liver & portal vein

7/30/2019 Liver & Portal Vein

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Anatomy of

Liver, Biliary system

&Portal vein

Dr Mohamad Aris Mohd Moklas (PhD)Department of Human AnatomyFPSK [email protected] 8947 2330/2331/2783
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]


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LIVER

It is the largest gland in

the body. Liver is a soft, dark

brown highly vascularorgan. It is readily torn inabdominal injur ies

causing severe intra-abdominal bleeding.

In adult it is

approximately 2% of the

body weight.


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LIVER

LocationMainly

present in right

hypochondriac region . It

also extends to epigastricregion.

Weight-

1400

1800 gms in males.12001400 gms in females.


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Lobes of liver Liver is divided into a large right lobe and a

small left lobe by the attachment of falciformligament , which extends from liver to theanterior abdominal wall.


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Lobes of liver

Right lobe is further divided into quadratelobe and caudate lobe.


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Surfaces of l iver

Five surfaces,anterior, posterior,superior, inferior and

right surfaces.

A sharp inferior

border separates theanterior from the

inferior surface.


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Relations of l iver:

Per itoneal relations

&

Visceral relations


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Relations of l iver :

Peritoneal relations

Liver is covered by the visceral layer of peritoneumexcept the bare area of liver.


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Relations of liver:

Visceral relations

Superiorly the liver is related to the diaphragm.


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Relations of liver:

Visceral relations

Posteroinferiorsurface: (Posteriorand inferior)

It is related toabdominal part ofoesophagus, the

stomach, the

duodenum, theright colic flexure,the right kidney,right suprarenaland the gallbladder.


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Relations of liver:

Visceral relations

Posteroinferiorsurface: (Posteriorand inferior)

Groove for Inferiorvena cava lodgesthe upper part of

I.V.C.


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Abdominal part of oesophagus is related to theposterior surface of the left lobe.

Bare area is related to the posterior surface of rightlobe .

Stomach is related to the inferior surface of the left

lobe.


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Right kidney and right colic flexure are related to theinferior surface of the right lobe .

Gall bladder fossa lodges the gall bladder on theinferior surface .


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Gastric

Colic

Renal

Left triangular ligament

Ligamentum teres

Bare area

Coronary ligamentsHepatic vein

Quadratelobe

Porta hepatis

Fissure for

ligamentum

venosum

Fissure for

ligamentumteres hepatis

Falciform ligament


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Porta hepatis of l iver (H ilum)

It is present on theposteroinferior surface andlies inbetween caudate and quadrate lobes.

Free edge of the lesser omentum is attached to its

margins.


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Porta hepatis of

liver (H ilum)

Right and lefthepatic ducts, right

and left branches ofhepatic artery andportal vein are passing

throughthe porta

hepatis.


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Vascular segments of Liver

On the basis of blood supply and biliary drainagethere are four main hepatic segments.

Left lateral (left lobe) Left medial (Left lobe) Right anterior (right lobe) Right posterior (right lobe)

Each of these main segments are furthersubdivided into upper and lower parts.


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Peritoneal l igaments of l iver

1. Falciform ligamentIt is a two- layered fold ofperitoneum.

It extends from the anterior abdominal wall to theanterior surface of liver.

I t contains the l igamentum teres, which is theremains of the umbilical vein.


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The right layer of falciform ligament forms theupper layer of the coronary ligament and its left layer

forms the upper layer of the left triangular ligament.


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Peritoneal ligaments of

liver

2. The lesser omentum -

It extends from theedges of theportahepatis and passes to

the lessercurvature ofstomach.


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Lesser omentum


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Bare areaof liver

This is the area of l iver which is devoid ofperitoneum.


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Bare areaof liver

To the right of the I.V.C the posterior part of thediaphragmatic surface is broad and a large part of itbetween the superior and inferior layers of the coronary

ligament is not covered by peritoneum

This is the bare area. Groove for I.V.C and the fossa for gall bladder are

also devoid of peritoneum.


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Blood supply

Hepatic artery, abranch of celiacartery. It divides intoright and left

terminal branchesthat enter the portahepatis.


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VeinsPortal vein divides into right and left

branches that enter the porta hepatis.

The hepatic veins emerge from the posteriorsurface of liver and drain into the I.V.C.


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Blood vessels of liver


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Nerve supplySympathetic and

parasympatheticfrom the celiac plexus.

Lymphatic drainageThe efferent vessels pass

to the celiac nodes.

A few vessels from the bare area pass to the

posterior mediastinal nodes.

Bil i t


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Bil iary system

It consists of thefollowing structures.

Right and left hepaticducts.

Common hepatic duct.

Gall bladder.

Cystic duct.

Common bile duct (bileduct).

Bil i t


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Bil iary system


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Right and left hepatic ducts

Emerge from the right and left lobes of the liver inthe porta hepatis.

The hepatic ducts unite to form the common hepatic

duct.


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Common hepatic duct

It is about 4 cm long. It descends within the freemargin of the lesser omentum. It is joined on the rightside by the cystic duct from the gall bladderto form

the bile duct.


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Gall bladder

It is a pear-shaped sac.

Lies on the undersurface of liver.

Capacity 3050 ml.

It has three partsFundus, bodyand neck. .

Fundus usually projects below the

inferior margin of liver and comesin contact with the anteriorabdominal wall .

E t h ti t f th bil i t


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Extr ahepatic parts of the bil iary system

The bile ducts and the Gall bladder


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Sur face marking of fundus of gal l bladder:

Fundus can be surface marked on the anteriorabdominal wall at the level of the tip of the r ight 9th

costal carti lage.

The body of gall bladder lies in contact with the

visceral surface of liver.

The neck is continuous with the cystic duct.

Theperitoneum completely surrounds the fundus ofgall bladder.

Blood supply Cystic artery a branch of right hepatic artery


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Blood supplyCystic artery a branch of right hepaticartery.

VeinsCystic vein which drains into portal vein.


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Lymphatic drainageDrains into cystic lymph node. From

here the lymph vessels pass to hepatic nodes and then tocel iac nodes.

Nerve supplySympathetic and parasympathetic.

Parasympathetic is the vagus nerve. Sympathetic and parasympathetic form the celiac plexus.

Thepain fibres from the gall bladder and bile ducts ascendthrough the celiac plexus


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Cystic duct

It is about 4 cm long.

It connects the neck ofgall bladder to commonhepatic duct to form the bileduct.

It descends in the freemargin of lesser omentum.

Extrahepatic biliary apparatus


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Bile duct (Common bile

duct)

It is about 8 cm long.

It lies in the right free

margin of lesser omentum.

Here it lies in front of the

portal vein and on the right of

hepatic artery.



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duct)

Itpasses behind the firstpart of the duodenum .

In the lower part of itscourse i t is poster ior tohead of pancreas.

The bile duct is joined by the main pancreatic duct


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The bile duct is joined by the main pancreatic ductto form hepatopancreatic ampul la(ampulla ofVater).

The ampulla opens in the second part of the


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The ampulla opens in the second part of theduodenum halfway down its length by means of asmall papilla major duodenal papilla.

The terminal parts of both ducts and ampulla aresurrounded by asphincter of Oddi.


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CLINICAL FEATURES

1.Errors in gall bladder surgery is due to the failure to

appreciate the variations in the anatomy of biliarysystem.

It is therefore important to identify all the threebiliary ducts together with the cystic and hepaticarteries before dividing any structures and removing

the gall bladder.


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2.Haemorrhage during cholecystectomy can

be controlled by compressing the hepaticartery between the finger and thumb when itlies in the anterior wall of the foramen of

Winslow (epiploic foramen).

3 St i th bil d t can s all be


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3.Stones in the common bile ductcan usually beremoved through an incision in the supraduodenal

part of the common bile duct.

4. Bi liary colicSpasmodic pain in abdomen

relating to bile passage. Biliary colic is mostintense when the calculus (stone) is impactedeither at the cystic duct or at the lower end of thebile duct.

Biliary colic referred pain is felt in the right

upper quadrant or the epigastrium.


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5.Liver biopsyHepatic tissue may be

obtained for diagnostic purposes by liverbiopsy.

6.Rupture of liverLiver may be torn by afractured rib.

7.HepatomegalyMany diseases cause liverenlargement, orhepatomegaly.


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8.Cirrhosis of liverDestruction of hepatocytes and

replacement of them by fibrous tissue.

9.Liver transplantationA person with end stage

liver disease may opt to have his liver removed to be

replaced with a normal liver.

10. Imaging of the biliary tractGall bladder and

biliary tract can be demonstrated by ultrasound.

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Portal vein


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Portal vein

Portal vein drains blood from abdominal part ofthe gastrointestinal tract, from the lower third of

oesophagus to half way down the anal canal.

It also drains blood from thespleen, pancreas and

gall bladder.


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The portal circulationbegins as capillary plexusand ends by emptying blood into the sinusoids ofliver.

Theportal vein enters the liver through the portahepatis.

Bloodfrom liver is collected by hepatic veins. Hepatic veins join the I.V.C.

Fig 20 The composition of the Portal system


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Fig.20 The composition of the Portal system


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Formation

By the joining ofsuperiormesenter ic and splenicveins.

Site of formationPosterior to neck ofpancreas.

Length - 6 to 8 cm.

Formation of portal Vein


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Formation of portal Vein

Relation of portal vein at its formation


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Relations


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At its formation, portal vein isposterior to neck ofpancreas.

It passes upwards poster ior to first part of duodenum

and enters the lesser omentum.

In lesser omentum it is related anter ior ly to bi le

duct (r ight), and hepatic artery (left). At the porta hepatis it divides into right and left

branches.

Relations of portal Vein


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Portal Vein relations (In lesser omentum)


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Portal Vein Tr ibutaries:

i.Splenic vein It receives the inferiormesenteric vein.

ii. Superior mesenteric vein

iii. Left gastric veiniv. Right gastric vein

v. Cystic vein.

Tributaries of portal vein.


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Portal - systemic anastomosis


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Portal systemic anastomosis

Smaller communications exist between the portal

and systemic veins and they become importantwhen the direct route becomes blocked.

These sites are,

1. At the lower end of oesophagusThe

oesophageal tributaries of the left gastric vein

(Portal tributary) anastomose with oesophagealveins (systemic tributary).


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2. Super ior rectal veinsdraining the upper part

of the anal canal (Portal tributary)anastomose with middle and inferior rectalveins (systemic tributaries).

3. Paraumbil ical veinsconnect the left branch

of portal vein with superficial veins of

anterior abdominal wall (systemictributaries).

Portal-systemic anastomosis


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CLINICAL FEATURES


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CLINICAL FEATURES

1. Portal hypertension

Liver cirrhosis obstruct the portal vein resulting in

increased pressure in portal vein causing portalhypertension.

At the sites of portal caval anastomosis portal

hypertension produces varicose veins. The veinsmay become so dilated that their walls ruptureresul ting in haemorrhage.

Bleeding from oesophageal varices, extremelydilated submucosal veins in oesophagus (at


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d ated sub ucosa ve s oesop agus (atthe distal end of the oesophagus) is often

severe and may be fatal .Oesophageal varices


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3. Paraumbil ical veinsmay become varicose

and look like small snakes radiating underthe skin around the umbilicus.

This condition is referred to as Caput

medusae.

Caput medusae


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4.Collateral circulation through the portal-

systemic communications formshaemorrhoids(piles) in the anal canal.

It may be responsible forrepeated

bleeding per rectum.

Haemorrhoids in anal canal


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liver & portal vein

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