THE LIVER I

Omar Hirsi
24th sep 2018
 Outline
• Anatomy
 Segmental
 Blood supply
 Innervation and lymphatic drainage
• Physiology
• Weighs approx 1.5kg
• Arises at embryonic junction(septum transversum)
• Has several ligaments:
 Falciform
 Round ligament
 Ligamentum venosum
 Triangular
 Coronary and hepatoduodenal
Hepatoduodenal and gastrohepatic
• These ligaments can be divided in a blood less
plane to fully mobilize the liver.
• For exposure of IVC and pringle’s maneuver
Porta Hepatis
 Segmental anatomy
• Liver is grossly separated into the right and left lobe by GB
and IVC…Cantlie’s line

• Falciform ligament does not divide the right and left lobes

• Couinaud divided the liver into 8segments numbering them in

an clockwise direction
• He began with the caudate lobe as segement 1
• Additional functional segments by bismuth based on hepatic
vein
 Blood Supply
• Hepatic artery:
 Liver has dual blood supply( hepatic artery and
portal vein)
 Hepatic artery delivers 25% and portal vein
delivers 75%
Classic Anatomy Hepatic artery
Accessory right hepatic artery
 Variants
• Accessory right hepatic artery from SMA(10-
15%).. Runs posterior to CBD
• 3-10% accessory left hepatic artery from left
gastric artery…runs obliquely in the
gastrohepatic ligament.

• Common hepatic coming off SMA(1-2%)

• Right hepatic artery passes deep and posterior
to CBD in 88% but crosses anterior in 12%
• Cystic artery arises usually from right hepatic
artery in calot’s triangle
Calot’s triangle
 Portal vein
• Formed by the confluence of the splenic vein
and SMV
• Inferior mesenteric vein usually drains into the
splenic vein
• Traverses through the porta hepatis
• Left portal supplies the segments 2 ,3, 4 and
caudate lobe
• Portal vein pressure 3-5mmHg
• Its valve less

• In portal HTN: 20-30mmHg; results in high pressures in the

left gastric hence esophageal and gastric varices
Portal vein
 Hepatic Vein
• Three: right, middle and left that pass through
the liver to drain into the IVC
• Right hepatic vein drains segments 5,6,7 & 8
• Middle hepatic vein.. 4,5 & 8
• Left …. 2 and 3
• Caudate lobe veins drain directly into the IVC
• Variants: large inferior accessory hepatic vein
that runs in the hepatocaval ligament
• The hepatic veins bisect between the portal
vein in the parenchyma
Hepatic vein
 Bile ducts
• Common bile duct lies anteriorly and to the
right in the porta hepatis
• Hepatic ducts follow the arterial branching
pattern
• Left hepatic duct has longer extrahepatic
course.
• Variations: accessory hepatic ducts, variable
drainage of cystic ducts…
 Neural innervation
• Parasympathetic innervation comes from left
and right vagus.
• Sympathetic from greater thoracic splanchnic
nerves
• Denervated liver after transplantation
functions with normal capacity
• Referred pain(right shoulder, scapula, back) is
usually due to stimulation of phrenic nerve by
stretching of glisson’s capsule.
 Lymphatic drainage
• Drains via the perisinusoidal space of Disse

• And periportal clefts of mall to larger lymphatics that drain to

the hillar cystic duct lymph nodes (calot’s triangle nodes)

………important for cholangiocarcinoma(high incidence of nodal

mets)

• Cardiophrenic nodes (cephalad drainage)

 Liver physiology
• Extraordinary spectrum of functions:
 Storage
 Metabolism
 Production
 Sectretion
• Ensures sufficient supply of glucose to CNS
during fasting(gluconeogenesis,
glycogenolysis)
• Reponsible for the synthesis of most
circulating proteins (albumin, coagulation
factors, complement factors)
 Bilirubin metabolism
• Is the end product of heme catabolism
• Bound to albumin…liver
• Conjugated to soluble bilirubin diglucoronide
• Hence excreted mostly via intestines

• Role of Intestinal bacteria..?

 Formation of Bile
• Complex fluid(organic and inorganic substance)
• Main components: water, electrolytes, bile pigment,
phospholipid and cholesterol

• Functions:
 Aid in digestion and absorption of lipids and vit ADEK
 Excretion of waste products(bilirubin and cholesterol)
• In between meals bile is stored in gall bladder

• Bile salts in conjunction with phospholipids are responsible

with digestion of lipids

• Bile salts exctreted into the small intestines are reabsorbed

and reused(enterohepatic circulation)…90%