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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