LIVER and BILIARY TRACT

by
S O Popoola, FICS
 Outline
Introduction
• Liver
Surface marking
Lobes
Segments
Blood supply
Lymph drainage
Nerve supply
Structure
Stability
o Biliary tract
Gall bladder
Blood supply
Lymph drainage
Structure
Common hepatic duct
Bile duct
Blood supply of the biliary tract
Nerve supply of the biliary tract
 Portal vein

Applied anatomy
Biopsy, lobectomy and transplantation
Surgical approach to the biliary tract
Conclusion
 Introduction (liver)
• Liver is the largest gland in the body
• Liver weighs 1500g and receives 1500 ml of blood per minute
• Liver’s form has nothing to do with its function; the large
wedge-shaped mass is merely a cast of the cavity into which it
grows
• It has two surfaces: diaphragmatic and visceral
• Diaphragmatic surface is boldly convex, moulded to the under
surface of the diaphragm
• Surface is subdivided into anterior, superior, posterior and
right which merge into one another without any clear
demarcation
 Introduction (biliary tract)
• There are intra- and extra- hepatic biliary tracts
• Extrahepatic biliary tract consists of the three hepatic ducts
(right, left and common), the gall bladder and cystic duct, and
the bile duct
• Bile is manufactured by the liver cells
• It is collected in bile canaliculi in the lobules
• It flows along the portal canals in the bile duct tributaries
• Rt & Lt hepatic ducts emerge at the porta hepatis where they
join to form common hepatic duct
• Common hepatic duct is joined by cystic duct from the gall
bladder to form the bile duct
 Liver (surface marking)
• Anteriorly, upper margin of liver is about the
level of xiphisternal joint
• To the left, it reaches the 5th intercostal space
about 7-8 cm from midline
• To the right, it reaches 5th rib, curving down to
right border which extends from ribs 7th to 11th in
midaxillary line
• Inferiorly, the border is along a line joining the
right lower and upper left extremities
 Liver
• Liver is divided into a large Rt and small Lt lobes
separated superiorly by falciform ligament and
posteriorly by H-shaped arrangement of fossae
• H-shaped arrangement:
Rt anterior-fossa for gallbladder
Rt posterior- groove for IVC
Lt anterior- fissure for ligamentum teres (obliterated
left umbilical vein)
Lt posterior- fissure for ligamentum venosum (remnant
of fetal ductus venosum)
Liver
Liver
Liver
Liver
Liver
Liver (segments)
 Liver (blood supply)
• Liver receives blood from two sources: hepatic artery
and portal vein
• Hepatic artery divides into right and left branches in the
porta hepatis
• The division is Y-shaped, in contrast to the T-shaped
division of the right and left branches of the portal vein
• The right branch of the hepatic artery normally passes
behind the common hepatic duct and in the liver divides
into anterior and posterior segmental branches
 Liver (blood supply)
• Left hepatic artery divides into medial and
lateral segmental branches
• Sometimes common hepatic artery arises from
the superior mesenteric artery or the aorta
(instead of the coeliac trunk
• The right and left hepatic branches may
themselves arise from the superior mesenteric
or left gastric arteries respectively constituting
the aberrant hepatic arteries
 Liver (blood supply)
• Venous blood is carried to the liver by the portal vein
which divides in the porta hepatis into right and left
branches which in turn give segmental branches like the
arteries
• Portal blood is laden with the products of digestion which
have been absorbed from the alimentary canal, and which
are metabolized by the liver cells
• The hepatic artery and portal vein are everywhere
accompanied by tributaries of the hepatic ducts; the three
together lie in 'portal canals' of histological sections
 Liver (blood supply)
• There is no communication between right and left
halves of the liver; indeed, even within each half the
arteries are end arteries-infarction of the liver
• There are often enough anastomoses with phrenic
vessels (across the bare area) to provide a collateral
circulation that is sufficient to allow ligation of the
hepatic artery
• From the portal canals the blood passes into the
sinusoids between the rows of liver cells to the
centre of each lobule
• The arterial and portal venous blood become mixed
in the sinusoids and then pass into the central vein in
the centre of each lobule
 Liver (blood supply)
• The central veins of all the lobules unite to form the hepatic veins
• The venous return differs in that it shows a mixing of right and left
halves of the liver
• Three main hepatic veins high up near the diaphragmatic surface,
drain into the inferior vena cava
• A large central vein runs in the plane between right and left halves
and receives from each lobe
• Further laterally lie a right and left vein; the middle vein frequently
(60%) joins the left very near the vena cava
• All the veins have no extrahepatic course and enter the vena cava
just below the central tendon of the diaphragm
 Liver (lymphatics)
• The lymphatics of the liver drain into three or
four nodes that lie in the porta hepatis
(hepatic nodes)
• These nodes also receive the lymphatics of the
gall bladder
• They drain downwards alongside the hepatic
artery to retropyloric nodes and so to the
coeliac nodes
 Liver (innervation)
• Nerve supply of the liver is derived from both
the sympathetic and vagus
• Sympathetic is by way of the coeliac ganglia-
run with the vessels in the free edge of the
lesser omentum and enter the porta hepatis
• Vagal fibres from the left vagal trunk reach the
porta hepatis along the lesser curve of the
stomach via the lesser omentum
 Liver (structure)
• The classic description of liver morphology is centred on the
liver lobule
• Lobule is pinhead size and hexagonal shape with a central
vein as the central feature and with sinusoids
• The plates or cords of hepatocytes radiating from it to the
periphery of the lobule
• Functional unit of the liver being the 'acinus' rather than the
lobule
• The acinus on section is a diamond-shaped area with central
veins at one pair of opposite corners and portal canals at the
other pair
Liver (microscopy)
 Liver (structure)
• The sinusoids intervening between the cords of hepatocytes are
lined (like all vessels) by endothelial cells which show frequent
intercellular spaces and fenestrations
• Many of the endothelial lining cells are capable of phagocytic
activity, constituting the Kupffer cells of the mononuclear
phagocyte system
• Bile manufactured by hepatocytes first enters the biliary
canaliculi which are situated between apposing sides of adjacent
hepatocytes
• Collectively the canaliculi form a meshwork which drains into the
bile ductules of the portal canals, and these in turn unite to form
the larger intrahepatic ducts
 Liver (stability)
• Liver is supported by the hepatic veins and the inferior vena
cava
• The hepatic veins are entirely intrahepatic and enter the vena
cava
• Liver is clasped in the deep groove on the posterior surface
• Autopsy: liver cannot be displaced caudally until the inferior
vena cava is divided below the diaphragm
• The thin inferior border of the liver is prevented from tilting
downwards by the attachments of the left triangular ligament
and the ligamentum teres
• Liver rest on the underlying viscera
 Biliary tract
• The extrahepatic biliary tract:
three hepatic ducts (right, left & common)
Gall bladder
cystic duct
bile duct
• Bile is manufactured by the liver cells
• Bile is collected in bile canaliculi in the lobules, flows along the portal
canals in the bile duct tributaries and so reaches the right and left hepatic
ducts
• Common hepatic duct passes down between two peritoneal layers at the
free edge of the lesser omentum
• The common hepatic duct joined by cystic duct from gall bladder form bile
duct
 Gall bladder
• Gall bladder stores and concentrates the bile
secreted by the liver
• Globular or pear-shaped viscus with a capacity of
about 50 ml
• Consists of three parts- fundus, body and neck
• Gall bladder fossa on the visceral surface of the
right lobe of the liver
• Gall bladder receives many small vessels from its
hepatic bed, but there is also a cystic artery
 Gall bladder
• Fundus, projects a little beyond the sharp lower border of
the liver and touches parietal peritoneum of the anterior
abdominal wall at the tip of the 9th costal cartilage
• At the transpyloric plane crosses the right costal margin at
the lateral border of the right rectus sheath
• common hepatic duct and cystic duct forms Calot’s
triangle
• Venous return is by multiple small veins in the gall bladder
bed into the substance of the liver and so into the hepatic
veins
 Gall bladder
• Lymphatic channels from the gall bladder drain to nodes in the
porta hepatis, to the cystic node (in Calot's triangle)
• From these nodes lymph passes in the free edge of the lesser
omentum to the coeliac group of preaortic nodes
• The gall bladder is a fibromuscular sac
• There is small amount of smooth
• muscle in its wall
• Its mucous membrane is a lax areolar tissue lined with a simple
columnar epithelium
• It is projected into folds which produce a honeycomb
appearance