Surgical Anatomy of

Liver
A good knowledge of the anatomy is

prerequisite for modern surgery of the liver.”

H. Bismuth
• Largest solid organ in body

• Weight around 1.5 kg

• Thoracoabdominal Organ

• Lies in the right upper quadrant of the abdomen

• Covered by a thin capsule “Glisson’s capsule”

 Surface anatomy of the liver

-The greater part of the

liver is situated under
cover of the right costal
margin

- Diaphragm separates
it from the pleura,
lungs, pericardium, and
heart.
 Anterior View of the liver
• Right lobe
• Cut edge of the
Falciform ligament left
lobe
• Diverging cut edges of
the superior part of
the coronary ligament
• Fundus of the gall
bladder
Surfaces of the liver, their relations & impressions
• Postero - inferior
surface= visceral
surface
• Superior surface =
Diaphragmatic
surface
• Anterior surface
• Posterior surface
• Right surface
Postero- infero surface= visceral surface
Relations
• I.V.C
• the esophagus
• the stomach
• the duodenum
• the right colic flexure
• the right kidney
• Rt. Suprarenal gland
• the gallbladder.
• Porta hepatic( bile duct,H.a.H.V)
• Fissure for lig. Venoosum & lesser omentum
• Tubular omentum
• Lig.teres
 Relations of Sup . surface of liver

• Diaphragm
• Pleura & lung
• Pericardium &
heart
Relations of the liver Anteriorly
• Diaphragm
• Rt & Lt pleura and lung
• Costal cartilage
• Xiphoid process
• Ant. abdominal wall
Posterior relation of the liver

• Diaphragm
• Rt. Kidney
• Supra renal gland
• T.colon(hepatic
flexure
• Duodenum
• Gall bladder
• I.V.C
• Esophagus
• Fundus of stomach
Lobes of the liver
• Rt. Lobe
• Lt .lobe
• Quadrate lobe
• Caudate lobe
Separation of the four lobes of the liver:
• Right sagittal fossa -
groove for inferior
vena cava and gall
bladder
• left sagittal fissure -
contains the
Ligamentum
Venoosum and round
ligament of liver
• Transverse fissure
(also porta hepatis) -
bile ducts, portal vein,
hepatic arteries
 Rt. Lobe
-Largest lobe
- Occupies the right
hypochondrium
- Divided into anterior and
posterior sections by the right
hepatic vein
- Reidel’s Lobe extend as far
caudally as the iliac crest
Left Lobe

• Varied in size
• Lies in the epigastric and
left hypochondriac
regions
• Divided into lateral and
medial segments by the
left hepatic vein
Rt. & Lt lobe separated by
• Falciform ligament
• Ligamentum Venoosum
• Ligamentum teres
 Caudate Lobe

-present in the posterior

surface from the Rt. Lobe
Two processes
1- c- process
2- papillary process
Relations of caudate lobe
- Inf.  the porta hepatis
- The right  the fossa for the
inferior vena cava
- The left the fossa for the
lig.venosum.
 Quadrate lobe

Present on the inferior surface

from the Rt. Lobe

Relation
- Ant. anterior margin of the
liver
- Sup. porta hepatis
- Rt. fossa for the gallbladder
- Lt by the fossa for lig.teres
Porta hepatis
-It is the hilum of the liver
-It is found on the
posteroinferior surface
- lies between the caudate
and quadrate lobes
-Lesser omentum attach to
its margin

Contents
- Gallbladder  ant.
- Hepatic. Art + nerve+
lymphatic node  middle.
- Portal vein  post.
 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)
1. 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
Segmental anatomy of the liver
• Rt .& Lt. lobes anatomically no
morphological significance.
Separation by ligaments
(Falciform, lig. Venoosum &
Lig.teres)
• True morphological and
physiological division by a line
extend from fossa of GB to fossa
of I.V.C each has its own arterial
blood supply, venous drainage
and biliary drainage
• No anastomosis between divisions
• 3 major hepatic veins  Rt, Lt &
central
• 8 segments based on hepatic and
portal venous segments
Segmental anatomy of the liver
• Liver segments are based on the portal and hepatic venous
segments
Blood supply of the liver
 Blood supply of the liver

• Proper hepatic artery 

The right and left hepatic
arteries enter the porta
hepatis.
• The right hepatic artery
usually gives off the cystic
artery, which runs to the
neck of the gallbladder.
Blood Circulation through the Liver
• The blood vessels conveying blood to the
liver are the hepatic artery (20%) and
portal vein (80%).
• The hepatic artery brings oxygenated
blood to the liver, and the portal vein
brings venous blood rich in the products
of digestion, which have been absorbed
from the gastrointestinal tract.
• The arterial and venous blood is
conducted to the central vein of each
liver lobule by the liver sinusoids.
• The central veins drain into the right and
left hepatic veins, and these leave the
posterior surface of the liver and open
directly into the inferior vena cava.
Vein drainage of the liver
• The portal vein divides
into right and left
terminal branches that
enter the porta hepatis
behind the arteries.
• The hepatic veins (three
or more) emerge from
the posterior surface of
the liver and drain into
the inferior vena cava.
Lymphatic drainage of the liver
• Liver produce large amount of lymph~ one third – one half of total body lymph
• Lymph leave the liver and enters several lymph nod in porta hepatis efferent vessels pass to celiac nods
• A few vessels pass from the bare area of the liver through the diaphragm to the posterior Mediastinal lymph
nodes.

Nerve supply
• Sympathetic  hepatic plexus>>> celiac plexuses  thoracic ganglion chain T1-T12
• Parasympathetic  vagous nerve( anterior part)

• Sympathetic and parasympathetic nerves form the celiac plexus.

• The anterior vagal trunk gives rise to a large hepatic branch, which passes directly to the liver
Liver Abscess
 Incidence & Prevalence
 Pyogenic liver abscess => 20 / 1,00,000 hospital admissions in a
western population

 WHO reported that Entamoeba Histolytica causes ~ 50 million

cases and 100,000 deaths annually.

 Common condition in India, 2nd highest incidence of liver abscess in the world.
(Ref: Kapoor OP. Amaoebic liver abscess, 1st eds, SS Publishers, Bombay, 1999.)
 Classification
• The 3 major forms of liver abscess, classified by etiologically

1. Pyogenic abscess, which is most often poly microbial

2. Amoebic abscess due to Entamoeba histolytica

3. Fungal abscess, most often due to Candida species, less common.

• Pyogenic abscess accounts for majority in developed countries whereas

amoebic liver abscess is largely a disease of developing countries like
India.
 Predisposing Factors
Males > Females

Diarrhoea & Dysentery (Hygeine)

Alcoholism

Immunosuppression (Malignancy, HIV, Corticosteroids)

Trauma
 Interventional Procedures
 Pyogenic Liver Abscess(PLA)
 Previously more often seen in Early 20s & 30s -- Portal in Origin
(Enterococcus Faecalis, Bacteroids)

 Now more common in Adults of 50s & 60s -- Hepatobiliary & Cryptogenic
(E.Coli, Klebsiella, Fungi)

 Other important causes are – Arterial/Systemic, Local infection, Traumatic.

(Staphylococcus, Fungi)
Common causes of pyogenic liver
abscess
Hepatobiliary (40%) Portal (20%)
Benign Benign
Diverticulitis
Lithiasis / Cholecystitis
Anorectal suppuration
Biliary enteric anastomosis Pelvic suppuration
Endoscopic / Percutaneous Postoperative sepsis
biliary procedures Appendicitis
Inflammatory bowel disease
Malignant
Malignant
Common bile duct/Gall bladder Colonic cancer
Head of pancreas (Periampullary) Gastric cancer
Common causes of pyogenic liver
abscess
Arterial (10%) Traumatic (!0%)
Endocarditis Open or closed abdominal
Vascular sepsis trauma
ENT infection
Dental infection Post-intervention
Chemoembolization
Local infection (6%) Percutaneous ethanol injection
SubPhrenic Abscess or radiofrequency ablation
Perinephric Abscess
Intestinal Perforation Cryptogenic
 Clinical Presentation
Symptoms & Signs: Acute & Fulminant < 7 days of symptoms
Subacute & Indolent > 7 days -2 Months

 Fever , Pain Right Hypochondrium

 Abscess adjacent to the diaphragm may cause chest & shoulder
pain, Cough and dyspnea.

Maingot’s abdominal operation: most patients manifest symptoms for

less than 2 weeks, a more indolent course occurs in 1/3rd of the patients.
 Clinical Features
Symptoms: Signs:
Fever Hepatomegaly
Abdominal pain Tenderness
Chills Rebound tenderness
Anorexia Jaundice (late)
Nausea, Vomiting
Right shoulder pain /

irritable cough
 Pyogenic Liver Abscess
Generally, Portal, Traumatic and Cryptogenic Abscesses are solitary &
Large.

Whereas, HepatoBiliary and Arterial/systemic origin abscesses are multiple &

Small.

 Fungal Hepatic Abscesses are multiple, bilateral and miliary in

nature.
 Diagnosis
• Ultrasonography (USG)is
the tool commonly used for
diagnosis of liver abscess.

• Ultrasound (USG): Initially

it is hyperechoic and
indistinct, with maturation it
becomes hypoechoic with
a distinct margin.
 Diagnosis
• When the pus is very thick, may be confused with a solid lesion.

• USG has a sensitivity of 75% to 95%, has the advantage of imaging underlying biliary
tract pathology.

• Limitations: in detecting an abscess high in the dome of the right hemiliver and
especially multiple small PLAs.

• A computed tomography (CT) scan is more accurate than USG in the differentiation of
PLA from other liver lesions and is reported to have a sensitivity of approximately 95%.
CECT abdomen with portal venous
phase
• It helps in detecting PLA accurately
(peripheral flare with non enhanced centre.)

• MRI : Tw1 : Centre Hypointense

Tw2: Centre Hyperintense

• Gallium Scan:
ALA: Cold spot
PLA: Warm Spot

• Radioisotope labelled Metronidazole

 Biochemical markers:
Correlate with severity of Liver abscess / Liver disease

Most commonly studied: Alkalinephosphatase (ALP),Aspartate

Aminotransferase (AST) and Alanine Aminotransferase(ALT)
Others:
GGT is more specific for Liver tissue.
C-reactive Protein (CRP) Value.
LDH is raised in cases of chronic liver pathology.
 Other investigations
• CBC: Neutrophilic leucocytosis
• Stool Examination: cyst or vegetative form of E. Histolytica
• Pus Culture
• Sigmoidoscopy
• Serology:
Indirect Haemagglutination test: Sensitive and remain positive for 1 year.
Gel Diffusion Precipitation test: Both tests are 96% Accurate
ELISA: Sensitive test for Ab detection in serum and Abscess aspirate
Chest X-Ray:
a) Elevation of right
hemidiaphragm

b) Right basilar
infiltrate
 Newer Methods of Diagnosis
• Detection of Protein antigen in faeces and serum by monoclonal antibody

• Detection of parasite DNA by Nuleotide Probe and PCR amplification.

• Commercial ELISA KIT using Monoclonal antibody against lectins of EH, helps
in differentiating EH with E. dispar.
 Treatment
• Antibiotic Therapy : Protocol in Practice
(Cephalosporin+ Metronidazole or Flouro Quinolones + Metronidazole)

• Drainage of Pus(USG Guided Aspiration or Pigtail Catheter placement)

• Treatment of Co morbid Condition and complications

• Indications for surgical drainage:

a)peritonits

b) Ruptured liver abscess

c) Multiple large abscesses

d) Abscess which cannot be drained percutaneously

 Amoebic Liver abscess
 Caused by Entamoeba Histolytica, a Protozoa with ability to change size and
capacity to dissolve and destroy tissues.

 Common in Tropical and Subtropical region. The tropics include the Equator
and parts of North America, South America, Africa, Asia, and Australia.
Amoebic Abscess
• Commonest extra-intestinal presentation of amoebiasis
• Common in alcoholics
• Caused by Entamoeba histolytica
• Entry by faeco-oral route
Pathology
• Amoeba multiply-block in intrahepatic portal radicles-focal infarction
of liver cells-
proteolytic enzymes released- destiny liver parenchyma
• Site: Right lobe of liver, supraanteriorly, just below the diaphragm
Large necrotic area which is liquefied into thick reddish-brown
pus (Anchovy sauce pus) due to liquefied necrosis, thrombosis of
blood vessels, lysis of liver cells
Histology
Necrotic area containing degenerated liver cells, leucocytes, RBCs,
connective tissue strands, debris & amoeba
Clinical features
• Symptoms:
High grade fever with rigor
Weight loss
Upper quadrant pain ( Initially dull aching, later on stabbing)
Jaundice (not common)
• Signs:
Hepatomegaly (tender)
Consolidation in right lower zone of lungs
Pleurisy
Complications
1) Rupture into lung/pleura
a) Empyema
b) Hepatobronchial fistula
c) Pulmonary abscess
d) Pneumonitis
e) Pleural effusion
2) Rupture into pericardium
3) Intraperitoneal rupture
4) Rupture into portal vein (rare)
5) Secondary infection
Investigations
1) Routine:
Leucocytosis
Anemia
2) Liver function test:
Increased Alkaline Phosphatase
Increased Transaminase
3) Stool examination: cysts/ trophozoites
4) Aspiration: Anchovy sauce pus
5) Chest X-Ray
Raised fixed diaphragm
Right lateral abscess
6) USG (most useful) : Round lesion
7) CT : Irregular edge
8) Serology: ELISA
Treatment
• Metronidazole 750mg orally/i.v. 3 daily x 4 days
If response, continue for 10 days; followed by luminal agents:
Iodoquinol 650mg 3 X 20 days
Paramomycin 500mg 3 X 10 days
 If no response,
Dihydroemetine 1.5mg/Kg i.m. 4 X 5 days
+
Chloroquine phosphate 600mg base/day orally 4 X 2 days,
then 300mg base/day orally 4 times
If no response to medical treatment: Percutaneous drainage
 Prognostic factors

• Bilirubin level > 3.5 mg/dl,

• Hypoalbuminemia (serum albumin level < 2.0 g/dl)

• Anaemia

• Volume of abscess cavity

• Role of CRP, GGT and LDH as prognostic marker is under evaluation

Cystic Lesions of Liver
CLASSIFICATION
• INFECTIOUS HEPATIC CYSTS
• Pyogenic Liver Abcess
• Amebic Liver Abcess
• Hydatid Cyst Of Liver
• CONGENITAL HEPATIC CYSTS
• Simple cysts
• Polycystic liver disease
• NEOPLASTIC HEPATIC CYSTS
• Cystadenoma
• Cystadenocarcinoma
• TRAUMATIC HEPATIC CYST
INFECTIOUS HEPATIC CYSTS

• PYOGENIC LIVER ABSCESS

• AMEBIC LIVER ABSCESS

• HYDATID CYST OF LIVER

HYDATID LIVER CYST
• E. granulosus and
• E. multilocularis
• Zoonosis
• Humans are accidental intermediate hosts, whereas animals can be
both intermediate hosts and definitive hosts.
• In humans, 50–75% of the cysts occur in the liver,
• 25% are located in the lungs, and
• 5–10% distribute along the arterial system
LIFE CYCLE OF ECHINOCOCCUS
GRANULOSUS
• parasite lives in the proximal small bowel
• Eggs are released into the host's intestine
• excreted in the feces
• humans are the intermediate host
• ingest the ovum
• The ovum loses the protective chitinous layer and is digested in the
duodenum
• The released hexacanth embryo (oncosphere) passes through the
intestinal wall into the portal circulation and develops into cysts within
the liver
Pathology
PERICYST

ECTOCYST

ENDOCYST IS THE GERMINAL MEMBRANE

BROOD CAPSULES

PROTOSCOLECES

A PROTOSCOLEX.

ADULT TAPE WORM DAUGHTER CYST

• endogenic vesiculation.
• Ectogenic vesiculation
CLINICAL PRESENTATION
Symptoms Percentage

Asymptomatic
Abdominal pain
Dyspepsia
Fever and chills
Jaundice
RADIOLOGY
• CHEST X RAYS
• Elevated diaphragm
• concentric calcifications in the cyst wall
• ULTRASOUND
• Specificity- approx 90%
• hydatid sand,daughter cyst,unilocular & calcified cyst wall
• Internal structure,number,and location of the cysts and the
presence of complication
TREATMENT

• PRINCIPLES
(1) Eradication Of The Parasite Within The Cyst
(2) Protection Of The Host Against Spillage Of Scoleces,
(3) Management Of Complications.
METHODS
• Medical
• Percutaneous
• surgical
Medical treatment
• Success rate of 30%
• -Albendazole (10-15mg/kg/day) is drug of choice
• - decreases the size of cyst
• - decreases intracystic pressure
• - decreases risk of rupture
• Mebendazole (50mg /kg)& Praziquantel ( 50mg/kg)
• Indications
• Small cysts (<4 cm) located deep in the
• parenchyma of the liver
 Surgical dictum
• “ PERCUTANEOUS PUNCTURE OF A HYDATID CYST IS A DANGEROUS AND
CONTRAINDICATED “
• 1983, Fornage challenged this axiom
• FREQUENTLY USED PROTOSCOLICIDAL AGENTS
• 15–20% Saline
• 95% Ethanol
• A Combination Of 30% Saline And 95% Ethanol,
• Mebendazole Solution.
• The PAIR technique (percutaneous aspiration, injection and re-
aspiration) has also been combined with albendazole therapy with 70%
success rate
SURGERY
• OBJECTIVES
• (1) Inactivate The Scoleces
• (2) Prevent Spillage Of Cyst Contents
• (3) Eliminate All Viable Elements Of The Cyst
• (4) Manage The Residual Cavity Of The Cyst.