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Liver, Gallbladder

and Biliary Tree
Dr. Aldwin A. Yaneza
Dept of Anatomy

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LIVER
- Largest gland
- Approx 1500 g, ¼ of BW
- Lies in R upper and L upper
quadrants [mainly on right]
- Inferior to diaphragm
- Function:
- 1] stores glycogen
2] secretes BILE

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SURFACES
 A. Diaphragmatic
 Smooth and dome
shaped
 Recesses
 Subphrenic – bet
diaphragm & liver
 Hepatorenal – bet liver
and R kidney

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Ligaments of liver
 Bare area of liver – not
covered–with peritoneum
 Ligaments

1] Coronary – superior
2] Triangular – lateral
3] Falciform – anterior,
middle
4] Round – inferior,
remnant of
umbilical vein

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SURFACES
 B. Visceral
 Covered w/ peritoneum
except at bed of gallbladder
and porta hepatis
 Relations
- R side of stomach –
gastric/pyloric area
- 1st part duodenum –
duodenal area
- Lesser omentum
- Gallbladder
- R colic flexure – colic area
- R kidney/suprarenal gl –
renal/ suprarenal` area

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Visceral surface
 Structures:
 IVC
 Portal triad
 Hepatic artery
 Portal Vein
 Hepatic duct
 Caudate lobe
 Quadrate lobe

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FUNCTIONAL PARTS
 Functionally independent R/ L lobes
 Can donate one lobe to relative
 Each lobe with own
 Blood supply
 Venous drainage
 Biliary drainage
 Division into R – L lobes
 GB fossa inferiorly and IVC fossa superiorly
 Facilform lig [ old terminology]

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Current [func’l]
terminology
L liver = caudate and quadrate lobe
+ L lobe
R liver = R lobe

OLD terminology
Falciform lig
– divides it into R
and L

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Functional parts
 Round ligament [L. ligamentum teres]
 Remnant of umbilical vein that carried
oxygenated blood from placenta to fetus
 Porta Hepatis
 Transverse fissure on visceral surface of
liver bet caudate and quadrate lobes
 Passage for portal triad
 1] Portal vein
 2] Hepatic artery
 3] Hepatic duct
 Others – hepatic nerve plexus, lymph

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Portal v

Hepatic art

Hepatic duct

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Peritoneal Relations
 Lesser omentum
- fr liver to lesser curve of
stomach and 1st part of
duodenum
- parts:
 Hepatoduodenal lig
 Extends bet porta hepatis and
duodenum
 Encloses portal triad
 Hepatic duct, hep. artery, portal
vein
 Hepatogastric lig
 Extends bet liver and lesser curve
of stomach

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Vessels and nerves
 Liver receives blood from 2 sources
 1] Portal vein [ 70 % ]
 2] Hepatic artery [ 30 %]

 Venous drainage
 Hepatic vein
 Formed by union of central veins of liver
 Drains into IVC

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Blood supply of liver
 1. PORTAL VEIN
 Formed by union of
superior mesenteric
vein [SMV] and
splenic vein
 Ascends anterior to
IVC, has R - L
branches
 Carries poorly
oxygenated but
nutrient rich blood fr
GIT to liver
 70%

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Blood supply of liver
 2. HEPATIC artery
 Br of celiac art
 Div into R and L
hepatic art
 Carries well
oxygenated blood
from aorta to liver
 30%

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SEGMENTS
 Horizontal plane thru R lobe and lateral
division of L lobe plus caudate lobe
 Divides liver into 8 vascular segments
 Based on divisions of the hepatic
artery and portal vein and hepatic
ducts
 Each segment:
 Supplied by br of hepatic art. and Portal V.
 Drained by branch of hepatic duct

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I-back
Posterior IVa II
superior

III

VIII
VII
IVb

V
VI
Posterior
inferior P A Me La

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Division
 Anatomic[2] – Falciform lig
 Functional[2] – L lobe is quadrate
+caudate + L anatomic
lobe
 Surgical[4] - R/ L Lateral and Medial
div
 Segments [8] - Couinauds

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P A Me La

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Segments
 I - Caudate
 II - Lateral superior
 III - Lateral inferior
 IVa - Medial superior
IVb – Medial inferior
 V - Anterior inferior
 VI - Posterior inferior
 VII – Posterior superior
 VIII - Anterior superior

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The Couinaud classification of liver anatomy divides the liver into
eight functionally indepedent segments.
Each segment = own vascular inflow, outflow and biliary
drainage.
In the centre of each segment - branch of the portal vein, hepatic
artery and bile duct.
In the periphery of each segment = vascular outflow through the
hepatic veins.

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4A

4B

Segments numbering
There are 8 liver segments.
Segment 4 is sometimes divided into segment 4a and 4b according to
Bismuth.
The numbering of the segments is in a clockwise manner (figure).
Segment 1 (caudate lobe) is located posteriorly. It is not visible on a
frontal view.
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Lymphatics
 Major lymph producing organ
 Occur as superficial lymphatics in
Glisson’s capsule and as deep lymphatics
in connective tissue that accomp the
p.triad
 Anterior superf lymph  hepatic LN 
celiac LN  chyle cistern [dilated sac of
t. duct]
 Posterior superf lymph  phrenic LN 
posterior mediastinal LN  thoracic duct

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Nerve Supply
 Hepatic Nerve Plexus
 Largest derivative of celiac plexus
 Accomp branches of p. triad to liver

 Consists of sympathetic and parasym
fibers
 Function: Vasoconstriction

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Variations in LIVER

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IRON MAN Robert Downey Jr

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The Dark Knight ,2008
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GALLBLADDER and
BILIARY DUCTS
Bile
 Produced by hepatocytes
 Yellow fluid

 Stored in GB

 Passes to via bile ducts duodenum

 Emulsifies fat

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Gallbladder

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I. General Information
A. Location:
1. Epigastric region
2. R hypochondriac

3. inferior surface
of liver
4. Between quadrate and right
lobes
B. Pear-shaped, hollow structure
thin walled greenish
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General Information, con’t.

C. Fundus slants inferiorly, to the right
D. Attached to liver by loose (areolar)
connective tissue
E. Peritoneum covers free surfaces

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Introduction, continued …

F. Normal measurements:
7-10 cm long
4 - 6 cm diameter
30 – 60 cc bile
G. Function:Stores and concentrates bile

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II. Detailed Anatomy
A. Fundus of GB:

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Parts Gallbladder
 Fundus
-wide end
-Projects fr inferior
border of liver
 Body
-Main part
-Contacts the R part
of transverse colon
and 1st part of
duodenum

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Body
-Contacts the R part of transverse colon and 1st part of
duodenum
- Chronic cholecystitis[inflammation], body forms
connection with
1] colon – cholecystocolonic fistula
2] duodenum – cholecystoduodenal fistula

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 Neck
Gallbladder
-Narrow,tapered
-Continuous w/ cystic duct
-Mucosa thrown into spiral fold
[valve of Heister]
-Serves as guide to omental
bursa
 Cystic duct
- 2- 4 cm long
- Joins common hepatic duct to
form common bile duct
-mucous membrane thrown
into spiral fold

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Gallbladder
 Arterial supply
 Cystic art [fr R
hepatic artery]
 Venous drainage
 Cystic vein [drains
into R branch of
portal vein]
 Lymphatic drainage
 Hepatic LN
 Nerve supply
 Celiac plexus [symp]
 Vagus n [parasymp]

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The Gallbladder and Biliary System with Pancreas

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Detailed Anatomy, con’t….

O. Lymphatic drainage of GB
1. Enlarged – [+]malignancy
2. Cystic node at neck of GB
a. Cystic node of Calot
b. Behind is cystic artery
c. Guide for laparoscopic surgeons
3. Other lymph vessels also drain
into hepatic nodes
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Lymph Nodes
 N1
 Choledochal
 Hilar
 Cystic duct

 N2
 Peripancreatic
 Retroduodenal
 Portal, celiac, or
superior mesenteric
vessels

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Biliary Ducts
 Hepatic ducts- drain the
liver
 R Hep duct – R lobe
 L Hep duct – L Lobe
 Common hepatic ducts-
when R and L hd unite
 4 cm, in lesser omentum
 Common bile duct
- after giving off cystic
duct on right

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2009 Movies

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Harry Potter and the Half blood
Prince

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Transformer 2: Revenge of
the Fallen

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Common Bile Duct
 8-10 cm long [ CBD ]
 5-6 mm diameter
 in lesser omentum
 Passes behind 1st part
of duodenum
 Unites w/ main
pancreatic duct to form
hepatopancreatic
ampulla
 Opens into descending
or 2nd part of duodenum

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CBD
 Arterial supply
 Proximal part – cystic a
 Middle part – R hepatic a
 Distal part – posterior
superior
pancreaticoduodenal a
 Venous drainage
 Posterior superior
pancreaticoduodenal vein
 Lymphatic
 Cystic LN
 Hepatic LN
 Celiac LN

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III. Gallbladder Diseases

A. Cholelithiasis & Cholecystitis
1. Cholecystitis = inflammation of GB
2. Cholelithiasis = Stone(s) in GB

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Cholelithiasis

 GB shows likely
sites of stone
formation/depositi
on

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Gallbladder Diseases, continued …

B. GB Carcinoma
a. US useful in diagnosis
b. mass producing thickening and
irregularity in wall
c. Calculi found frequently

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Gallbladder Diseases, continued …

C. Polyps of GB
a. Intraluminal echogenic projections
b. Do not change position with patient
c. Must be differentiated from
stones

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Gallbladder diseases, continued …

D. Viscid Bile, “sludge”
a. Due to intermittent obstruction of
CBD or cystic duct
b. Seen in patients with bile stasis
c. Produces linear, echogenic
interface within GB

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Cystic artery
 Ligated during
surgical removal of
gallbladder
[cholecystectomy]

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Variations in Anatomy of Cystic Duct

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Anatomy /Histology
 Mucosa
 Smooth muscle
 Serosa

 Attachment to liver
 Tumors can extend
directly into liver

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Laparoscopic Cholecystectomy

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Identify the gallbladder

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Triangle of CALOT = area formed by the cystic duct, hepatic duct and edge of
liver. The cystic artery will be located in this triangle

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Isolate and ligate the cystic
artery

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Isolate and ligate the cystic duct

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Clinical correlation:
Calculous cholecystitis
 Diet high in fat
produces cholesterol
stones inside GB
 After eating GB
contracts, it expels
stone w/c lodges at
cystic duct
 Trigger inflammation of
GB [cholecystitis]
 Pain at RUQ
 Diagnosed by:

-History, PE and
ultrasound

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Empyema of gallbladder
 Longstanding impaction of stone
at cystic duct
 Remaining bile cannot exit the
GB because of impacted stone
 Bacteria will set in
 Abscess forms inside GB
 GB enlarges, wall thickens
Clinical :
 Fever, RUQ pain, palpable GB at
RUQ
 Common among diabetics and
noncompliant patients

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Ruptured Cholecystitis

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National Kidney Institute,East Ave

FEU Medical
Center,Fairview

The end

Aldwin A. Yaneza,MD
General and Laparoscopic Surgery

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SET A
SET B

Gallbladder
Pear shaped sac
 Along R edge of quadrate lobe of
liver in depression called
gallbladder fossa,V
 Hangs by stem = cystic duct
 Rounded fundus projects beyond
inferior margin of liver
 Thin walled greenish
 Covered on its posterior and
inferior surfaces by peritoneum
 Concentrates and stores bile
secreted by liver
 Holds 30-60 ml of bile

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END

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Quiz
 Set A  Set B
 Tabulate the 7  Draw and label the 8
differences between the Couinauds segments
jejunum and ileum  Tabulate the 7
 Draw and label the 8 differences between the
surgical segments jejunum and ileum
 Draw and label the  Draw and label parts of
biliary tree/ tract gallbladder

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