LIVER ANATOMY

ANATOMY OF LIVER

1. LIVER Dr. Kumar Satish Ravi MBBS,MD(JIPMER),MNAMS,FAIMER(M-FIILIPE), FIMSA, D.Litt. Editor In Chief, National Journal of Clinical Anatomy Professor(Additional) of Anatomy All India Institute of Medical Sciences Rishikesh ..

2. 2 “ A good knowledge of the Anatomy is a PREREQUISITE for Surgey of the Liver” - Henri Bismuth

3. Learning objectives Introduction Functions Surface anatomy External features Internal features Peritoneal relations Blood supply Innervation A pplied aspects Questions 3

4. Introduction Largest gland Foregut derivative Location- E xtends from right upper quadrant to left upper quadrant of abdomen Shape- wedge, four sided pyramid laid on one side Weight – 1 .6 kg in males & 1.3kg (females) Colour - Red - Brown 4

5. Weight- - At birth: 150 g. - In males: 1.4 to 1.8 kg. - In females: 1.2 to 1.4 kg . Proportional weight- - Newborn: 5% of body weight - Adult: 2.5% of body wt Attached to diaphragm by: - Falciform & coronary ligaments - Left & right triangular ligaments 5 Contd …

6. 1. False ligaments Lesser omentum Falciform ligament Coronary ligaments Triangular ligaments 2. True ligaments Round ligament of the liver Ligamentum venosum 6 Ligaments of Liver

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8. Bile production & secretion Detoxification Storage of glycogen Protein synthesis Production of heparin & bile pigments Erythropoiesis (in fetus) - occupies 2/5 th of abdomen Note: Liver is much larger in newborn & young children due to its hemopoietic function in fetal life, & occupies 2/5th of the abdomen 8 Functions

9. Surface anatomy 9

10. S urfaces Diaphragmatic surface: Smooth & dome-shaped surface Superior surface Anterior surface Right lateral surface Inferior to diaphragm Posterior surface Separated from diaphragm by subphrenic recess & from posterior organs {kidney & suprarenal glands} by hepatorenal recess 10

11. Ligaments: Lig amentum teres hepatis - obliterated umbilical vein Falciform hepatic ligament (attachment to peritoneum of anterior abdominal wall) - Coronary hepatic lig ament - Triangular hepatic lig ament 11

12. Visceral surface Covered by visceral peritoneum except porta hepatis & gall bladder bed Inferior surface V isceral surface is related to: Right side of stomach i.e. gastric & pyloric areas Superior part of duodenum i.e. duodenal area Lesser omentum Gall bladder Right colic flexor & right transverse area - colic area Right kidney & suprarenal gland; Renal area 12

13. Visceral surface ‘H’ Cross-bar of H = Porta hepatis - Hepatic artery, Portal vein, Bile ducts, Nerves and Lymphatic vessels Left inferior of H = Ligamentum teres hepatis or round ligament of liver (Remnant of umbilical vein) c. Left superior of H = Ligamentum venosum (Remnant of ductus venosus ) d. Rt. inferior of H = Gall bladder e. Rt. superior of H = Inferior vena cava 13

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15. Posterior view 15

16. Liver lobes Right and left lobe Functionally independent i .e. each with own blood & nerve supply Blood supply by: Hepatic artery Portal vein Blood out through: Vein s & B iliary drainage 16

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18. Liver lobes Right lobe Demarcated by : Gall bladder fossa Inferior vena cava fossa Imaginary line from fundus of gall bladder & inferior vena cava 18

19. Left lobe Divided into: Medial & lateral segments a) Medial superior – caudate lobe b) Medial inferior - quadrate lobe 19

20. VISCERAL SURFACE LOBES : Lobus dexter – right lobe l. sinister – left l. l. caudatus – caudate l. l. quadratus – quadrate l. 20

21. Imprints of surrounding organ s Right lobe- duodenum, right kidney and suprarenal gland, right colic flexure Left lobe - Sto mach, oesophagus 21

22. Caudate L obe : post. Surface Rt. – Groove fr IVC Lt.- Fissure fr Lig . Ven. Inf.- Porta hepatis Quadrate Lobe : Inf. Surface Ant. – Inf. Border Post.- Porta hepatis Rt.- fossa fr G.B. Lt.- Fissure fr Lig . Teres PORTA HEPATIS 22

23. Caudate L obe : posterior Surface Right - Groove for IVC Left - Fissure for Lig . Ven. Inferior - Porta hepatis Quadrate Lobe : Inferior surface Anterior -Inferior Border Posterior - Porta hepatis Right - fossa for Gall bladder Left - fissure for Lig . teres 23

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25. Parasagittal section through liver Showing subphrenic recess and hepatorenal recess (Rutherford-Morison pouch) 25

26. Left lobe cont… L ateral segment is separated from the medial segments by: On visceral surface: fissure of ligamentum teres (round ligament) fissure of li g ame n t u m venosum On diaphragmatic surface: a ttachment of falciform ligament 26

27. Visceral surface R ound ligament(ligamentum teres) – obliterated umbilical vein L igamentum venosum – fibrous remnant of fetal ductus vein Porta hepatis ( hepatic potal : portal fissure) - transverse fissure on the visceral surface of liver. It gives passage to the: Portal vein Hepatic artery Hepatic nerve plexus Hepatic ducts Lymphatic vessels 27

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29. PORTA HEPATIS - hepatic triad Inf. Surface Deep ,Transverse fissure, 5 cm long. Between Caudate l. & Quadrate l. PORTAL VEIN PROPER HEPATIC ARTERY (branch of common HA) Hepatic plexus of nerves RIGHT and LEFT HEPATIC DUCT - lymphatics , - vegetative nerve 29

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31. Liver is composed of hexagonal shaped units- lobules Radiate from central vein to the periphery Between the rows of hepatocytes are sinusoids which supply blood 31 Internal features

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33. Portal Triad Branches of portal vein, hepatic artery and the biliary ducts bound together in the perivascular fibrous capsule 33

34. Peritoneal relations Lesser omentum Encloses portal triad (bile duct, hepatic artery and portal vein ) Passes from liver to lesser curvature of stomach + 1 st inch of first part of duodenum. duodenum Thick free edge -- hepatoduodenal ligament Sheet like remainder – hepatogastric ligament 34

35. Contd … Posterior Surface- Bare area- Diaphragm & Rt. Suprarenal gland Groove for IVC. Caudate lobe- crura of diaphragm, Inf. Phrenic art. & Coeliac trunk Fissure for lig . Venosum Post. Surf of lt. lobe is maked by oesophageal impression. 35

36. Bare areas of the liver peritoneum b/t Ant. & Post. Coronary ligaments Fossa for gall bladder Porta hepatis Fissure for Lesser omentum Fissure for ligamentum venosum Fossa for IVC 36

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38. Intraparenchymal branches of right division of portal vein (portal) -> retroperitoneal veins (systemic) 38

39. Couinaud segments Segments I, II, III and IV make up the functional left lobe Segments V, VI, VII and VIII make up the functional right lobe Segment I corresponds to the gross anatomical caudate lobe and segment IV to the quadrate lobe 39

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42. Couinaud segments 42

43. Functional lobes 43

44. Functional lobes 44

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47. Blood supply Rt. & Lt. hepatic arteries carry oxygenated blood (25%). Portal vein ( valveless ) carries venous blood (75%) rich in nutrients. Hepatic veins drain venous blood to IVC. Right & left branches -> segmental vessels -> Interlobular – Hepatic sinusoids. Mixes Venous Drainage- Hepatic sinusoids- interlobular + sublobular veins + Hepatic veins IVC 47

48. Hepatic Veins (Right, Middle, Left) Interlobular veins Central Vein Portal Venules Hepatic Arterioles Aorta IVC Heart Hepatic Artery Portal Vein Spleen Intestine Splenic Vein Messenteric Vein 48 Contd ….

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50. 50 Venous Drainage

51. Nerve supply Hepatic plexus contains sympathetic & parasympathetic or vagal fibers Nerve also reach liver various peritoneal ligaments Capsule is supplied by some fine branches of the lower intercostal nerves , which also supply parietal peritoneum Particularly in the area of the 'bare area' & superior surface This is seen clinically when distension or disruption of liver capsule causes quite well localized sharp pain 51

52. Hepatic plexus is the largest derivative of the coeliac plexus. It also receives branches from the anterior and posterior vagi . These branches not only supply vasomotor fibres to the hepatic vessels and biliary tree, but also innervate the hepatocytes directly and are involved in the control of some homeostatic mechanisms. V agal fibres are motor to the musculature of gallbladder and bile ducts & inhibitory to the sphincter of bile duct. 52

53. Referred pain Pain arising from the parenchyma of liver is poorly localized In common with other structures of foregut origin, pain is referred to the central epigastrium Stretch of or involvement of the liver capsule by inflammatory or neoplastic processes rapidly produces well-localized pain of a 'somatic' nature 53

54. Lymphatic drainage Liver is a major lymph-producing organ ( 1/4 -1/2 of lymph → Thoracic duct) Diaphragmatic surface of liver drains to Phrenic nodes Visceral surface & deep lymphatics along portal triads drains to Porta Hepatis → Hepatic nodes → Coeliac nodes → Cisterna chyli → Thoracic duct 54

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56. Hepatitis Inflammation of liver due to viral infections Causes- viral infection, autoimmune hepatitis , drugs, toxins, & alcohol Types – hepatitis A hepatitis B hepatitis C hepatitis D hepatitis E 56

57. Liver Cirrhosis SYMPTOMS: Early symptoms- asymptomatic - Non specific (weight loss, weakness & fatigue Later – jaundice - Ascites - Hepatic encephalopathy 57 Cirrhosis is scarring (fibrosis) of the liver caused by long-term liver damage. The scar tissue prevents the liver working properly

58. Normal liver Liver cirrhosis 58

59. Acute Liver Failure Rapid deterioration of liver function, without known pre existing disease 59

60. Portal Hypertension P ortal vein provides about 75% of the liver's blood flow & about 60% of its O 2 supply Normal portal pressure is 5-10 mmHg (7-14 cm H 2 O), which exceeds inferior vena caval pressure by 4-5 mm Hg (portal venous gradient) Higher values are defined as portal hypertension 60

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62. CALOT’S TRIANGLE The borders are as follows: Medial  – common hepatic duct. Inferior  – cystic duct. Superior  – inferior surface of the liver. Contents Right hepatic artery Cystic artery   Lymph node of Lund  – the first lymph node of the gallbladder. Lymphatics 62

63. Pringle’s maneuver 63

64. Hepatocellular Carcinoma C ancer that starts in liver Diagnosis: - B lood test (alpha fetoprotein) - Imaging test- CT- scan,MRI , X-ray - Liver biopsy Treatment: Radiation, Chemotherapy, Immunotherapy ,Liver transplant 64

65. MCQ Q-The bare area of the liver is located on the _______________ surface of the liver? Inferior Anterior Posterior superior 65

66. Q- Liver is completely covered by a dense fibroelastic connective tissue layer called ? Parenchyma Glisson's  capsule Visceral capsule Liver sheath 66

67. Q- Which ligament is the remnant of ductus venosus ? Ligamentum teres Ligamentum venosus Falciform ligament Coronary ligament 67

68. Q- The Couinaud’s segmental nomenclature is based on the position of the : Hepatic veins and portal vein Hepatic veins and biliary ducts Portal vein and biliary ducts Portal vein and hepatic artery 68

69. Q- A 29 yr old male presented with abdominal pain and fever for 15-20 days, with loss of appetite for 5 days. On abdominal examination there was tenderness and guarding in the right upper quadrant with hepatomegaly extending 5 cm below right costal margin. Ultrasound examination showed abscess in right lobe of the liver. The patient tested positive for amoebic antibody by ELISA test. What is the probable diagnosis? Ans. Amoebic liver abscess 69

70. Q- A 49-year-old man presents with acute abdominal pain and jaundice resulting from a tumor at the head of the pancreas. The tumor will most likely obstruct which of the following structures? A. Bile duct B. Common hepatic duct C. Left hepatic duct D. Cystic duct 70

71. Q- Which of the following doesn’t contribute in forming hepatic plexus ? Celiac plexus Left phrenic nerve Rt and Lt. vagus nerve Right phrenic nerve Ans - b 71

72. References Williams PL.  Gray’s Anatomy . The Anatomical Basis of Clinical Practice. 41 st Ed. Edinburgh: Churchill Livingstone; p.1098-1107. Snell , Richard S. (2018)  Clinical neuroanatomy  /Philadelphia : Wolters Kluwer Health/Lippincott Williams & Wilkins Moore KL, Agur AM, Dalley AF, Moore KL. Essential clinical anatomy. Wolters Kluwer Health,; 2015. Lautt WW. Hepatic circulation: physiology and pathophysiology . InColloquium Series on Integrated Systems Physiology: from Molecule to Function 2009 Jan 1 (Vol. 1, No. 1, pp. 1-174). Morgan & Claypool Publishers. 72