Surgical Anatomy of the Liver : Ηepatectomies - Dimitris P. Korkolis

Surgical Anatomy of the Liver - Surgical Anatomy of the Liver - ΗΗepatectomiesepatectomies

Dimitris P. Korkolis

SurgeonSaint Savvas Anticancer - Oncological Hospital of Athens

Liver• The liver is the largest gland in the body and has a wide variety of

functions• Weight: 1/50 of body weight in adult & 1/20 of body weight in infant• It is exocrine(bile) & endocrine organ(Albumin , prothrombin &

fibrinogen)

• Function of the liver

• Secretion of bile & bile salt• Metabolism of carbohydrate, fat and protein• Formation of heparin & anticoagulant substances• Detoxication• Storage of glycogen and vitamins• Activation of vita .D

EmbryologyEmbryology

44thth Week of Development Week of Development– Projection from ventral wall of Projection from ventral wall of

MidgutMidgut Cranial Bud Cranial Bud Liver Liver Caudal Bud Caudal Bud Gallbladder, extrahepatic Gallbladder, extrahepatic

biliary treebiliary tree Ventral PancreasVentral Pancreas

EmbryologyEmbryology

Bile ducts develop from Bile ducts develop from hepatocytes, originating at hilumhepatocytes, originating at hilum

77thth Week Week– Biliary lumen recanalize Biliary lumen recanalize

1212thth Week Week– Liver begins to secrete bileLiver begins to secrete bile

Developmental Developmental AnomaliesAnomalies Agenesis rareAgenesis rare

– Left lobe agenesis reportedLeft lobe agenesis reported Reidel’s LobeReidel’s Lobe

– Long tongue of liver extending Long tongue of liver extending inferiorly from right lobeinferiorly from right lobe

– Usually asymptomatic, may be Usually asymptomatic, may be associated with colonic or pyloric associated with colonic or pyloric obstructionobstruction

Heterotopic liver tissueHeterotopic liver tissue– Gallbladder, pancreas, adrenals, Gallbladder, pancreas, adrenals,

omphaloceleomphalocele

AnatomyAnatomy

PositionPosition– Between 4Between 4thth intercostal intercostal

space and costal marginspace and costal margin– extends across midlineextends across midline

AnatomyAnatomy

Glisson’s CapsuleGlisson’s Capsule– Peritoneal MembranePeritoneal Membrane

PeritoneumPeritoneum– Bare patch under diaphragm next to Bare patch under diaphragm next to

IVCIVC

LigamentsLigaments

FalciformFalciform– Attaches to anterior abdominal wall Attaches to anterior abdominal wall

from diaphragm to umbilicusfrom diaphragm to umbilicus– Includes Ligamentum Teres (round Includes Ligamentum Teres (round

ligament) at inferior borderligament) at inferior border Former Umbilical VeinFormer Umbilical Vein May recanalize in portal hypertension, May recanalize in portal hypertension,

or malignant hematologic disordersor malignant hematologic disorders

LigamentsLigaments

Right and Left CoronaryRight and Left Coronary– Connect diaphragm to liverConnect diaphragm to liver– Lateral aspects become Triangular Lateral aspects become Triangular

LigamentsLigaments

LigamentsLigaments

GastrohepaticGastrohepatic– Anterior layer of lesser omentumAnterior layer of lesser omentum– Continuous with Left Triangular Continuous with Left Triangular

LigamentLigament HepatoduodenalHepatoduodenal

– Anterior border of Foramen of Anterior border of Foramen of WinslowWinslow

– Contains Portal TriadContains Portal Triad

The Ligamentum Venosum

-Fibrous band that is the remains of the ductus venosus

-Ligament of Aranthius

- It is attached to the left branch of the portal vein and ascends in a fissure on the visceral surface of the liver to be attached above to the inferior vena cava

Topographic AnatomyTopographic Anatomy

RightRight LeftLeft QuadrateQuadrate CaudateCaudate

Lobar Anatomy Lobar Anatomy (American System)(American System) Right and Left Lobe determined by Right and Left Lobe determined by

Cantlie’s Line (portal fissure)Cantlie’s Line (portal fissure)– Gallbladder Fossa to IVCGallbladder Fossa to IVC

•Claude Couinaud 1922 - 2008

Segmental Anatomy Segmental Anatomy (Couinaud System)(Couinaud System) Caudate LobeCaudate Lobe

– Segment ISegment I Left LobeLeft Lobe

– Segments II – IV Segments II – IV Right LobeRight Lobe

– Segments V-VIIISegments V-VIII

Segmental Anatomy Segmental Anatomy (Couinaud System)(Couinaud System) Caudate LobeCaudate Lobe

– Segment ISegment I Left LobeLeft Lobe

– Segments II – IV Segments II – IV Right LobeRight Lobe

– Segments V-VIIISegments V-VIII

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 supply of the liver

Portal VeinPortal Vein

75% of hepatic 75% of hepatic blood flowblood flow

1-3cm diameter1-3cm diameter 5-8cm length5-8cm length 4-5mm Hg4-5mm Hg

Portal VeinPortal Vein

Laminar Blood flowLaminar Blood flow– Affects distribution of amebic abscesses Affects distribution of amebic abscesses

and tumor metastasesand tumor metastases

Portal-Systemic Portal-Systemic communicationcommunication Submucosal veins of distal esophagus Submucosal veins of distal esophagus

and proximal stomachand proximal stomach Umbilical and periumbilical veinsUmbilical and periumbilical veins

– Caput MedusaeCaput Medusae– Cruveilhier-Baumgarten bruit Cruveilhier-Baumgarten bruit

Tributaries of inferior mesenteric veinsTributaries of inferior mesenteric veins– Superior hemmorhoidalsSuperior hemmorhoidals

Retroperitoneal communicationRetroperitoneal communication– Adrenal veinsAdrenal veins

Hepatic ArteryHepatic Artery

Hepatic ArteryHepatic Artery

CautionsCautions– Only 55-65% of population has Only 55-65% of population has

“normal” hepatic arterial anatomy“normal” hepatic arterial anatomy– Aberrant R hepatic artery may be Aberrant R hepatic artery may be

mistaken for cystic arterymistaken for cystic artery– Cystic artery may originate from the Cystic artery may originate from the

gastroduodenal artery, the left gastroduodenal artery, the left hepatic artery, or the common hepatic artery, or the common hepatic arteryhepatic artery

Biliary SystemBiliary System

Triangle of CalotTriangle of Calot– Cystic Duct, Common Hepatic Duct, Cystic Duct, Common Hepatic Duct,

and hilum of liverand hilum of liver

Biliary AnomaliesBiliary Anomalies

Hepatic VeinsHepatic Veins

Short extrahepatic Short extrahepatic segmentsegment– RightRight– MiddleMiddle

Usually joins leftUsually joins left

– LeftLeft Direct communication to IVC from Direct communication to IVC from

Segment I (caudate)Segment I (caudate)

LymphaticsLymphatics

LIVER Histology

• lobules >> roughly hexagonal structures consisting of hepatocytes. Radiate outward from a central vein. • At each of the six corners of a lobule is a portal triad ( p.arteriole,p.venule & bile duct) •Between the hepatocytes are the liver sinusoids.

Where do the two blood supplies mix?

• Liver surrounded by a thin capsule at portahepatic(it is thick)Glisson’s capsule invests the liver and send septa into liver subset subdivide the parenchyma into lobules

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 GD 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

•Source: HPB 2000; 2(3):333-39•Terminology Committee of the International Hepato-Pancreato-Biliary Association