Transcript
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Liver, Gallbladder Liver, Gallbladder and Biliary Treeand Biliary Tree
Dr. Aldwin A. YanezaDr. Aldwin A. Yaneza
Dept of AnatomyDept of Anatomy
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LIVERLIVER- Largest glandLargest gland- Approx 1500 g, ¼ of Approx 1500 g, ¼ of
BWBW- Lies in R upper and Lies in R upper and
L upper quadrants L upper quadrants [mainly on right][mainly on right]
- Inferior to diaphragmInferior to diaphragm- Function:Function:- 1] stores glycogen1] stores glycogen
2] secretes BILE 2] secretes BILE
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SURFACES SURFACES A. DiaphragmaticA. Diaphragmatic
Smooth and dome Smooth and dome shapedshaped
RecessesRecesses Subphrenic – bet Subphrenic – bet
diaphragm & liverdiaphragm & liver Hepatorenal – bet liver Hepatorenal – bet liver
and R kidneyand R kidney
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Ligaments of liverLigaments of liver Bare area of liver – not covered–Bare area of liver – not covered–
with peritoneum with peritoneum LigamentsLigaments
1] Coronary – superior1] Coronary – superior
2] Triangular – lateral2] Triangular – lateral
3] Falciform – anterior, middle3] Falciform – anterior, middle
4] Round – inferior, remnant of 4] Round – inferior, remnant of umbilical vein umbilical vein
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SURFACESSURFACES B. VisceralB. Visceral
Covered w/ peritoneum Covered w/ peritoneum except at bed of gallbladder except at bed of gallbladder and porta hepatisand porta hepatis
RelationsRelations- R side of stomach – R side of stomach –
gastric/pyloric areagastric/pyloric area- 11stst part duodenum – part duodenum –
duodenal areaduodenal area- Lesser omentumLesser omentum- GallbladderGallbladder- R colic flexure – R colic flexure – colic areacolic area- R kidney/suprarenal gl – R kidney/suprarenal gl –
renal/ suprarenal` arearenal/ suprarenal` area
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Visceral surfaceVisceral surface
Structures:Structures: IVCIVC Portal triadPortal triad
Hepatic arteryHepatic artery Portal VeinPortal Vein Hepatic ductHepatic duct
Caudate lobeCaudate lobe Quadrate lobeQuadrate lobe
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FUNCTIONAL PARTSFUNCTIONAL PARTS Functionally Functionally independent R/ L lobesindependent R/ L lobes
Can donate one lobe to relativeCan donate one lobe to relative Each lobe with ownEach lobe with own
Blood supplyBlood supply Venous drainageVenous drainage Biliary drainageBiliary drainage
Division into R – L lobesDivision into R – L lobes GB fossa inferiorly and IVC fossa GB fossa inferiorly and IVC fossa
superiorlysuperiorly Facilform lig [ old terminology]Facilform lig [ old terminology]
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Current [func’l] Current [func’l] terminologyterminology
L liver = caudate and quadrate lobe + L liver = caudate and quadrate lobe + L lobeL lobe
R liver = R lobeR liver = R lobe
OLD terminologyOLD terminology
Falciform ligFalciform lig
– – divides it into R divides it into R and L and L
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Functional partsFunctional parts Round ligament [L. Round ligament [L. ligamentum teresligamentum teres]]
Remnant of umbilical vein that carried Remnant of umbilical vein that carried oxygenated blood from placenta to fetusoxygenated blood from placenta to fetus
Porta HepatisPorta Hepatis Transverse fissure on visceral surface of Transverse fissure on visceral surface of
liver bet caudate and quadrate lobesliver bet caudate and quadrate lobes Passage for Passage for portal triadportal triad
1] Portal vein1] Portal vein 2] Hepatic artery2] Hepatic artery 3] Hepatic duct3] Hepatic duct Others – hepatic nerve plexus, lymphOthers – hepatic nerve plexus, lymph
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Hepatic art
Hepatic duct
Portal v
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Peritoneal RelationsPeritoneal Relations Lesser omentumLesser omentum
- fr liver to lesser curve of stomach - fr liver to lesser curve of stomach and 1and 1stst part of duodenum part of duodenum
- parts:- parts: Hepatoduodenal ligHepatoduodenal lig
Extends bet porta hepatis and Extends bet porta hepatis and duodenumduodenum
Encloses Encloses portal triad portal triad Hepatic duct, hep. artery, portal veinHepatic duct, hep. artery, portal vein
Hepatogastric ligHepatogastric lig Extends bet liver and lesser curve of Extends bet liver and lesser curve of
stomachstomach
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Vessels and nervesVessels and nerves Liver receives Liver receives blood from 2 sourcesblood from 2 sources
1] Portal vein [ 70 % ]1] Portal vein [ 70 % ] 2] Hepatic artery [ 30 %] 2] Hepatic artery [ 30 %]
Venous drainageVenous drainage Hepatic veinHepatic vein
Formed by union of central veins of liver Formed by union of central veins of liver Drains into IVCDrains into IVC
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Blood supply of liverBlood supply of liver 1. PORTAL VEIN1. PORTAL VEIN
Formed by Formed by union of union of superior mesenteric superior mesenteric vein [SMV] and vein [SMV] and splenic veinsplenic vein
Ascends anterior to Ascends anterior to IVC, has R - L IVC, has R - L branchesbranches
Carries poorly Carries poorly oxygenated but oxygenated but nutrient rich blood nutrient rich blood fr GIT to liverfr GIT to liver
70% 70%
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Blood supply of liverBlood supply of liver
2. HEPATIC artery2. HEPATIC artery Br of celiac artBr of celiac art Div into R and L Div into R and L
hepatic arthepatic art Carries well Carries well
oxygenated bloodoxygenated blood from aorta to liverfrom aorta to liver
30%30%
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SEGMENTSSEGMENTS Horizontal plane thru R lobe and Horizontal plane thru R lobe and
lateral division of L lobe plus caudate lateral division of L lobe plus caudate lobelobe
Divides liver into Divides liver into 88 vascular vascular segmentssegments
Based on Based on divisions of the hepatic divisions of the hepatic artery and portal vein and hepatic artery and portal vein and hepatic ductsducts
Each segment:Each segment: Supplied by br of Supplied by br of hepatic arthepatic art. and . and Portal V.Portal V. Drained by branch of Drained by branch of hepatic ducthepatic duct
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I-back
II
III
IVa
VVI
VII VIII
Posterior
superior
Posterior
inferior
IVb
P A Me La
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DivisionDivision
Anatomic[2] – Falciform ligAnatomic[2] – Falciform lig Functional[2] – L lobe is quadrate Functional[2] – L lobe is quadrate
+caudate +caudate + L anatomic + L anatomic lobelobe
Surgical[4] - R/ L Lateral and Surgical[4] - R/ L Lateral and Medial divMedial div
Segments [8] - CouinaudsSegments [8] - Couinauds
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P A Me La
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SegmentsSegments I - CaudateI - Caudate II - Lateral superiorII - Lateral superior III - Lateral inferiorIII - Lateral inferior IVa - Medial superiorIVa - Medial superior
IVb – Medial inferiorIVb – Medial inferior V - Anterior inferiorV - Anterior inferior VI - Posterior inferiorVI - Posterior inferior VII – Posterior VII – Posterior
superiorsuperior VIII - Anterior VIII - Anterior
superiorsuperior
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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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Segments numberingThere 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.
4A
4B
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LymphaticsLymphatics Major lymph producing organMajor lymph producing organ Occur as superficial lymphatics in Occur as superficial lymphatics in
Glisson’s capsuleGlisson’s capsule and as deep and as deep lymphatics in connective tissue that lymphatics in connective tissue that accomp the p.triadaccomp the p.triad
Anterior superf lymph Anterior superf lymph hepatic LN hepatic LN celiac LN celiac LN chyle cistern [dilated sac chyle cistern [dilated sac of t. duct]of t. duct]
Posterior superf lymph Posterior superf lymph phrenic LN phrenic LN posterior mediastinal LN posterior mediastinal LN thoracic thoracic ductduct
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Nerve SupplyNerve Supply Hepatic Nerve PlexusHepatic Nerve Plexus
Largest derivative of celiac plexusLargest derivative of celiac plexus Accomp branches of p. triad to liverAccomp branches of p. triad to liver Consists of sympathetic and parasym Consists of sympathetic and parasym
fibersfibers Function: VasoconstrictionFunction: 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 GALLBLADDER and BILIARY DUCTSBILIARY DUCTS
BileBile Produced by hepatocytesProduced by hepatocytes Yellow fluidYellow fluid Stored in GBStored in GB Passes to via bile ducts duodenum Passes to via bile ducts duodenum Emulsifies fat Emulsifies fat
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GallbladderGallbladder
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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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GallbladderGallbladderPartsParts FundusFundus -wide end-wide end -Projects fr inferior -Projects fr inferior
border of liverborder of liver BodyBody -Main part-Main part -Contacts the R -Contacts the R
part of transverse part of transverse colon and 1colon and 1stst part of part of duodenumduodenum
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BodyBody -Contacts the R part of transverse colon and 1st part of -Contacts the R part of transverse colon and 1st part of duodenumduodenum - Chronic cholecystitis[inflammation], body forms - Chronic cholecystitis[inflammation], body forms connection withconnection with1] colon – cholecystocolonic fistula1] colon – cholecystocolonic fistula2] duodenum – cholecystoduodenal fistula2] duodenum – cholecystoduodenal fistula
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GallbladderGallbladder NeckNeck -Narrow,tapered-Narrow,tapered -Continuous w/ cystic duct-Continuous w/ cystic duct -Mucosa thrown into spiral -Mucosa thrown into spiral
fold [valve of Heister]fold [valve of Heister] -Serves as guide to omental -Serves as guide to omental
bursabursa Cystic ductCystic duct - 2- 4 cm long- 2- 4 cm long - Joins common hepatic duct - Joins common hepatic duct
to form common bile ductto form common bile duct -mucous membrane thrown -mucous membrane thrown
into spiral foldinto spiral fold
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GallbladderGallbladder
Arterial supplyArterial supply Cystic art [fr R Cystic art [fr R
hepatic artery]hepatic artery] Venous drainageVenous drainage
Cystic vein [drains Cystic vein [drains into R branch of into R branch of portal vein]portal vein]
Lymphatic drainageLymphatic drainage Hepatic LNHepatic LN
Nerve supplyNerve supply Celiac plexus [symp]Celiac plexus [symp] Vagus n [parasymp]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 GBa. Cystic node of Calotb. Behind is cystic arteryc. Guide for laparoscopic
surgeons
3. Other lymph vessels also drain into hepatic nodes
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Lymph NodesLymph Nodes N1N1
CholedochalCholedochal HilarHilar Cystic ductCystic duct
N2N2 PeripancreaticPeripancreatic RetroduodenalRetroduodenal Portal, celiac, or Portal, celiac, or
superior superior mesenteric vesselsmesenteric vessels
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Biliary DuctsBiliary Ducts Hepatic ducts-Hepatic ducts-
drain the liverdrain the liver R Hep duct – R lobeR Hep duct – R lobe L Hep duct – L LobeL Hep duct – L Lobe
Common hepaticCommon hepatic ductsducts-when R and -when R and L hd uniteL hd unite 4 cm, in lesser 4 cm, in lesser
omentumomentum Common bile ductCommon bile duct - after giving off - after giving off
cystic duct on rightcystic duct on right
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2009 Movies2009 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 Common Bile Duct [ CBD ][ CBD ] 8-10 cm long8-10 cm long
5-6 mm diameter5-6 mm diameter in lesser omentumin lesser omentum Passes behind 1Passes behind 1stst
part of duodenum part of duodenum Unites w/ main Unites w/ main
pancreatic duct to pancreatic duct to form form hepatopancreatic hepatopancreatic ampullaampulla
Opens into Opens into descending or 2descending or 2ndnd part of duodenumpart of duodenum
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CBDCBD Arterial supplyArterial supply
Proximal part – cystic aProximal part – cystic a Middle part – R hepatic aMiddle part – R hepatic a Distal part – posterior Distal part – posterior
superior superior pancreaticoduodenal apancreaticoduodenal a
Venous drainageVenous drainage Posterior superior Posterior superior
pancreaticoduodenal veinpancreaticoduodenal vein LymphaticLymphatic
Cystic LNCystic LN Hepatic LNHepatic LN Celiac LNCeliac 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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CholelithiasisCholelithiasis
GB shows likely GB shows likely sites of stone sites of stone formation/depositformation/depositionion
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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 GBa. Intraluminal echogenic projectionsb. Do not change position with patientc. 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 arteryCystic artery
Ligated during Ligated during surgical removal of surgical removal of gallbladder gallbladder [cholecystectomy][cholecystectomy]
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Variations in Anatomy of Cystic DuctVariations in Anatomy of Cystic Duct
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Anatomy /HistologyAnatomy /Histology MucosaMucosa Smooth muscleSmooth muscle SerosaSerosa
Attachment to liver Attachment to liver Tumors can extend Tumors can extend
directly into liverdirectly 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:Clinical correlation:Calculous cholecystitisCalculous cholecystitis
Diet high in fat Diet high in fat produces cholesterol produces cholesterol stones inside GBstones inside GB
After eating GB After eating GB contracts, it expels contracts, it expels stone w/c lodges at stone w/c lodges at cystic ductcystic duct
Trigger inflammation Trigger inflammation of GB [cholecystitis] of GB [cholecystitis]
Pain at RUQPain at RUQ Diagnosed by:Diagnosed by:-History, PE and -History, PE and
ultrasoundultrasound
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Empyema of gallbladderEmpyema of gallbladder Longstanding impaction of Longstanding impaction of
stone at cystic ductstone at cystic duct Remaining bile cannot exit Remaining bile cannot exit
the GB because of the GB because of impacted stoneimpacted stone
Bacteria will set inBacteria will set in Abscess forms inside GBAbscess forms inside GB GB enlarges, wall thickensGB enlarges, wall thickensClinical :Clinical : Fever, RUQ pain, palpable Fever, RUQ pain, palpable
GB at RUQGB at RUQ Common among diabetics Common among diabetics
and noncompliant patientsand noncompliant patients
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Ruptured CholecystitisRuptured Cholecystitis
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National Kidney Institute,East Ave
FEU Medical Center,Fairview
The end
Aldwin A. Yaneza,MD
General and Laparoscopic Surgery
SET A
SET B
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GallbladderGallbladder Pear shaped sacPear shaped sac Along R edge of quadrate lobe Along R edge of quadrate lobe
of liver in depression called of liver in depression called gallbladder fossa,Vgallbladder fossa,V
Hangs by stem = cystic ductHangs by stem = cystic duct Rounded fundus projects beyond Rounded fundus projects beyond
inferior margin of liverinferior margin of liver Thin walled greenish Thin walled greenish Covered on its posterior and Covered on its posterior and
inferior surfaces by peritoneum inferior surfaces by peritoneum Concentrates and stores bile Concentrates and stores bile
secreted by liversecreted by liver Holds 30-60 ml of bileHolds 30-60 ml of bile
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ENDEND
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QuizQuiz Set ASet A Tabulate the 7 Tabulate the 7
differences differences between the between the jejunum and ileumjejunum and ileum
Draw and label the Draw and label the 8 surgical 8 surgical segmentssegments
Draw and label the Draw and label the biliary tree/ tractbiliary tree/ tract
Set BSet B Draw and label the Draw and label the
8 Couinauds 8 Couinauds segmentssegments
Tabulate the 7 Tabulate the 7 differences differences between the between the jejunum and ileumjejunum and ileum
Draw and label Draw and label parts of gallbladderparts of gallbladder
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