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The Liver
It is the largest abdominal organ.
The liver is a huge glandular
organ belonging to the GI system.
Dr M Idris ...
 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 cardia...
LIVER
 Its surfaces are in contact with the diaphragm and
the anterior abdominal wall.
 The falciform ligament attache...
Embryology
Developed from
proliferationn of blind end
of a Y shaped diverticulum
which grows from foregut
into septum tra...
 It extends into the left hypochondrium,
inferior to the diaphragm, which separates
it from
 The pleura,
 The Lungs ,
...
Shape
 Blunt wedge shaped
rounded base to the
right
anterior
superior
Right
Oblong block with inferior
surface shizzled a...
 Anatomic and nonanatomic factors responsible
for the fixation of the liver at the right upper
quadrant of the abdomen.
...
Note
 Inferior surface is set obliquely facing
not only downwards but also
backwards & to the left.
 Posterior & inferio...
Lobes of the Liver
 Functionally, the liver is divided
into two lobes, the left and right
lobes.
  This is by a plane t...
Gross anatomical lobes
 Historically the gross anatomical appearance of the
liver has been divided into right, left, caud...
Anatomical Lobes of the Liver
 On the slanted visceral surface, the right and
left sagittal fissures surround and the
tra...
Functional Subdivision of the Liver
 Although not distinctly demarcated internally, where
the parenchyma appears continuo...
The liver has
 Diaphragmatic and
 Visceral surfaces .
 These surfaces are separated from each other
by the sharp inferi...
 The liver has a convex diaphragmatic
surface (anterior, superior, and some
posterior) and a relatively flat or
even conc...
The Diaphragmatic Surface of the Liver
 This is smooth and convex as it conforms to the
cavity of the inferior surface of...
The Visceral Surface of the Liver
 This surface is directed inferiorly, posteriorly,
and to the left.
 It is separated f...
The visceral surface of the liver has an
H-shaped group of deep fissures and
fossae.
  The crossbar of the H is the por...
IVC
GB
The Caudate Lobe of the Liver
 This lobe lies between the fissure for the
ligamentum venosum and the fossa for the
IVC.
...
3 features of caudate lobe
 It is related to posteriorly to diaphragm
which separates it from thoracic aorta &
last two t...
The Quadrate Lobe of the Liver
 This lobe is four-sided (L. quadri, four).
 It lies between the fissure for ligamentum
...
3 Structures related to Quadrate
lobe
 In anterior part:
Transverse colon
 In middle part:
Pylorus & 1st part of duode...
Inferior surface of right lobe
on right side of gall bladder
1. 2nd part of duodenum: forms an
impression on right side of...
The Left Lobe of the Liver
The functional left lobe includes the
caudate lobe and most of the
quadrate lobe.
 It is sepa...
Peritoneal Attachments of the
Liver
 Ligamentum teres
  This is the obliterated left umbilical vein,
connecting the lef...
Falciform ligament
 This is a fold of peritoneum, which connects the liver to the
diaphragm and supraumbilical part of th...
Coronary ligament
 This is a reflection of peritoneum from the
diaphragm to the liver's superior and posterior
surfaces....
Triangular ligaments
Left triangular ligament
This is formed from the left layer
of the falciform and lower layer
of th...
Lesser Omentum
 This lesser omentum connects the liver
to the stomach and the 1st part of the
duodenum.
 It inserts al...
Porta Hepatis
 Lying in the porta hepatis (which is 2 in (5 cm)
long) are:
 1◊◊the common hepatic duct—anteriorly;
 2◊◊...
posteriorposterior
Left anteriorRight anterior
Liver lobules
Hepatic lobule:
Centered on central vein
Portal lobule:
Centered on portal tract(triad)
Liver acinus
 The smallest functional unit of the
liver, comprising all of the liver
parenchyma supplied by a terminal
br...
Arterial Supply to the Liver
  The liver has a double blood supply from
the hepatic artery (30%) and the portal vein
(70...
Common Hepatic Artery
  This arises from the coeliac trunk and passes
anteriorly to the right in the posterior wall of t...
The Portal Vein
  This is formed posterior to the neck of the
pancreas by the union of the superior
mesenteric vein and ...
Venous Drainage of the Liver
  The hepatic veins draining the blood from
the liver are formed by the union of the
centra...
Lymphatic drainage of liver
 The liver is a major lymph-producing organ.
 The lymphatic vessels of the liver occur as
 ...
Lymphatic drainage of liver
 Lymph from the posterior aspect of the
liver (superficial and deep) flows toward
the bare ar...
Superficial lymphatics
 Superficial lymphatics from the anterior aspects of the
diaphragmatic and visceral surfaces and t...
Deep Lymphatics
 Most of the deep lymph vessels from the liver
converge at the porta hepatis and end in the hepatic
lymp...
Innervation of the Liver
  The nerves to the liver contain both
sympathetic and parasympathetic fibres.
  These nerves...
The bare area of liver
 The bare area is demarcated by the reflection of peritoneum
from the diaphragm to it as the anter...
Bare area
 Triangle laid on its side
 Apex pointing to right formed by right
triangular ligament
 Two sides are upper &...
Hepatic segmentation
 Surgical resectable area each served independently by
secondary or tertiary branches of portal tria...
Hepatic segmentation
 Couinaud divided the liver into a functional left
and right liver by a main portal scissurae
contai...
Subphrenic Abscesses
 Peritonitis may result in the formation of localized
abscesses in various parts of the peritoneal c...
Rupture of the Liver
 The liver is easily injured because it is large,
fixed in position, and friable (easily crumbled).
...
Aberrant Hepatic Arteries
 A more common variety of right or left
hepatic artery that arises as a terminal
branch of the ...
Hepatomegaly
 When the liver is massively enlarged, its inferior
edge may be readily palpated below the right
costal marg...
Cirrhosis of the Liver
 The liver is the primary site for detoxification of substances
absorbed by the digestive system, ...
Surface Anatomy of the Liver
 The liver lies mainly in the right upper quadrant of the
abdomen where it is hidden and pro...
 Outlines of the Liver on the Anterior Body Wall
to trace the outline of the liver on the anterior
body wall:
 Point A i...
Liver Biopsy
 Hepatic tissue may be obtained for diagnostic
purposes by liver biopsy. Because the liver is
located in the...
 Liver biopsies frequently are performed by
needle puncture through the right intercostal
space 8, 9, or 10.
 The needle...
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Liver anatomy Slide 1 Liver anatomy Slide 2 Liver anatomy Slide 3 Liver anatomy Slide 4 Liver anatomy Slide 5 Liver anatomy Slide 6 Liver anatomy Slide 7 Liver anatomy Slide 8 Liver anatomy Slide 9 Liver anatomy Slide 10 Liver anatomy Slide 11 Liver anatomy Slide 12 Liver anatomy Slide 13 Liver anatomy Slide 14 Liver anatomy Slide 15 Liver anatomy Slide 16 Liver anatomy Slide 17 Liver anatomy Slide 18 Liver anatomy Slide 19 Liver anatomy Slide 20 Liver anatomy Slide 21 Liver anatomy Slide 22 Liver anatomy Slide 23 Liver anatomy Slide 24 Liver anatomy Slide 25 Liver anatomy Slide 26 Liver anatomy Slide 27 Liver anatomy Slide 28 Liver anatomy Slide 29 Liver anatomy Slide 30 Liver anatomy Slide 31 Liver anatomy Slide 32 Liver anatomy Slide 33 Liver anatomy Slide 34 Liver anatomy Slide 35 Liver anatomy Slide 36 Liver anatomy Slide 37 Liver anatomy Slide 38 Liver anatomy Slide 39 Liver anatomy Slide 40 Liver anatomy Slide 41 Liver anatomy Slide 42 Liver anatomy Slide 43 Liver anatomy Slide 44 Liver anatomy Slide 45 Liver anatomy Slide 46 Liver anatomy Slide 47 Liver anatomy Slide 48 Liver anatomy Slide 49 Liver anatomy Slide 50 Liver anatomy Slide 51 Liver anatomy Slide 52 Liver anatomy Slide 53 Liver anatomy Slide 54 Liver anatomy Slide 55 Liver anatomy Slide 56 Liver anatomy Slide 57 Liver anatomy Slide 58 Liver anatomy Slide 59 Liver anatomy Slide 60 Liver anatomy Slide 61 Liver anatomy Slide 62 Liver anatomy Slide 63 Liver anatomy Slide 64 Liver anatomy Slide 65 Liver anatomy Slide 66 Liver anatomy Slide 67 Liver anatomy Slide 68 Liver anatomy Slide 69 Liver anatomy Slide 70 Liver anatomy Slide 71 Liver anatomy Slide 72 Liver anatomy Slide 73 Liver anatomy Slide 74 Liver anatomy Slide 75 Liver anatomy Slide 76 Liver anatomy Slide 77 Liver anatomy Slide 78 Liver anatomy Slide 79 Liver anatomy Slide 80 Liver anatomy Slide 81 Liver anatomy Slide 82 Liver anatomy Slide 83 Liver anatomy Slide 84 Liver anatomy Slide 85
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Liver anatomy

  1. 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
  2. 2.  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
  3. 3. 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.
  4. 4. Embryology Developed from proliferationn of blind end of a Y shaped diverticulum which grows from foregut into septum transversum
  5. 5.  It extends into the left hypochondrium, inferior to the diaphragm, which separates it from  The pleura,  The Lungs ,  The Pericardium , and The Heart
  6. 6. Shape  Blunt wedge shaped rounded base to the right anterior superior Right Oblong block with inferior surface shizzled away
  7. 7.  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
  8. 8. 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.
  9. 9. 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)
  10. 10. 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.
  11. 11. 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.
  12. 12. 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.
  13. 13. 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
  14. 14.  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
  15. 15. 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.
  16. 16. 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.
  17. 17. 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.
  18. 18. IVC GB
  19. 19. 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.
  20. 20. 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.
  21. 21. 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.
  22. 22. 3 Structures related to Quadrate lobe  In anterior part: Transverse colon  In middle part: Pylorus & 1st part of duodenum.  In posterior part: Lesser omentum
  23. 23. 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
  24. 24. 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.
  25. 25. 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.
  26. 26. 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.
  27. 27. 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.
  28. 28. 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.
  29. 29. 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.
  30. 30. 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.
  31. 31. posteriorposterior Left anteriorRight anterior
  32. 32. Liver lobules Hepatic lobule: Centered on central vein Portal lobule: Centered on portal tract(triad)
  33. 33. 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.
  34. 34. 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.
  35. 35. 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.
  36. 36. 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.
  37. 37. 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.
  38. 38. 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.
  39. 39. 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.
  40. 40. 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.
  41. 41. 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.
  42. 42. 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.
  43. 43. 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.
  44. 44. 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
  45. 45. 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.
  46. 46. 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.
  47. 47. 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.
  48. 48. 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.
  49. 49. 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
  50. 50. 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).
  51. 51. 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).
  52. 52. 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.
  53. 53.  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
  54. 54. 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.
  55. 55.  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
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