bladder.
• Cholecystolithiasis – obstruction within the gall bladder or the cystic
duct
• Choledocolithiasis – obstruction in the common bile duct

SOURCES:
• Outline and illustrations from Dr. Bañez discussion and presentation
• Supplement text from previous transcriptions and Snell



FAR EASTERN UNIVERSITY – NICANOR REYES MEDICAL FOUNDATION
GROSS A HSB
James Taclin C. Bañez, MD, FPCS, FPSGS, FPALES
LIVER and BILIARY APPARATUS

JEJUNUM/ ILEUM VENOUS DRAINAGE (JEJUNUM/ ILEUM)

Location and Description • The veins correspond to the branches of the superior
• measure about 20 ft (6 m) long mesenteric artery → superior mesenteric vein
• upper 2/5 of this length make up the jejunum.
• Lower 3/5 make up the ileum LYMPH DRAINAGE (JEJUNUM/ ILEUM)
• Each has distinctive features, but there is a gradual change • The lymph vessels pass through many intermediate
from one to the other. The jejunum begins at the mesenteric nodes and finally reach the superior
duodenojejunal flexure, and the ileum ends at the ileocecal mesenteric nodes, which are situated around the origin
junction. of the superior mesenteric artery.
• The coils of jejunum and ileum are freely mobile and are
attached to the posterior abdominal wall by a fan- NERVE SUPPLY (JEJUNUM/ ILEUM)
shaped fold of peritoneum known as the mesentery of the • sympathetic and parasympathetic vagus nerves from
small intestine. the superior mesenteric plexus.
• The long free edge of the fold encloses the mobile intestine.
The short root of the fold is continuous with the parietal
peritoneum on the posterior abdominal wall along a line
that extends downward and to the right from the left side
of the 2nd lumbar vertebra to the region of the right
sacroiliac joint.
• The root of the mesentery permits the entrance and exit of
the branches of the superior mesenteric artery and vein,
lymph vessels, and nerves into the space between the two
layers of peritoneum forming the mesentery.

In the living, the jejunum can be distinguished from the
ileum by the following features:
• The jejunum lies coiled in the upper part of the peritoneal
cavity below the left side of the transverse mesocolon; the
ileum is in the lower part of the cavity and in the pelvis.
• The jejunum is wider bored, thicker walled, and redder
than the ileum.
• The jejunal wall feels thicker because the permanent
infoldings of the mucous membrane - plicae circulares -
are larger, more numerous, and closely set in the jejunum,
• whereas in the upper part of ileum - smaller and more
widely separated; in the lower part they are absent.
• Jejunal mesentery is attached to the posterior abdominal

wall above and to the left of the aorta
• Ileal mesentery - attached below and to the right of aorta.
• The jejunal mesenteric vessels form only 1-2 arcades,
with long and infrequent branches passing to the intestinal
wall.
• The ileum receives numerous short terminal vessels that
arise from a series of 3 or more arcades.
• At the jejunal end of the mesentery, the fat is deposited
near the root and is scanty near the intestinal wall. At the
ileal end of the mesentery, the fat is deposited through- out
so that it extends from the root to the intestinal wall
• Aggregations of lymphoid tissue (Peyer’s patches) are
present in the mucous membrane of the lower ileum
along the antimesenteric border.

HEPATIC BLOOD SUPPLY (JEJUNUM/ ILEUM)
Superior Mesenteric Artery branches
• The intestinal branches arise from the left side of the artery
and run in the mesentery to reach the gut.
• anastomose with one another to form a series of arcades.
Ileocolic artery
• Supplies the lowest part of the ileum

SOURCES:
• Outline and illustrations from Dr. Bañez discussion and presentation
• Supplement text from previous transcriptions and Snell