Anatomy of liver and biliary tree with its surgical importance.pptx

Liver anatomy

1. LIVER AND BILIARY TREE ANATOMY BY Dr PRAVALIKA SRINIVAS; JR-3 UNDER THE GUIDANCE OF Dr G KIRAN KUMAR M.S PROFESSOR AND CHIEF S-IV GMC

2. MICROSCOPIC ANATOMY OF LIVER microscopic functional units - acinus or lobule. Zone 1 (periportal zone) - rich in nutrients and oxygen. Zone 2 (intermediate zone) and zone 3 (perivenular zone) - poorer in oxygen and nutrients.

3. This anatomic arrangement also explains the phenomenon of centrilobular necrosis from hypotension because zone 3 is the most susceptible to decreases in oxygen delivery.

4. SPACE OF DISSE Sinusoidal endothelial cells are separated from hepatocytes by the space of Disse (perisinusoidal space) allows proteins and other plasma components from the sinusoids to be taken up by the hepatocytes. contain multiple large fenestrations.

5. KUPFFER CELLS derived from the macrophage-monocyte system irregularly shaped cells Kupffer cells are phagocytic, can migrate along sinusoids to areas of injury,

6. GALLBLADDER The gallbladder sits on the cystic plate on the inferior surface of the liver at its midplane Located in the gallbladder fossa of segment IVB, V Anatomic variations: Agenesis Multiple Bilobed Double cystic ducts Left sided GB Intrahepatic GB

7. DEFORMITY Phyrgian cap Hartmann’s pouch- Dilated infundibulum with eccentric bulge on medial side associated With inflammation, impaction.

8. CONGENITAL DISORDERS OF BILIARY TRACT Biliary atresia

9. 2. CHOLEDOCHAL CYSTS

10. 3. ANOMALOUS PANCREATICO-BILIARY JUNCTION Pancreatic duct and bile duct join outside duodenal wall but 1-2cms proximal to ampulla due to delayed recanalization of bile duct. Associated with increased risk of carcinoma gallbladder and bile duct cancer.

11. CYSTIC DUCT Types of cysto-hepatic junction: Angular(75%)- associated with increased risk of bile duct injury Parallel Spiral

12. operations involving the upper end (as in hepaticojejunostomy or a whole liver graft) - bile duct should be divided above the cystic duct junction close to the confluence of the right and left ducts. operations related to the distal end (as in liver transplant recipients) - level of division should not be extended too much to the hilum and care should be taken to preserve the soft tissue covering the epicholedochal plexus around the duct.

13. The lymphatic drainage of bile ducts diverges into two pathways. The superior pathway involves lymph nodes along the cystic duct, hepatic artery, and celiac plexus, whereas the inferior pathway involves the nodes along the cystic duct, the anterolateral aspect of the portal vein, the posterior pancreas, and the aortocaval region.

14. SURGICAL SIGNIFICANCE The parallel configuration of the confluence of the cystic duct and the common hepatic - common hepatic duct to injury at the side, particularly if dissection is performed with diathermy. Tiny bile ducts (ducts of Luschka) may enter the gallbladder through the cystic plate and may be divided. A right hepatic sectional duct, which joins the common hepatic duct at a low level may be mistaken for the cystic duct and be injured. AVOID EXCESSIVE USE OF POWERFUL HEMOSTATIC DEVICES!!!! BEFORE ANY TUBULAR STRUCTURE THOUGHT TO BE CYSTIC DUCT IS CLAMPED, IT HAS TO BE DISSECTED UPTO THE INFUNDIBULUM OF GB!!!!

15. preoperative magnetic resonance cholangiography intraoperative cholangiogram preferably with radiopaque markers - superior

16. CYSTIC ARTERY VARIATIONS

17. CYSTIC VEIN Multiple Responsible for spread to liver segments IV, V in carcinoma gallbladder.

18. LYMPHATIC PATHWAYS Cholecystoretropancreatic Cholecystocoeliac Cholecystomesenteric Lymph node of Hiatus- At the junction of D1-D2

19. DUCT OF LUSCHKA 2 nd most common cause of bile leak post cholecystectomy Types- 1: sectoral subvesical duct 2: accessory subvesical duct (M/C) 3: hepatocholecystic 4: aberrant subvesical

20. LANDMARKS DURING CHOLECYSTECTOMY Calot’s triangle Hepatocystic triangle Rouviere’s sulcus 2-3 cms . sulcus running to the Rt of hilum contains Rt portal pedicle/ its branches CD, CA lie anterior, superior to it KEEP THE DISSECTION ABOVE!

21. R4U line- Line joining the Rouviere’s sulcus, base of segment IVB, umbilical fissure.

22. LAPAROSCOPIC CBD EXPLORATION THREE LINES AND ONE PLANE CONCEPT: Line A- upper curve of duodenal bulb Line B- arc of incisure of Rt posterior pedicle Line C- midline between CHD, CBD Plane D- plane of hilar plate

23. STRASBERG CLASSIFICATION

24. McMAHON CLASSIFICATION

25. LIVER TRANSPLANTATION

26. INDICATIONS symptomatic liver failure hepatocellular cancer if tumor location or accompanying liver disease prevents resection.

27. BROAD INDICATIONS FOR LIVER Tx Hepatic encephalopathy Hyperbilirubinemia with intractable pruritus Portal hypertension (varices, upper gastrointestinal [GI] bleeding, ascites, hypersplenism) Synthetic dysfunction (coagulopathy, hypoalbuminemia) Poor quality of life (QOL) (severe fatigue, lethargy).

28. CONTRAINDICATIONS active alcohol or drug abuse HCC beyond Milan and UCSF criteria extrahepatic malignancy severe and irreversible cardiac comorbidities uncorrectable pulmonary hypertension (mean pulmonary artery pressure >35 mm Hg) uncontrollable infection irreversible cerebral injury extensive portal and mesenteric vein thrombosis unstable psychiatric disease incompliance. advanced cardiac disease / Severe valvular disease / pulmonary hypertension / CHD

29. ACUTE LIVER FAILURE clinical syndrome of hepatic encephalopathy and elevated prothrombin time (PT)/international normalized ratio (INR) due to injury to the liver in patients without preexisting liver disease. Hyperacute liver failure : <7 days of symptom onset Acute : 7 to 21 days Subacute : 21 days and 26 weeks. The shorter the duration of symptoms -cerebral edema. longer duration - portal hypertension

30. KING’S COLLEGE CRITERIA FOR ALF-

31. ALLOCATION Status 1 patients are prioritized above patients with MELD scores. additional points are given, termed “exception points,” to reflect the desire of the community to prioritize these patients h low MELD scores (less than 15) do not benefit from transplantation

32. CHILD-TURCOTTE PUGH SCORE Liver transplantation is offered to patients with CTP score >9

33. LIVER TRANSPLANTATION FOR HCC Nearly 90% HCC develop a background of cirrhosis Liver transplantation offers best chance of survival( approx. 75% 5 year survival) About 80% liver transplantations are performed in HCC Criteria for selecting patients: MILAN CRITERIA- single tumor ≤5 cms . Or 3 nodules ≤3 cms . UCSF CRITERIA- single tumor ≤6.5 cms . Or 3 nodules ≤4.5 cms . & cumulative tumor ≤8 cms .

34. 4 BASIC STEPS Procurement of liver allograft Removal of native diseased liver Fashioning of liver allograft for implantation Implantation of liver allograft in orthotopic position

35. Portal dissection - ligating the right and left branches of the hepatic artery and transecting the bile duct high in the hilum. orthotopic placement - the inferior vena cava is encircled above the renal veins and the suprahepatic cava above the hepatic veins. The recipient liver is removed with the retrohepatic cava and the donor liver is then placed with the donor cava anastamosed to recipient cava. piggyback technique, the caudate is dissected off of the retrohepatic cava, leaving the recipient cava intact. The donor cava is anastamosed to the cloaca fashioned using the confluence of the three hepatic veins.

36. BASICS OF IMPLANTATION OUTFLOW RESTORATION Hepatic veins/ Retrohepatic veins are anastomosed to native IVC using 4-0 prolene sutures INFLOW RESTORATION Stump of native portal vein anastomosed to graft portal vein using 5-0 prolene sutures ARTERIAL CONTINUITY Restored by common/ proper hepatic artery to graft ‘s common/ proper hepatic artery using 7-0/ 8-0 prolene BILIARY CONTINUITY Restored by performing end-end or Roux-en-y hepaticojejunostomy CHOLECYSTECTOMY

37. TYPES 1.DECEASED DONOR LIVER TRANSPLANTATION(DDLT) Criteria- Age≤65 years ICU stay <7 days Hemodynamically stable S.Na <160mEq/L Normal LFT Liver steatosis <10% No evidence of malignancy, sepsis, drug abuse, HIV, Hep B, HCV

38. RULE OF 100 FOR DONOR MAINTANENCE SBP >100mm Hg HR <100 bpm PaO2 >100mm Hg Urine output >100 ml/hr

39. TECHNIQUES FOR IMPLANTATION CLASSICAL Deceased liver removed along with retrohepatic IVC after clamping supra/ infrahepatic IVC Anastomosis done between Graft SHIVC to Recipient SHIVC, Graft IHIVC to recipient IHIVC Followed by Portal vein, Hepatic artery, biliary anastomosis.

40. PIGGYBACK TECHNIQUE Infrahepatic IVC is closed and Graft’s suprahepatic IVC is anastomosed to MHV/LHV/IVC Recipient’s IVC preserved Maintains venous return to heart, hence better intraoperatively hemodynamic stability.

41. LIVE DONOR LIVER TRANSPLANTATION Based on segmental anatomy of liver and ability of liver to regenerate after resection. Most common grafts used in LDLT are- Rt lobe grafts, Lt lobe grafts, Lt lateral segment, Rt posterior segment, mono segmental For better outcomes, recipient receives graft of adequate volume and adequate remnant liver left behind. Graft recipient body weight ratio atleast 0.8 for metabolic requirement of recipient.

42. Small-for-size syndrome : when the amount of functioning transplanted liver parenchyma is inadequate to support the recipient and manifests with jaundice, coagulopathy, ascites, encephalopathy, and renal impairment that may progress to death. Retransplantation with a larger allograft.

43. IMMUNOSUPPRESSION antithymocyte globulin, Basiliximab Steroids Mycophenolate mofetil Calcineurin tacrolimus INDUCTION MAINTENANCE