ppt

1. The Liver
It is the largest abdominal organ.
The liver is a huge glandular
organ belonging to the GI system.
Dr M Idris Siddiqui

4.  It is the largest gland in the body (about 2.5%
of the body mass in adults). i.e. 1500 gm
 Receives blood 25% of cardiac output.
 In the late fetus in which it also serves as a
hematopoietic organ, it is proportionately twice
as large (5% of body weight). From early
childhood onward, it occupies almost all of the
right hypochondrium and epigastrium.
 In adults: the liver lies in the right
hypochondrium, epigastrium, and left
hypochondrium.
 In normal individuals, it should not be
palpable below the right costal margin.
LIVER

5. LIVER
 Its surfaces are in contact with the diaphragm and
the anterior abdominal wall.
 The falciform ligament attaches the liver to both of
these structures.
 In most living persons the liver is a soft reddish
brown organ.
 Glisson's capsule surrounds the liver as a
strong connective tissue.
The liver receives venous blood returning from
the GI tract through the portal vein.
This venous blood is laden with the products of
digestion, especially fats.
 In addition to its many metabolic activities, the liver
is a storehouse for glycogen and it secretes bile.

6. Embryology
Developed from
proliferationn of blind end
of a Y shaped diverticulum
which grows from foregut
into septum transversum

8.  It extends into the left hypochondrium,
inferior to the diaphragm, which separates
it from
 The pleura,
 The Lungs ,
 The Pericardium , and The Heart

10. Shape
 Blunt wedge shaped
rounded base to the
right
anterior
superior
Right
Oblong block with inferior
surface shizzled away

12.  Anatomic and nonanatomic factors responsible
for the fixation of the liver at the right upper
quadrant of the abdomen.
 Anatomic
 Inferior vena cava
 Suprahepatic veins
 Several ligaments such as the round ligament
and coronary ligament
 Peritoneal folds
 Nonanatomic:
 Positive intraabdominal pressure

14. Note
 Inferior surface is set obliquely facing
not only downwards but also
backwards & to the left.
 Posterior & inferior surfaces merge
together to form posteroinferior
surface(visceral surface) as
distinction between them is difficult.

15. Lobes of the Liver
 Functionally, the liver is divided
into two lobes, the left and right
lobes.
  This is by a plane that passes
through the gallbladder fossa
and fossa for the IVC(Cantlie’s
line)

16. Gross anatomical lobes
 Historically the gross anatomical appearance of the
liver has been divided into right, left, caudate and
quadrate lobes by the surface peritoneal and
ligamentous attachments.
 The falciform ligament superiorly and the ligamentum
venosum inferiorly, mark the division between right
and left lobes. On the inferior surface, to the right of
the groove formed by the ligamentum venosum, there
are two prominences separated by the porta hepatis.
 The quadrate lobe lies anteriorly,
 The caudate lobe posteriorly.
 The gallbladder usually lies in a shallow fossa
to the right of the quadrate lobe.

17. Anatomical Lobes of the Liver
 On the slanted visceral surface, the right and
left sagittal fissures surround and the
transverse porta hepatis demarcates two
accessory lobes (parts of the anatomic right
lobe): the quadrate lobe anteriorly and
inferiorly and the caudate lobe posteriorly and
superiorly.
 The caudate lobe is so named because it
often gives rise to a tail in the form of an
elongated papillary process at the lower left
angle .
 A caudate process extends to the right, between the
IVC and the porta hepatis, connecting the caudate
and right lobes.

18. Functional Subdivision of the Liver
 Although not distinctly demarcated internally, where
the parenchyma appears continuous, the liver has
functionally independent right and left livers (parts or
portal lobes) that are much more equal in size than the
anatomical lobes; however, the right liver is still
somewhat larger. Each part receives its own primary
branch of the hepatic artery and portal vein and is
drained by its own hepatic duct.
 The caudate lobe may in fact be considered a third liver; its
vascularization is independent of the bifurcation of the portal triad (it
receives vessels from both bundles) and is drained by one or two small
hepatic veins, which enter directly into the IVC distal to the main hepatic
veins.
 The liver can be further subdivided into four
divisions and then into eight surgically
resectable hepatic segments, each served
independently by a secondary or tertiary
branch of the portal triad.

19. The liver has
 Diaphragmatic and
 Visceral surfaces .
 These surfaces are separated from each other
by the sharp inferior border, except
posteriorly.
Surfaces of the Liver

20.  The liver has a convex diaphragmatic
surface (anterior, superior, and some
posterior) and a relatively flat or
even concave visceral surface
(posteroinferior), which are
separated anteriorly by its sharp
inferior border.
 The diaphragmatic surface of the
liver is smooth and dome shaped,
where it is related to the concavity of
the inferior surface of the diaphragm

21. The Diaphragmatic Surface of the Liver
 This is smooth and convex as it conforms to the
cavity of the inferior surface of the diaphragm.
Although this surface fits into the dome of the
diaphragm, it is largely separated from the
diaphragm by part of the peritoneal cavity called the
subphrenic recess.
 The bare area is not separated from the diaphragm
by the peritoneal cavity. Here there is a thin layer of
loose connective tissue. The diaphragm separates the
superior part of the liver from the thoracic organs.
The superior part of the liver is covered with
peritoneum, except posteriorly at the edge of the bare
area.
 The IVC occupies a fossa in the left part of the bare area, just to
the right of the median plane.
 Diaphragmatic surface is divided into
 Anterior, superior, right & posterior.
 Its posterior surface is discussed in conjunction with inferior surface of liver.

23. The Visceral Surface of the Liver
 This surface is directed inferiorly, posteriorly,
and to the left.
 It is separated from the diaphragmatic surface
of the liver by the inferior border.
 Under cover of the visceral surface are:
 1. The superior right portion of the anterior
surface of the stomach; (body & pylorus)
 2. The superior part of the duodenum(1st & 2nd )
 3. The lesser omentum;
 4. The gall-bladder;
 5. The right colic flexure;& transverse colon
 6. Right kidney & suprarenal.

26. The visceral surface of the liver has an
H-shaped group of deep fissures and
fossae.
  The crossbar of the H is the porta hepatis,
a deep transverse fissure, about 5 cm long.
  It contains the portal vein, hepatic artery
proper, hepatic nerve plexus, hepatic ducts,
and lymphatic vessels.
  The left sagittal limbs of the H are deep
fissures containing the ligamentum teres and
the ligamentum venosum.
  The right sagittal limbs of the H are
fossae for the gallbladder and IVC.

27. IVC
GB

28. The Caudate Lobe of the Liver
 This lobe lies between the fissure for the
ligamentum venosum and the fossa for the
IVC.
 It is functionally part of the left lobe.
 It is part of the anatomic right lobe.
 It is bounded inferiorly by the porta hepatis.
 On the right, the caudate lobe has a small,
tail-like caudate process (L. cauda, tail).
 The bridge of liver tissue between caudate lobe &
right lobe is called the caudate process.
 This process separates the portal vein from the IVC.
 Below & to the left it sends a papillary process
towards porta hepatis.

30. 3 features of caudate lobe
 It is related to posteriorly to diaphragm
which separates it from thoracic aorta &
last two thoracic vertebrae.
 Forms anterior wall of upper recess of
lesser sac.
 Has a tail like process caudate process
which forms upper boundary of epiploic
foramen & below & to the left it sends a
papillary process towards porta hepatis.

31. The Quadrate Lobe of the Liver
 This lobe is four-sided (L. quadri, four).
 It lies between the fissure for ligamentum
teres (left) and the gallbladder fossa(right).
 It is bounded posteriorly by the porta
hepatis.
 In front bounded by inferior border of liver.
 Most of it is functionally part of the left lobe.
 The part of the inferior border of the liver
between the notch for the ligamentum teres
and the gallbladder is formed by the quadrate
lobe.

32. 3 Structures related to Quadrate
lobe
 In anterior part:
Transverse colon
 In middle part:
Pylorus & 1st part of duodenum.
 In posterior part:
Lesser omentum

33. Inferior surface of right lobe
on right side of gall bladder
1. 2nd part of duodenum: forms an
impression on right side of fossa for gall
bladder.
2. Right colic flexure: forms a colic
impression in front near inferior border
3. Right kidney: anterior surface of it forms
a renal impression lateral to duodenal
impression & below bare area on
posterior surface of right lobe

34. The Left Lobe of the Liver
The functional left lobe includes the
caudate lobe and most of the
quadrate lobe.
 It is separated from the caudate and
quadrate lobes by the by the fissures for
ligamentum teres and ligamentum
venosum, respectively, and on the
diaphragmatic surface by the attachment
of the ligamentum teres.

35. Peritoneal Attachments of the
Liver
 Ligamentum teres
  This is the obliterated left umbilical vein,
connecting the left branch of the portal vein to
the umbilicus.
  This ligament runs in the free edge of the
falciform ligament and in a groove named after
it in the visceral surface of the liver.
 The left umbilical vein is of great importance as
it carried all the blood from the placenta to the
fetus.

36. Falciform ligament
 This is a fold of peritoneum, which connects the liver to the
diaphragm and supraumbilical part of the anterior abdominal
wall.
 It is attached to the anterior and superior surface of the
liver and to the notch for the ligamentum teres.
 It contains the small paraumbilical veins and the ligamentum
teres in its free edge.
 Its left layer continues as the anterior layer of the left
triangular ligament.
 Its right layer continues as the upper layer of the coronary
ligament.
 The line of attachment of the falciform ligament (together
with the grooves for the ligamentum venosum and teres) is
said to the divide the left and right lobes.

37. Coronary ligament
 This is a reflection of peritoneum from the
diaphragm to the liver's superior and posterior
surfaces.
 It has upper and lower layers, which are continuous
at the right as the right triangular ligament and
enclose the bare area of the liver.
 To the left, the upper layer becomes the right layer
of the falciform, while the lower layer becomes the
posterior layer of the left triangular ligament.
 The lower layer of the coronary ligament may
reflect onto the upper pole of the right kidney (as the
hepatorenal ligament) instead of the diaphragm.

39. Triangular ligaments
Left triangular ligament
This is formed from the left layer
of the falciform and lower layer
of the coronary as they meet at
the left.
 Right triangular ligament
This is formed from the two
layers of the coronary ligament
meeting at the right.

40. Lesser Omentum
 This lesser omentum connects the liver
to the stomach and the 1st part of the
duodenum.
 It inserts along the groove for the
ligamentum venosum and encircles the
porta hepatis.
 The groove for the ligamentum
venosum contains the obliterated
remnant of the ductus venosus, which in
fetal life connected the left branch of
the portal vein to the IVC, or the left
hepatic vein, just before it enters the IVC.

42. Porta Hepatis
 Lying in the porta hepatis (which is 2 in (5 cm)
long) are:
 1◊◊the common hepatic duct—anteriorly;
 2◊◊the hepatic artery—in the middle;
 3◊◊the portal vein—posteriorly.
 As well as these, autonomic nerve fibres
(sympathetic from the coeliac axis and
parasympathetic from the vagus), lymphatic
vessels and lymph nodes are found there.

43. posterior
posterior
Left anterior
Right anterior

46. Liver lobules
Hepatic lobule:
Centered on central vein
Portal lobule:
Centered on portal tract(triad)

48. Liver acinus
 The smallest functional unit of the
liver, comprising all of the liver
parenchyma supplied by a terminal
branch of the portal vein and hepatic
artery; typically involves segments of
two lobules lying between two
terminal hepatic venules.
 Syn: Rappaport's acinus.

50. Arterial Supply to the Liver
  The liver has a double blood supply from
the hepatic artery (30%) and the portal vein
(70%).
  The right and left hepatic arteries carry
oxygenated blood while the portal vein carry
products of digestion absorbed from the GI
tract.
  The arterial blood is conducted to the
central vein of each liver lobule.

51. Common Hepatic Artery
  This arises from the coeliac trunk and passes
anteriorly to the right in the posterior wall of the
omental bursa.
  It runs inferior to the omental foramen to reach
the superior part of the duodenum.
  After giving off the gastroduodenal artery, it
passes between the layers of the lesser omentum as
the hepatic artery proper.
  This artery ascends anterior in the free edge of
the lesser omentum, anterior to the portal vein and
to the left of the bile duct.
  Near the portal hepatis, the hepatic artery proper
divides into the left and right hepatic arteries.

52. The Portal Vein
  This is formed posterior to the neck of the
pancreas by the union of the superior
mesenteric vein and the splenic vein.
  It runs in the free right edge of the lesser
omentum, posterior to the bile duct and
hepatic artery, and anterior to the omental
foramen.
  At the right end of the porta hepatis, the
portal vein divides into left and right branches,
each supplying about 1/2 of the liver.

54. Venous Drainage of the Liver
  The hepatic veins draining the blood from
the liver are formed by the union of the
central veins of the liver lobules.
  The hepatic veins empty into the IVC just
inferior to the diaphragm.
 There are superior and inferior groups of veins.
 The superior group may consist only of right and
left veins, though there is usually a middle vein
from the caudate lobe.
 The inferior group consists of 6 to 18 small
veins, which drain the blood from the right lobe,
including part of the caudate lobe.

55. Lymphatic drainage of liver
 The liver is a major lymph-producing organ.
 The lymphatic vessels of the liver occur as
 1. Superficial lymphatics in the subperitoneal fibrous
capsule of the liver (Glisson capsule), which forms its
outer surface
 2. Deep lymphatics in the connective tissue, which
accompany the ramifications of the portal triad and
hepatic veins.
 Most of the lymph is formed in the perisinusoidal spaces (of
Disse) and drains to the deep lymphatics in the surrounding
intralobular portal triads.

56. Lymphatic drainage of liver
 Lymph from the posterior aspect of the
liver (superficial and deep) flows toward
the bare area to enter the phrenic lymph
nodes, or pass with the IVC through the
caval foramen in the diaphragm to enter
mediastinal lymph nodes.
 Lymph from the anterior and inferior
aspects (superficial and deep) flows
toward the porta hepatis to enter hepatic
lymph nodes in the lesser omentum.

57. Superficial lymphatics
 Superficial lymphatics from the anterior aspects of the
diaphragmatic and visceral surfaces and the deep lymphatic
vessels accompanying the portal triads converge toward the porta hepatis.
They drain to the hepatic lymph nodes scattered along the hepatic vessels
and ducts in the lesser omentum
 Efferent lymphatic vessels from the hepatic nodes drain into celiac lymph nodes,
which in turn drain into the chyle cistern, a dilated sac at the inferior end of the
thoracic duct.
 Superficial lymphatics from the posterior aspects of the
diaphragmatic and visceral surfaces of the liver drain toward
the bare area of the liver. Here they drain into phrenic lymph nodes, or join
deep lymphatics that have accompanied the hepatic veins converging on the
IVC, and pass with this large vein through the diaphragm to drain into the
posterior mediastinal lymph nodes.
 Efferent vessels from these nodes join the right lymphatic and thoracic ducts.
 A few lymphatic vessels follow different routes:
 From the posterior surface of the left lobe toward the esophageal hiatus of the
diaphragm to end in the left gastric lymph nodes.
 From the anterior central diaphragmatic surface along the falciform ligament to
the parasternal lymph nodes.
 Along the round ligament of the liver to the umbilicus and lymphatics of the
anterior abdominal wall.

58. Deep Lymphatics
 Most of the deep lymph vessels from the liver
converge at the porta hepatis and end in the hepatic
lymph nodes.
 These are scattered along the hepatic vessels and
ducts in the lesser omentum.
 Efferent vessels from the hepatic lymph nodes drain
into the coeliac lymph nodes and from then to the
thoracic duct.
 Some of the deep lymph vessels follow the
hepatic veins to the vena caval foramen of the
diaphragm.
 These end in the middle group of phrenic lymph nodes
and from there to the parasternal lymph nodes.

60. Innervation of the Liver
  The nerves to the liver contain both
sympathetic and parasympathetic fibres.
  These nerves reach the liver via the hepatic
plexus, the largest derivation of the coeliac
plexus, which also receives filaments from the
left and right vagus and right phrenic nerves.
  The hepatic plexus of nerves accompanies
the hepatic artery and portal vein and their
branches and enter the liver at the porta
hepatis.

61. The bare area of liver
 The bare area is demarcated by the reflection of peritoneum
from the diaphragm to it as the anterior (upper) and posterior
(lower) layers of the coronary ligament.
 These layers meet on the right to form the right triangular
ligament and diverge toward the left to enclose the triangular
bare area.
 The anterior layer of the coronary ligament is continuous on the
left with the right layer of the falciform ligament, and the
posterior layer is continuous with the right layer of the lesser
omentum. Near the apex (the left extremity) of the wedge-
shaped liver, the anterior and posterior layers of the left part of
the coronary ligament meet to form the left triangular ligament.
The inferior vena cava traverses a deep groove for the vena
cava within the bare area of the liver.

62. Bare area
 Triangle laid on its side
 Apex pointing to right formed by right
triangular ligament
 Two sides are upper & lower layers of
coronary ligament
 Base is groove for IVC.
 Bare area is in direct contact with liver but
right kidney & suprarenal encroach

63. Hepatic segmentation
 Surgical resectable area each served independently by
secondary or tertiary branches of portal triad. Hepatic
veins are intersegmental.
 Except caudate lobe(segment1)liver is subdivided into
right & left halves based on primary division of portal
triad. An imaginary line running from notch for fundus
of gall bladder to IVC). The right & left livers are
subdivided vertically into medial & lateral division.
Each division receives secondary branch of portal
triad. A transverse plane 3 of 4(except left
medial,numbered-IV) into 6 hepatic segments. Left
medial division is a hepatic segment so that total 7
segments(II to VIII). The caudate lobe is segment I.
Each segment thus has its own blood supply
and biliary drainage.

64. Hepatic segmentation
 Couinaud divided the liver into a functional left
and right liver by a main portal scissurae
containing the middle hepatic vein. This is
known as Cantlie's line.
Cantlie's line runs from the middle of the
gallbladder fossa anteriorly to the inferior vena
cava posteriorly.

76. Subphrenic Abscesses
 Peritonitis may result in the formation of localized
abscesses in various parts of the peritoneal cavity.
A common site for pus to collect is in a subphrenic
recess or space.
 These subphrenic abscesses are more common on
the right side because of the frequency of ruptured
appendices and perforated duodenal ulcers.
 Because the right and left subphrenic recesses are
continuous with the hepatorenal recess (the lowest
[most gravity dependent] parts of the peritoneal
cavity when supine), pus from a subphrenic
abscess may drain into one of the hepatorenal
recesses, especially when patients are bedridden.

77. Rupture of the Liver
 The liver is easily injured because it is large,
fixed in position, and friable (easily crumbled).
Often a fractured rib that perforates the
diaphragm tears the liver. Because of the liver's
great vascularity and friability, liver lacerations
often cause considerable hemorrhage and right
upper quadrant pain.
 In such cases, the surgeon must decide
whether to remove foreign material and the
contaminated or devitalized tissue by dissection
or to perform a segmentectomy.

78. Aberrant Hepatic Arteries
 A more common variety of right or left
hepatic artery that arises as a terminal
branch of the hepatic artery proper may
be replaced in part or entirely by an
aberrant (accessory or replaced) artery
arising from another source. The most
common source of an aberrant right
hepatic artery is the SMA. The most
common source of an aberrant left hepatic
artery is the left gastric artery

79. Hepatomegaly
 When the liver is massively enlarged, its inferior
edge may be readily palpated below the right
costal margin and may even reach the pelvic
brim in the right lower quadrant of the
abdomen. Tumors also enlarge the liver. The
liver is a common site of metastatic carcinoma
(secondary cancers spreading from organs
drained by the portal system of veins).

80. Cirrhosis of the Liver
 The liver is the primary site for detoxification of substances
absorbed by the digestive system, and so it is vulnerable to
cellular damage and consequent scarring, accompanied by
regenerative nodules. There is progressive destruction of
hepatocytes (parenchymal liver cells) in hepatic cirrhosis and
replacement of them by fat and fibrous tissue.
 Alcoholic cirrhosis, the most common of many causes of portal
hypertension, is characterized by enlargement of the liver
resulting from fatty changes and fibrosis. The liver has great
functional reserve, and so the metabolic evidence of liver
failure is late to appear. Fibrous tissue surrounds the
intrahepatic blood vessels and biliary ducts, making the liver
firm, and impeding the circulation of blood through it (portal
hypertension).

82. Surface Anatomy of the Liver
 The liver lies mainly in the right upper quadrant of the
abdomen where it is hidden and protected by the
thoracic cage and diaphragm.
 The normal liver lies deep to ribs 7 to 11 on the right
side and crosses the midline toward the left nipple.
Consequently, the liver occupies most of the right
hypochondrium, the upper epigastrium, and extends
into the left hypochondrium.
 The liver is located more inferiorly when one is erect
because of gravity. Its sharp inferior border follows
the right costal margin. When a person in the supine
position is asked to inspire deeply, the liver may be
palpated because of the inferior movement of the
diaphragm and liver.

83.  Outlines of the Liver on the Anterior Body Wall
to trace the outline of the liver on the anterior
body wall:
 Point A is 1 cm (about one-half fingerwidth)
below the right nipple at the level of the fifth
rib
 Point B is located approximately 2 cm (about
one fingerwidth) inferior to and medial to the
left nipple, at the level of the left fifth
intercostal space
 Point C is in the right costal margin at the
anterior axillary line

84. Liver Biopsy
 Hepatic tissue may be obtained for diagnostic
purposes by liver biopsy. Because the liver is
located in the right hypochondriac region where
it receives protection from the overlying thoracic
cage, the needle is commonly directed through
the right 10th intercostal space in the midaxillary
line. Before the physician takes the biopsy, the
person is asked to hold his or her breath in full
expiration to reduce the costodiaphragmatic
recess and to lessen the possibility of damaging
the lung and contaminating the pleural cavity.

85.  Liver biopsies frequently are performed by
needle puncture through the right intercostal
space 8, 9, or 10.
 The needle passes through the following
structures:
 1. Skin
 2. Superficial fascia
 3. External oblique muscle
 4. Intercostal muscles
 5. Costal parietal pleura
 6. Costodiaphragmatic recess
 7. Diaphragmatic parietal pleura
 8. Diaphragm
 9. Peritoneum