Liver Anatomy: Principles of Liver Resection, Physiology

Liver Anatomy
Principles of liver resection , physiology
Dr. Mahmoud W. Qandeel

Outlines
• Liver surfaces • Principles of resection

• Liver ligaments • Nomenclature of surgery (Brisbane 2000)
• Liver segments • Physiology
• Blood supply • Imaging
– Hepatic artery
– Portal vein
– Hepatic veins
• Variations
• Radiological Anatomy

Liver Anatomy
• The liver is a solid gastrointestinal organ whose mass (1.2 to 1.6 kg)
largely occupies the right upper quadrant of the abdomen.
• Weight: 1/50 of body weight in adult & 1/20 of body weight in infant
• The liver is the largest gland in the body
• It’s the second largest organ after ??
• It is reddish brown and is surrounded by a fibrous sheath known as
Glisson’s capsule.

Surfaces of the liver, their relations & impressions
• Postero - inferior surface=

Visceral surface
• Superior surface =
Diaphragmatic surface
• Anterior surface
• Right surface

Peritoneum of the liver
• The liver is covered by peritoneum

(intraperitoneal organ)except at bare area(it is
origin from septum transversum).
• Inferior surface covered with peritoneum of

greater sac except porta hepatis, G.B &
Lig.teres fissure.
• Rt. Lateral surface covered by peritoneum,

related to diaphragm which separate it from Rt.
Pleura , lung and the Rt Ribs (6-11).

The ligaments of the liver
1. The Falciform ligament of liver

2. The Ligamentum teres hepatis
3. The coronary ligament
4. The right triangular ligament
5. The left triangular ligament
6. The Hepatogastric ligament
7. The hepatoduonedenal ligament
8. The Ligamentum Venoosum

• The liver is held in place by several ligaments
• The round ligament is the remnant of the obliterated umbilical vein and
enters the left liver hilum at the front edge of the falciform ligament.
• The falciform ligament separates the left lateral and left medial
segments along the umbilical fissure and anchors the liver to the
anterior abdominal wall.

• Deep in the plane between the caudate lobe and the left lateral segment is the
fibrous ligamentum venosum (Arantius’ ligament), which is the obliterated ductus
venosus and is covered by the plate of Arantius.
• The left and right triangular ligaments secure the two sides of the liver to the
diaphragm.
• Extending from the triangular ligaments anteriorly on the liver are the coronary
ligaments. The right coronary ligament also extends from the right undersurface of
the liver to the peritoneum overlying the right kidney, thereby anchoring the liver to
the right retroperitoneum.
• These ligaments (round, falciform, triangular, and coronary) can be divided in a

bloodless plane to fully mobilize the liver to facilitate hepatic resection.

• Centrally and just to the left of the gallbladder fossa, the liver attaches via the
hepatoduodenal and the gastrohepatic ligaments.
• The hepatoduodenal ligament is known as the porta hepatis and contains the common
bile duct, the hepatic artery, and the portal vein.
• From the right side and deep (dorsal) to the
porta hepatis is the foramen of Winslow,
also known as the epiploic foramen .
• This passage connects directly to the lesser sac

and allows complete vascular inflow control
to the liver when the hepatoduodenal
ligament is clamped using the Pringle maneuver.

Segmental anatomy of Liver
• The right lobe typically accounts for 60% to 70% of the liver mass, with the left lobe (and
caudate lobe) making up the remainder.
• The falciform ligament does not separate the right and left lobes, but rather it divides
the left lateral segment from the left medial segment.
• The left lateral and left medial segments also are referred to as sections
• Couinaud divided the liver into eight segments, numbering them in a clockwise direction
beginning with the caudate lobe as segment I.

Cantlie’s Line

Segments

• Additional functional anatomy was highlighted by Bismuth based on the
distribution of the hepatic veins.
• The three hepatic veins run in corresponding scissura (fissures) and
divide the liver into four sectors.
• The main scissura contains the middle hepatic vein, which runs in an
anteroposterior direction from the gallbladder fossa to the left side of
the vena cava.
• It divides the liver into right and left hemilivers.
• The line of the main scissura is also known as Cantlie line.

• The right liver is divided into anterior (segments V and VIII) and
posterior (segments VI and VII) sectors by the right scissura, which
contains the right hepatic vein.
• The right portal pedicle is composed of the right hepatic artery, portal
vein, and bile duct.
• It splits into right anterior and right posterior pedicles, which supply the
segments of the anterior and posterior sectors.

• The left liver has a visible fissure along its inferior surface called the umbilical
fissure.
• The umbilical fissure is not a scissura and does not contain a hepatic vein; it
contains the left portal pedicle, which contains the left portal vein, hepatic
artery, and bile duct.
• This pedicle runs in this fissure and branches to feed the left liver.
• The left liver is split into anterior (segments III and IV) and posterior (segment
II) sectors by the left scissura.
• The left scissura runs posterior to the ligamentum teres and contains the left
hepatic vein.

• The caudate lobe can be the origin of primary liver tumors or the sole site of liver
metastases.
• This lobe is anatomically divided into 3 parts: Spiegel's lobe (Couinaud's
segment 1), paracaval portion (Couinaud's segment 9), and the caudate process.
• Segment IX is a newly described segment, and indicates the part of segment I that
is posterior to segment VIII.

Blood supply
• Hepatic Artery
• The liver has a dual blood supply consisting of the hepatic artery and the
portal vein.
• The hepatic artery delivers approximately 25% of the blood supply, and the
portal vein approximately 75%.
• The standard arterial anatomy is present in only approximately 76% of cases.

Portal vein

• The portal vein is the final common pathway for the transport
of venous blood from the spleen, pancreas, gallbladder, and
the abdominal part of the gastrointestinal tract.
• It is formed by the union of the splenic vein and the superior

mesenteric vein posterior to the neck of the pancreas at the
level of vertebra LII.

• Ascending towards the liver, the portal vein passes posterior to the
superior part of the duodenum and enters the right margin of the lesser
omentum.
• As it passes through this part of the lesser omentum, it is anterior to the

omental foramen and posterior to both the bile duct, which is slightly to
its right, and the hepatic artery proper, which is slightly to its left .

Mickey mouse appearance

• On approaching the liver, the portal vein divides into right and left
branches, which enter the liver parenchyma.
• Tributaries to the portal vein include:

• right and left gastric veins draining the lesser curvature of the stomach
and abdominal esophagus;
• cystic veins from the gallbladder;
• The para-umbilical veins, which are associated with the obliterated
umbilical vein and connect to veins on the anterior abdominal wall

• At the hilum of the liver, the right portal triad has a short extrahepatic
course of approximately 1 to 1.5 cm before entering the substance of
the liver and branching into anterior and posterior sectoral branches.
• The left portal triad, however, has a long extrahepatic course of up to

3 to 4 cm and runs transversely along the base of segment IV in a
peritoneal sheath, which is the upper end of the lesser omentum.
• This connective tissue is known as the hilar plate.

• The continuation of the left portal triad runs anteriorly and caudally in
the umbilical fissure and gives branches to segments II and III and
recurrent branches to segment IV.

Variations
• Lobar variation
– Riedel lobe
– Agenesis of the right hepatic lobe
– Agenesis of the left hepatic lobe
– Accessory hepatic lobes / ectopic liver tissue
– Supradiaphragmatic liver
– Beaver tail liver
• Duct variations

Riedel lobe

Principles of liver resection
• A major advance in the ability to perform liver resections is the

understanding of the segmental anatomy of the liver, as described by
Couinaud in 1957.
• In addition to the portal vein, the arterial supply, biliary drainage, and
hepatic outflow must also be considered in planning the resection.
• Because of the significant variations in liver mass, vascular and biliary

anatomy, tumor location, and extent of resection margin, adequate
preoperative imaging is critical.
• For primary liver tumors, a margin of 1 to 2 cm is preferred.
• The resection margin for metastatic lesions is somewhat more

controversial, but recent studies on resection of colorectal liver
metastasis demonstrated a survival advantage with a resection margin
of at least 1 cm.
• When a liver resection is planned, the future liver remnant needs to

have adequate mass for the patient as well as adequate arterial, portal,
and hepatic vein flow. The remnant must also have adequate biliary
drainage.

Resections
• Anatomic vs. Non-anatomic

• Glissonian vs. Non- Glissonian:
– Glissonian: Onestep division of the entire intrahepatic Glissonian

pedicle.
– Non glissonian resection: To divide the HA, HD, and PV in an
extrahepatic fashion.

Nomenclature

Brisbane 2000

Histology

Physiology

Imaging

Liver lesions
Benign and malignant

Outlines
• Introduction
• Cystic lesions of liver
• Benign solid lesions of liver
• Malignant solid lesions of liver

Cystic liver lesions
Simple cyst:
• Majority are simple cysts, have no malignant potential and rarely become
symptomatic.
• Surgical treatment is considered for symptomatic giant cysts stretching the
liver capsule or compressing the adjacent organs.
• Laparoscopic unroofing may be the ideal approach for these lesions

Polycystic Liver Disease
• Approximately 80% to 90% of PLD cases represent AD disease associated

with polycystic kidney disease.
• US guided puncture of the cysts should be the first choice to decompress
the distended cysts and drain the fluid.
• If percutaneous aspiration is not effective, the next option is laparoscopic
fenestration of the cysts.
• Liver resection or transplantation should be the final treatment option

Extra-hepatic associated conditions
• Intracranial arterial aneurysms can affect 6% of patients without a family history of

ADPKD and up to 16% of patients with family history of ADPKD.
• Screening for intracranial aneurysm by magnetic resonance angiography (MRA) is
recommended only for patients with
– ADPKD,
– Older than 30 years or
– For those patients with family history of hemorrhagic strokes or intracranial
arterial aneurysms
– Cases of a sudden severe headache,
– Candidates to liver or kidney transplantation

• Mitral-valve prolapse
• Colonic diverticulosis that can be detected in 25% of patients with PLD.
• Finally, patients with ADPKD may have asymptomatic cysts within other
organs, such as the pancreas, spleen, ovaries, and lungs.
• Pancreatic cysts are the most common with a reported incidence of 9%

among ADPKD patients older than 30 years.

Biliary Cystadenoma
• Cystic lesion with malignant potential, accounting for 5% of all cystic lesions
in the liver.
• Arise from the biliary epithelium and typically present in middle-aged

women.
• Has a propensity toward local recurrence and malignant degeneration To

cystadenocarcinoma, surgical resection is indicated primarily when biliary
cystadenoma is suspected.
Caroli’s disease

Benign Solid Lesions
• Hemangioma
• Hepatic adenoma
• Focal Nodular Hyperplasia

Hemangiomas
• Most common benign lesion observed in the liver, prevalance 3% to 20%
• Age (40 to 60 years) more common in women
• Well-circumscribed and compressible lesions
• Histopathologically, multiple blood vessels lined by endothelial cells are present.
• The majority are small asymptomatic can be managed non-surgically.
• The risk of malignancy is nil
• The risk of rupture is considered very low
• Biopsy is relatively contraindicated
• Contrast-enhanced CT demonstrates a typical pattern of nodular enhancement from the
periphery with central filling on delayed images ( centripetal ).

Surgical resection is warranted in the setting of:
• Abdominal symptoms
• Spontaneous rupture
• Rapid growth of the lesion
• Coagulopathy due to Kasabach–Merritt syndrome.

Focal Nodular Hyperplasia
• The 2ND most common benign neoplasm of the liver.

• Occurs in 4% to 8% of individuals.
• Women aged 20 to 50 years, questionable relation to OCP.
• FNH is thought to be due to hyperplastic growth of normal hepatocytes with a malformed
biliary draining system or a hyperplastic response to a pre-existing arteriovenous
malformation.
• FNH does not contain a portal venous supply.
• The risk of malignancy is nil
• The risk of rupture is considered very low
• Treatment reserved for patients with persistent symptoms not explained by another
problem.

Hepatic Adenoma
• Rare benign tumor , prevalence 1%

• More in women of child-bearing age who often have a history of long-term use of oral
contraceptives
• Well-circumscribed lesions that contain sheets of hepatocytes without intervening biliary
ductules or portal tracts. (no Kupffer cells)
• Have a risk of either rupture or malignant transformation (estimated risk of 4.2% to
4.5%)
– The HA-B subtype has been found to be more frequently associated with the development of HCC
• High-risk groups for malignant transformation include:

“male patients, androgenic or anabolic steroid intake, glycogen storage disease”
• On CT scan, it hs sharply defined borders and can be confused with
metastatic tumors.
• With venous phase contrast, they can look hypodense or isodense in

comparison with background liver, whereas on arterial phase contrast,
subtle hypervascular enhancement often is seen.

• On MRI scans, adenomas are hyperintense on T1-weighted images and
enhance early after gadolinium injection.
• With the use of liver-specific MRI contrast agents such as gadoxetate

hepatic adenomas can be better distinguished from FNH by their
enhancement characteristics during the hepatobiliary phase of imaging

Treatment
• For small lesions (<5 cm), some recommended withdrawal of oral contraceptives
– Regression of HA upon cessation of oral contraceptives does not remove the risk of
malignant transformation in women.
• Surgical resection is recommended for:

– HAs >5 cm
– Those with intratumoral hemorrhage
– Those that increase in size
– If can not rule out malignancy
– Male
– Pregnant

Hepatic malignancies
• Hepatocellular carcinoma
• Fibrolamellar HCC
• Intrahepatic cholangicarcinoma
• Liver metastasis

Hepatocellular Carcinoma
• Second-leading cause of cancer related deaths worldwide.
• HCC is the most common type of hepatic malignancy
• In the United States, the incidence of HCC is increasing the second-fastest of

all tumor types, probably due primarily to the HCV epidemic

Risk factors
• HBV and HCV infections are the leading causes of HCC, accounting for 75% of the cases
worldwide.
– HBV infection is more common except in Japan and ? , where HCV infection is the most
common cause of HCC.
• Alcoholic liver disease accounts for a significant proportion of HCC in the Western countries.
• Aflatoxin exposure is also an important risk factor in China and sub-Saharan Africa
• Hemochromatosis, schistosomiasis, and carcinogens such as chlorinated hydrocarbons,

nitrosamines, polyvinyl chloride, organochloride pesticides.

Screening measures
The American Association for the Study of Liver Disease (AASLD) has created guidelines
• Serial hepatic ultrasonography and serum AFP measurement every 6 to 12 months for at-
risk populations (e.g., any patient with cirrhosis)
The Japanese Society of Hepatology has recommended:

• Hepatic US and serum AFP or plasma DCP measurement every 3 to 4 months and dynamic CT
or MRI every 6 to 12 months for very high- risk populations (e.g., those with HBV- or HCV-
related cirrhosis)

• When a suspected nodule is detected during regular screening, a contrast-
enhanced three-phase CT or MRI is needed.
• Because HCCs are fed mainly by arterial flow, early enhancement and washout
of contrast on the delayed phase of the scan are typical findings suggestive of
HCC
• These enhancement characteristics increase the specificity of the scan to >95%.

Management
• In the guidelines proposed by the Japan Society of Hepatology:
• Surgical resection is indicated for CTP class A or class B patients with HCCs
with up to three nodules irrespective of the size of each tumor, while liver
transplantation is limited to CTP class C patients meeting the Milan
criteria

• For HCC patients undergoing liver resection, strict assessment of the hepatic
functional reserve is important because HCC usually develops in an injured
liver
• Measurement of indocyanine green (ICG) retention rate at 15 minutes (ICG-

R15) is the most frequently used test.

Fibrolamellar HCC
• Rare variant of HCC
• Equal in males and females
• Younger at presentation
• Uncommon to be associated with underlying cirrhosis
• Better prognosis
• Resembles FNH
• ON CT , the central scar doesn’t enhance unlike FNH

Colorectal Liver Metastases
• About 20% to 25% of colorectal cancer patients are found to have synchronous
CLM
• 35% to 55% develop CLM during the course of the disease.
• The 5-year survival rate after curative resection of CLM has been reported to
be up to 58%
• The median survival duration for patients with CLM without any treatment is
approximately 6 months.

• The surgical indication for CLM should be considered from two standpoints:
– Oncologic resectability and technical resectability.

– The presence of extrahepatic disease does not necessarily represent an absolute
contraindication for surgery.

Liver abscesses and hydatid
cyst

Outlines
• Introduction
• Pyogenic liver abscess
• Amebic liver abscess
• Hydatid liver disease

Introduction
• The liver contains the largest portion of the reticuloendothelial
system in the human body.
• Therefore it’s able to handle the continuous low-level exposure to

enteric bacteria that it receives through the portal venous system.
• Due to the high level of reticuloendothelial cells in the liver, non-

viral infections are unusual.

Pyogenic liver abscess
• Usually seen in elderly patients
• Can be multiple or solitary
• Arise as a result of biliary sepsis
• Mortality is high as diagnosis is often delayed
• Commonest organisms involved - E. coli, Klebsiella, Proteus and
Bacteroides species

Causes
• Biliary disease; commonest - cholecystitis, ascending cholangitis or pancreatitis
• Portal pylophlebitis - appendicitis, diverticulitis or pelvic infections
• Trauma - blunt or penetrating
• Direct extension - empyema of the gall bladder, subphrenic, perinephric abscess
• Septicemia
• Infected liver cysts or tumors

• Approximately 40% of abscesses are monomicrobial, an additional 40%
are polymicrobial, and 20% are culture-negative

Clinical features
• Patients are generally systemically unwell
• Severe abdominal pain usually localized to right hypochondrium
• Swinging pyrexia, rigors and weight loss
• MAY present with jaundice
• Examination shows an hypochondrial or epigastric mass
• MAY have a pleural effusion

Investigation
• Leukocytosis, elevated ESR, and an elevated AP level are the most
common laboratory findings.
• Significant abnormalities in the results of the remaining liver function tests
are unusual.
• Blood cultures will only reveal the causative organism in approximately
50% of cases
• Chest x-ray often shows a raised right hemidiaphragm and pleural effusion

Imaging
Ultrasound
Round or oval hypoechoic lesions with well-defined borders and a variable number of
internal echoes.
CT scan
Is highly sensitive, appear hypodense with peripheral enhancement and may contain
air-fluid levels indicating a gas-producing infectious organism

Cluster sign
Management
• Empiric antibiotic therapy should cover gram-negative and anaerobic organisms.
• Percutaneous needle aspiration and culture of the aspirate may be useful in guiding
subsequent antibiotic therapy.
• IV ab should be continued for at least 8 weeks and can be expected to be effective
in 80% to 90% of patients.
• Placement of a percutaneous drainage catheter is beneficial only for a minority of
patients, as most pyogenic abscesses are quite viscous and catheter drainage is
often ineffective

Surgery may be required if
• Failure of resolution with percutaneous drainage

• Intraperitoneal rupture
➢ Laparoscopic drainage may succeed after failure of percutaneous route

Amoebic liver abscess
• E. histolytica exists as cysts in a vegetative form that are capable of
surviving outside the human body.
• The cystic form passes through the stomach and small bowel unharmed
and then transforms into a trophozoite in the colon.
• Here it invades the colonic mucosa forming typical flask-shaped ulcers,
enters the portal venous system, and is carried to the liver.
• Occasionally, the trophozoite will pass through the hepatic sinusoid and
into the systemic circulation, which results in lung and brain abscesses.

• Amebae multiply and block small intrahepatic portal radicles with consequent focal
infarction of hepatocytes.
• They contain a proteolytic enzyme that also destroys liver parenchyma.
• The abscesses formed are variable in size and can be single or multiple.
• Most commonly located in the superior-anterior aspect of the rt lobe near the
diaphragm and has a necrotic central portion.
• Amebic abscesses are the most common type of liver abscesses worldwide

Clinical features
• Presents with malaise pyrexia and weight loss
• Right hypochondrial pain is often mild
• Less than 20% of patients present with diarrhoa
• Jaundice is uncommon
• Complications can arise as a result of abscess rupture or extension of
infection

Complications
–Amoebic empyema
–Hepato-bronchial fistula
–Lung abscess
–Pericarditis
–Peritonitis

Investigations
• Leukocytosis is common, whereas elevated transaminase levels and
jaundice are unusual.
• The most common biochemical abnormality is a mildly elevated AP level
• Sigmoidoscopy, stool microscopy and rectal biopsy may identify the
organism
• Chest x-ray may show a raised right hemidiaphragm, atelectasis or
abscess

• Most patients have a positive fluorescent antibody test for E. histolytica,
and test results can remain positive for some time after a clinical cure.
• This serologic test has a high sensitivity, and therefore amebiasis is

unlikely if the test results are negative.

• The abscess can often be identified on ultrasound
• Aspiration produces a typical 'anchovy sauce' appearing pus (chocolate

sauce)
• Pus is odorless and sterile on routine culture

Imaging
• Ultrasound and CT scanning of the abdomen are both very sensitive but
nonspecific for the detection of amebic abscesses.
• Usually appear on CT as well defined low-density round lesions that

have enhancement of the wall, somewhat ragged in appearance with a
peripheral zone of edema ( double wall sign)

Management
• Metronidazole 750 mg 3 times a day for 7 to 10 days is the treatment of

choice and is successful in 95% of cases
• Surgery is only rarely required

Aspiration should be reserved for:
• Patients with large abscesses
• Those who do not respond to medical therapy,
• Who appear to be superinfected.
• Abscesses of the left lobe of the liver ?

Hydatid disease
• Due to infection with the helminth Ecchinococcus granulosa

• Adult worm is found normally in the dog and sheep intestine
• Man is an accidental intermediate host
• Infection seen in Mediterranean areas, Australia and South America
(west bank, Turkey)

Introduction
The most common sites of hydatid disease:
• Liver (60–70%), which acts as a first filter,
• Lungs (10–40%), which acts as second filter.
• The rare sites include: spleen, thyroid, gall bladder, central nervous
system, kidney, psoas sheet, retroperitoneal region, orbit.
• Practically any organ can be infested by hydatid disease.

• Cysts are unilocular, can be up to 20 cm in diameter and may be
multiple
• Daughter cysts may develop
• 70% develop in the right lobe of the liver

• Pathologically hydatid liver cyst has three distinct layers:
– Ectocyst - fibrous advential layer due to host response

– Middle layer - laminated membrane of proteinaceous material
– Endocyst - inner germinal layer from which the scolices may be detached

• Most hydatid cysts are acquired in childhood but a latent period of five
to twenty years occurs before the diagnosis is made.
• The growth of hydatid cyst remains indolent
• As a very crude estimate hydatid cysts increase their diameter by about

0.3-1 cm each year.
• The rate of growth of hydatid appears to be dependent on immunologic
relationship between the parasites and humans as also on the
resistance offered by the enveloping structure.

Clinical features
• Clinical presentation is often non-specific and may be asymptomatic
• 60% have right hypochondrial pain
• Only 15% become jaundiced
• Other features include skin rashes, pruritus and allergic reactions
• Cysts can rupture resulting in bronchobiliary fistula

Investigation
• 30% of patients have an eosinophilia
• Diagnosis can be confirmed by indirect haemagglutinin assay
• Serological tests: (ELIZA) has a sensitivity of 80 % overall.

• Plain abdominal x-ray may show calcification in cyst wall
• Cyst can be imaged with ultrasound or CT
• Aspiration should not be performed if hydatid disease is suspected
• Associated with risk of dissemination of infection or anaphylaxis

Ghabri ultrasound classification of liver cyst:
• Type 1 :purely cyst
• Type 2 :purely cystic plus sand
• Type3 : membrane undulating in the cystic cavity
• Type4 : has peripheral or diffuse coarse echoes in a complex mass.

CT abdomen:
• More than 95% sensitive.
• Findings range from purely cystic lesions to a completely solid
appearance and are classified on the basis of appearance.
• Simple cyst with no internal architecture, cyst with daughter cysts and
matrix, calcified cyst, or complicated cyst can be observed.

Water Lilly sign
Management
• Medical treatment with albendazole relies on drug diffusion through
the cyst membrane.
• The concentration of drug achieved in the cyst is uncertain but is better
than that of mebendazole,
• Albendazole can be used as initial treatment for small, asymptomatic
cysts

• Unless the cysts are small or the patient is not a suitable candidate for
surgical resection, the treatment of hydatid disease is surgically based
because of the high risk of secondary infection and rupture.

• For most cysts, surgical resection involving laparoscopic or open complete
cyst removal with instillation of a scolicidal agent is preferred and usually is
curative.
• If complete cystectomy is not possible, then formal anatomic liver resection

can be undertaken.

• During surgical resection, caution must be exercised to avoid rupture of
the cyst with release of protoscolices into the peritoneal cavity.
• Peritoneal contamination can result in an acute anaphylactic reaction or

peritoneal implantation of scolices with daughter cyst formation and
inevitable recurrence.

Complications
• Secondary infection
• Compression of other viscera
• Intra-abdominal rupture causing severe pain
• Severe anaphylactic reactions due to rupture of the cyst are also
reported leading to fever, pruritus, dyspnea, stridor and edema of the
face.
• Fistulization to the bowel, mainly colon and may prove to be life-
threatening massive gastrointestinal bleeding

Recurrent hydatid disease
• Recurrence remains one of the major problems in the management of
hydatid disease, ranging from 4.6% to 22.0% in different series.
• The main reasons for recurrence appeared to be microscopic spillage of

live parasites, failure to remove all viable cysts at inaccessible or difficult
locations, or leaving a residual cyst wall at the initial operation.

• Recurrence detected during the early post-operative period is indicative
of inadequately treated cysts in the first operation.
• Recurrence is actually never seen following complete resection of an

intact cyst with radical surgical interventions when feasible.
• However, with more conservative procedures, the rate of recurrence

reaches 12%.
• The post-operative follow-up period should be at least 3 years and

continued as long as possible

Echinococcus multilocularis
• Echinococcus multilocularis occurs in the Northern Hemisphere and can
infect the liver in a fashion similar to that described earlier, although the
cysts are multilocular.
• Infection of the lung also is common (alveolar echinococcosis).
• Canine species such as wolves, foxes, and dogs ingest infected viscera of
an intermediate host (e.g., rodents, moose) and become infected
• Humans become infected incidentally by ingesting contaminated food or
water


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Liver Anatomy

Principles of liver resection , physiology

Dr. Mahmoud W. Qandeel

• Liver surfaces • Principles of resection

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• Postero - inferior surface=

Dr. Mahmoud W. Qandeel

• The liver is covered by peritoneum

• Inferior surface covered with peritoneum of

• Rt. Lateral surface covered by peritoneum,

Dr. Mahmoud W. Qandeel

1. The Falciform ligament of liver

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• These ligaments (round, falciform, triangular, and coronary) can be divided in a

Dr. Mahmoud W. Qandeel

• This passage connects directly to the lesser sac

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• It is formed by the union of the splenic vein and the superior

Dr. Mahmoud W. Qandeel

• As it passes through this part of the lesser omentum, it is anterior to the

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• Tributaries to the portal vein include:

Dr. Mahmoud W. Qandeel

• The left portal triad, however, has a long extrahepatic course of up to

• This connective tissue is known as the hilar plate.

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• A major advance in the ability to perform liver resections is the

• Because of the significant variations in liver mass, vascular and biliary

• The resection margin for metastatic lesions is somewhat more

• When a liver resection is planned, the future liver remnant needs to

Dr. Mahmoud W. Qandeel

• Anatomic vs. Non-anatomic

– Glissonian: Onestep division of the entire intrahepatic Glissonian

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• Approximately 80% to 90% of PLD cases represent AD disease associated

Dr. Mahmoud W. Qandeel

• Intracranial arterial aneurysms can affect 6% of patients without a family history of

Dr. Mahmoud W. Qandeel

• Pancreatic cysts are the most common with a reported incidence of 9%

Dr. Mahmoud W. Qandeel