ASSIGNMENT NO.

13
THE LIVER, BILIARY APPARATUS, JEJUNUM AND ILEUM

At the end of the course the students must be able to:

LIVER
1. Give a brief general description of the liver
2. Discuss the surface anatomy
3. Enumerate the functions
4. Describe the divisions.
4.1 anatomical
4.2 physiologic
5. Name the lobes. Describe each
6. Name the ligaments. Describe each
7. Describe bare area. Name the boundaries
8. Discuss the surfaces.
8.1 Superior
8.2 Right
8.3 Posterior
8.4 Anterior
8.5 Inferior/visceral surface
9. Describe the hepatorenal recess. Give the significance
10. Discuss the blood supply
10.1 Hepatic artery
10.2 Portal vein
11. Trace the venous and lymphatic drainage
12. Discuss the innervation

Clinical correlation
1. Discuss portal hypertension
2. Define caput medusa
3. Define porto –caval (systemic) anastomosis occur
4. Enumerate the sites where porto-systemic anastomosis occur
5. Define Murphy’s sign. Give the significance

BILIARY APPARATUS – Gallbladder

1. Describe the common hepatic duct
1.1 Usual length
1.2 Formation
1.3 Termination
2. Describe the gallbladder.
2.1 Function
2.2 Location
2.3 Capacity
2.4 Parts

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 2.5 Peritoneal covering
2.6 Relations
3. Define Phrygian cap.
4. Define Hartmann’s pouch
5. Describe the common bile duct.
5.1 Formation
5.2 Function
5.3 Course
5.4 Termination
5.5 Blood supply
5.6 Venous and lymphatic drainage
5.7 Nerve supply
6. Describe the cystohepatic triangle (triangle of Calot)
6.1 Boundaries
6.2 Significance

JEJUNUM AND ILEUM

At the end of the course the students must be able to:

1. Give the function.
2. Tabulate the differences between the jejunum and ileum.
3. Give the blood supply.
4. Trace the venous and lymphatic drainage.
5. Give the nerve supply.
6. Describe the mesentery proper.
6.1 Peritoneal layers
6.2 Attachments
6.3 Contents

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 ASSIGNMENT NO.13
THE LIVER, BILIARY APPARATUS, JEJUNUM AND ILEUM
LABORATORY PROCEDURE

Observe the location and position of the liver. Take note the liver is protected by the
lower part of the thoracic cage below the diaphragm.

Insert your hand between the liver and the thoracic wall or diaphragm covering its
anterior surface. Try to pull the liver downward. Give the name of the space where your
hand is inserted.
- RIGHT SUBPHRENIC SPACE

Take note of the peritoneal fold attaching the liver to the under surface of the diaphragm
that extends down to the inner surface of anterior abdominal wall. This is the falciform
ligament.
Enumerate the other ligaments of the liver.
• CORONARY LIGAMENT – Attaches the liver to the diaphragm, and the right
kidney and adrenal gland.
• TRIANGULAR LIGAMENT – Asymmetrical. Right and left components.
Covers left lobe of the liver.
• FALCIFORM LIGAMENT – Sickle-shaped. Anchors the liver the anterior
abdominal wall and the diaphragm
• LIGAMENTUM TERES (HEPATIS) – Round ligament of the liver. A remnant
of the left umbilical vein
• LIGAMENTUM VENOSUM – A remnant of the ductus venosum. Occupies the
fissure of the ligamentum venosum.
• LESSER OMENTUM – L-shaped. It has two parts: hepatogastric ligament,
hepatoduodenal ligament.

Beyond the lower margin of the liver the falciform ligament encloses a cord-like structure
which is called the ROUND LIGAMENT/LIGAMENTUM TERES.

This cord-like structure is remnant of what embryonic structure?

- REMNANT OF THE LEFT UMBILICAL VEIN

Open up the remaining portion of the anterior chest wall covering the liver. Using bone
scissors cut along the midline upward. Cut the attachments of the diaphragm and the
attachment of the falciform ligament. Retract the cut ends laterally. This will expose the
anterior surface of the liver. Do not detach the liver yet.

Trace the falciform ligament upward until the two layers diverge laterally. This,
diverging layers are the anterior layers of the coronary ligaments, left and right. These
ligaments and the corresponding posterior layers surround an area at the upper surface of
the liver devoid of peritoneal covering called the CORONAL LIGAMENT.

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The posterior layers of the coronary ligament are derived from the peritoneum of the
lesser sac. Where the anterior and posterior layers of the coronary ligament meet
laterally is a ligament called TRIANGULAR LIGAMENT.

Retract the liver upward. Observe the position/relation of the gallbladder.

Get a preserved liver specimen and study the under surface. Identify the gallbladder, the
cystic duct, porta hepatic, hepatic duct, portal vein and hepatic artery. Identify the
boundaries of cystohepatic triangle.
• Medial - Common hepatic duct
• Inferior - Cystic duct
• Superior - Inferior surface of the liver

State the significance of the cystohepatic triangle (of Calot).

• The Cystohepatic Triangle is a small anatomical space in the abdomen. It is
located at the porta hepatis of the liver – where the hepatic ducts and
neurovascular structures enter and exit the liver.
• The significance of Cystohepatic Triangle or Triangle of Calot is for the
removal of the gallbladder where the triangle is carefully dissected by the
surgeon, and its contents and borders can easily be identified. This allows the
surgeon to take into account any anatomical variation and permits safe
ligation and division of the cystic duct and cystic artery. Of particular
importance is the right hepatic artery – this must be identified by the
surgeon prior to ligation of the cystic artery.
• If Calot’s triangle cannot be delineated (such as in cases of severe
inflammation), the surgeon may elect to perform a subtotal cholecystectomy,
or convert to open surgery.

Identify the quadrate and caudate lobes, the ligamentum venosum, between the left lobe
and the caudate lobe; the ligamentum teres hepatic between the left lobe and the quadrate
lobe.

Take note of the impressions left by the visceral organs related to inferior surface of the
liver. Identify them.
• Impression left by the visceral organs to the inferior surface:
o Gastric Impression and Esophageal Impression on the left lobe
respectively.
o Suprarenal Impression, Renal Impression, Duodenal Impression and
Colic Impression on the right lobe respectively.

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In the photograph below, label the lobes and ligament in the anterior view of the liver.

In the photograph below, label the porta hepatic and its contents, lobe and lobules of the
liver, inferior vena cava and the biliary apparatus in the inferior view of the liver.

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Content of Porta Hepatis

Portal Vein - delivers approximately 70% of the blood that passes through the liver,
drains blood from most of the gastrointestinal tract

Hepatic Artery - delivers roughly 30% of the blood and supplies the liver and the
gallbladder

Common Bile Duct - delivers bile from the liver and gallbladder

JEJUNUM AND ILEUM

Review the previous dissection. Trace the ascending part of the duodenum. Identify the
duodeno-jejunal junction/flexure. A ligament attaches this junction to the posterior
abdominal wall. This is the LIGAMENT OF TREITZ.

State the significance of this junction and the ligament.

• Contacts to help the contents of the intestines move along
• Helps anchor the transition from duodenum to jejunum
• Clinically serves as a marker between the upper and lower gastrointestinal
tract
• Extension from Right Crus of the diaphragm
• Fixes the terminal part of the duodenum and prevents it from inferiorly

Closely examine the jejunum. Identify the peritoneal fold (mesentery) that attaches this to
the posterior abdominal wall. Observe the branching of the blood vessels contained in
this peritoneal fold.

How many arterial arcades have you seen? SINGLE

Trace the whole jejunum proximal to distal portion until it joins with the ileum.
Is there a landmark between the jejunum and ileum? Explain.
The Meckel’s diverticulum is often used as landmark to separate the
Jejunum and Ileum. It is a true diverticulum which contains all layers of the small
bowel wall. It arise from the antimesenteric surface of the middle-to-distal ileum
and represents a persistent remnant of the omphalomesenteric duct, which connects
the midgut to the yolk sac in the fetus.

Examine the ileum and the peritoneal fold (mesentery) that attaches it to the posterior
abdominal wall. Again, count the number of arterial arcades enclosed in this peritoneal
fold. How many have you counted? DOUBLE

Trace the ileum distally until it ends at the cecum.

What abdominal region is this junction found? RIGHT INGUINAL

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In the photograph below, label the segment of the jejunum and the segment of the ileum.

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