Liver, pancreas, biliary

system
•The liver is a large organ found in the
upper right quadrant of the abdomen.
It is a multifunctional accessory organ
of the gastrointestinal tract and
performs several essential functions
such as detoxification, protein
synthesis, bile production and nutrient
storage to name only a few. It is the
largest gland in the human body,
weighing approximately 1.5 kilograms.
•There are four anatomical lobes, which are further divided into even smaller segments in accordance with
the blood supply of the liver.
•The right lobe is the largest of the four lobes and the left lobe is a flattened smaller one. These two lobes
are separated by the fossae for the gallbladder and the inferior vena cava.
•The caudate lobe sits between the fissure for the ligamentum venosum and the inferior vena cava, while
the quadrate lobe is located between the gallbladder and the fissure for the ligamentum teres hepatis.
•The Couinaud classification
•divides the liver into eight functionally independent
lobes:
• – Each of the eight lobes has its own blood
supply derived from branches of the hepatic
artery and portal vein, along with its own
hepatic venous drainage and biliary drainage.
• – The segments are numbered 1–8 in a
clockwise direction, starting from the caudate
lobe.
• – The point where the portal vein, common
bile duct and hepatic artery enter the liver is
known as the hilum or porta hepatis.
•An imaginary line between the
gallbladder fossa and inferior
vena cava (called Cantlie’s line)
separates the functional right
and left halves of the liver (this is
not the falciform ligament). The
vessels of the porta hepatis
divide into right and left
branches at this point.
•From a surgical perspective, the
Couinaud classification is much
more useful: any given lobe can
continue its normal function
when neighbouring lobes are
resected.
•Current thinking considers the functional unit of the liver to
be the acinus. The elliptical acinus has a terminal branch of the
hepatic vein at either end, with two portal triads at the
midpoint of the flattened sides (Figure 65.1b). Blood flows
from the portal triad towards the terminal vein. The further a
hepatocyte is positioned from the portal triad, the lower the
O2 tension. Each acinus is therefore said to have three zones of
oxygenation – zones 1, 2 and 3:
• – Zone 1 is the area of the acinus closest to the two
portal triads and is therefore the best oxygenated.
The most energy-consuming processes (e.g.
gluconeogenesis and β- oxidation of fatty acids) occur
in zone 1.
• – Zone 2 is an intermediate area where hepatocytes
carry out processes characteristic of both zone 1 and
zone 3.
• Zone 3 is the area of the acinus closest to the
terminal vein and is therefore the area of lowest O2
tension. The hepatocytes of zone
3 carry out the least energy-consuming processes
(e.g. glycolysis and drug metabolism).
•The two main surfaces of the liver are the diaphragmatic
surface and the visceral surface. The latter is covered by
visceral peritoneum except at the porta hepatis and the bed
of the gallbladder. This surface is directly related to several
anatomical structures which include the:
•duodenum
•gallbladder
•hepatic flexure of colon
•transverse colon
•right kidney
•suprarenal gland
•The diaphragmatic surface lies against the inferior surface
of the diaphragm and is also covered by the visceral
peritoneum except in the bare area.
•There are five types of ligaments that are directly related to the liver:
•Coronary ligament - formed by folds of peritoneum reflect form the
inferior surface of the diaphragm, connecting this structure to the liver;
has two layers: (anterior and posterior).
•Left and right triangular ligament - are the lateral extensions of the
coronary ligaments and also connect the diaphragm to the left and right
lobes of the liver, respectively.
•Falciform ligament - it is a peritoneal reflection that connects the liver to
the upper anterior abdominal wall; has the round ligament of the liver on
its free edge.
•Ligamentum teres hepatis - also known as the round ligament of the liver,
is a fibrous remnant of the umbilical vein, and extends from the internal
aspect of the umbilicus up to the liver.
•Ligamentum venosum - is also an embryonic remnant, in this case of the
ductus venosus of the fetal circulation. In utero, the ductus venosus shunts
blood from the umbilical vein to the inferior vena cava.
Left triangular ligament
Right triangular ligament
Falciform ligament
Round ligament
( ligamentum teres)
Ligamentum venosum
•The porta hepatis is the
central intraperitoneal fissure
of the liver (in the visceral
surface) that separates the
caudate and the quadrate
lobes. It is the entrance and
exit point for several important
structures including the
portal vein, the hepatic
arteries, the hepatic ducts, the
hepatic nervous plexus and the
lymphatic vessels.
•The subphrenic recess is a space
between the diaphragmatic
surface of the liver from the
inferior surface of the
diaphragm; it is split by the
falciform ligament of the liver
into right and left areas.
•The hepatorenal recess is a
space located on the inferior
right aspect of the liver, between
this organ and the right kidney
and suprarenal gland.
Lymphatic drainage
•The lymphatic drainage of the liver is split
into deep and superficial drainage systems.
•The deep system consists of hepatic lymph
vessels which follow the hepatic portal veins,
therefore most of the lymph will flow towards
the hepatic nodes at the hilum of the liver,
which drain to the celiac nodes. These drain to
the cisterna chyli (if present) and onto
the thoracic duct. Additional lymphatic vessels
exit via the bare area following the hepatic veins
as they join the inferior vena cava. Therefore,
some of the hepatic lymph vessels drain to
the inferior diaphragmatic/phrenic nodes (or
uppermost members of the the right lumbar
lymph nodes) which drain to the right posterior
mediastinal nodes. From there, lymph flows up
the right mediastinal lymphatic chain and flows
into the right lymphatic duct or thoracic duct.
•The superficial system transports
lymphatic fluid through channels in the
subserosal areolar tissue (Glisson’s
capsule) which envelopes the liver. The
inferior, anterior and superior surfaces
drain to hepatic nodes at the liver
hilum. The right superior surface will
often drain to lymph vessels following
the inferior phrenic artery and connect
with the celiac nodes. The posterior
surface of the liver is conducted
towards the bare area of the liver and
into the inferior diaphragmatic
nodes/right lumbar nodes, which drain
as described above.
Liver blood supply
•The liver is a special organ in the sense that it receives
more venous blood than arterial blood because it helps
clean the blood via detoxification. The majority of the
vascular supply is brought into this organ by the
portal vein which carries blood from the gastrointestinal
tract filled with metabolites absorbed in the intestines
. The rest of the blood supply to this organ comes from
the common hepatic artery which originates from the
celiac trunk and carries oxygenated blood to the liver.
•The hepatic veins are formed
by the union of the central
veins. They drain blood from
the liver directly into the
inferior vena cava just before it
passes through the diaphragm.
innervation
•The nervous supply of the
liver comes from the hepatic
plexus which travels along with
the hepatic artery and the
portal vein. The liver also
receives sympathetic fibers
from the celiac plexus and
parasympathetic fibers from
the anterior and posterior
vagal trunks.
pancreas