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Biliary Tree
Dr. Aldwin A. Yaneza
Dept of Anatomy
1
LIVER
- Largest gland
- Approx 1500 g, ¼ of BW
- Lies in R upper and L
upper quadrants [mainly
on right]
- Inferior to diaphragm
- Function:
- 1] stores glycogen
2] secretes BILE
2
SURFACES
A. Diaphragmatic
Smooth and dome shaped
Recesses
Subphrenic – bet diaphragm &
liver
Hepatorenal – bet liver and R
kidney
3
Ligaments of liver
Bare area of liver – not covered–with
peritoneum
Ligaments
1] Coronary – superior
2] Triangular – lateral
3] Falciform – anterior, middle
4] Round – inferior, remnant of
umbilical vein
4
SURFACES
B. Visceral
Covered w/ peritoneum except at
bed of gallbladder and porta hepatis
Relations
- R side of stomach – gastric/pyloric
area
- 1st part duodenum – duodenal area
- Lesser omentum
- Gallbladder
- R colic flexure – colic area
- R kidney/suprarenal gl – renal/
suprarenal` area
5
Visceral surface
Structures:
IVC
Portal triad
Hepatic artery
Portal Vein
Hepatic duct
Caudate lobe
Quadrate lobe
6
FUNCTIONAL PARTS
Functionally independent R/ L lobes
Can donate one lobe to relative
Each lobe with own
Blood supply
Venous drainage
Biliary drainage
Division into R – L lobes
GB fossa inferiorly and IVC fossa superiorly
Facilform lig [ old terminology]
7
Current [func’l] terminology
L liver = caudate and quadrate lobe + L lobe
R liver = R lobe
OLD terminology
Falciform lig
– divides it into R and L
8
Functional parts
Round ligament [L. ligamentum teres]
Remnant of umbilical vein that carried oxygenated
blood from placenta to fetus
Porta Hepatis
Transverse fissure on visceral surface of liver bet
caudate and quadrate lobes
Passage for portal triad
1] Portal vein
2] Hepatic artery
3] Hepatic duct
Others – hepatic nerve plexus, lymph
9
Portal v
Hepatic art
Hepatic duct
10
Peritoneal Relations
Lesser omentum
- fr liver to lesser curve of stomach and
1st part of duodenum
- parts:
Hepatoduodenal lig
Extends bet porta hepatis and duodenum
Encloses portal triad
Hepatic duct, hep. artery, portal vein
Hepatogastric lig
Extends bet liver and lesser curve of
stomach
11
Vessels and nerves
Liver receives blood from 2 sources
1] Portal vein [ 70 % ]
2] Hepatic artery [ 30 %]
Venous drainage
Hepatic vein
Formed by union of central veins of liver
Drains into IVC
12
Blood supply of liver
1. PORTAL VEIN
Formed by union of
superior mesenteric
vein [SMV] and splenic
vein
Ascends anterior to
IVC, has R - L
branches
Carries poorly
oxygenated but nutrient
rich blood fr GIT to
liver
70%
13
Blood supply of liver
2. HEPATIC artery
Br of celiac art
Div into R and L hepatic
art
Carries well oxygenated
blood from aorta to liver
30%
14
SEGMENTS
Horizontal plane thru R lobe and lateral
division of L lobe plus caudate lobe
Divides liver into 8 vascular segments
Based on divisions of the hepatic artery and
portal vein and hepatic ducts
Each segment:
Supplied by br of hepatic art. and Portal V.
Drained by branch of hepatic duct
15
16
17
I-back
Posterior
IVa II
superior
III
VIII
VII
IVb
V
VI
Posterior
inferior P A Me La
18
Division
Anatomic[2] – Falciform lig
Functional[2] – L lobe is quadrate +caudate
+ L anatomic lobe
Surgical[4] - R/ L Lateral and Medial div
Segments [8] - Couinauds
19
P A Me La
20
Segments
I - Caudate
II - Lateral superior
III - Lateral inferior
IVa - Medial superior
IVb – Medial inferior
V - Anterior inferior
VI - Posterior inferior
VII – Posterior superior
VIII - Anterior superior
21
The Couinaud classification of liver anatomy divides the liver into
eight functionally indepedent segments.
Each segment = own vascular inflow, outflow and biliary
drainage.
In the centre of each segment - branch of the portal vein, hepatic
artery and bile duct.
In the periphery of each segment = vascular outflow through the
hepatic veins.
22
4A
4B
Segments numbering
There are 8 liver segments.
Segment 4 is sometimes divided into segment 4a and 4b according to
Bismuth.
The numbering of the segments is in a clockwise manner (figure).
Segment 1 (caudate lobe) is located posteriorly. It is not visible on a
frontal view.
23
Lymphatics
Major lymph producing organ
Occur as superficial lymphatics in Glisson’s
capsule and as deep lymphatics in
connective tissue that accomp the p.triad
Anterior superf lymph hepatic LN
celiac LN chyle cistern [dilated sac of t.
duct]
Posterior superf lymph phrenic LN
posterior mediastinal LN thoracic duct
24
25
Nerve Supply
Hepatic Nerve Plexus
Largest derivative of celiac plexus
Accomp branches of p. triad to liver
Function: Vasoconstriction
26
Variations in LIVER
27
IRON MAN Robert Downey Jr
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The Dark Knight ,2008
29
30
GALLBLADDER and BILIARY
DUCTS
Bile
Produced by hepatocytes
Yellow fluid
Stored in GB
Emulsifies fat
31
Gallbladder
32
I. General Information
A. Location:
1. Epigastric region
2. R hypochondriac
3. inferior surface
of liver
4. Between quadrate and right
lobes
B. Pear-shaped, hollow structure
thin walled greenish
33
General Information, con’t.
34
Introduction, continued …
F. Normal measurements:
7-10 cm long
4 - 6 cm diameter
30 – 60 cc bile
G. Function:Stores and concentrates bile
35
II. Detailed Anatomy
A. Fundus of GB:
36
Parts Gallbladder
Fundus
-wide end
-Projects fr inferior
border of liver
Body
-Main part
-Contacts the R part of
transverse colon and 1st
part of duodenum
37
Body
-Contacts the R part of transverse colon and 1st part of
duodenum
- Chronic cholecystitis[inflammation], body forms
connection with
1] colon – cholecystocolonic fistula
2] duodenum – cholecystoduodenal fistula
38
Neck
Gallbladder
-Narrow,tapered
-Continuous w/ cystic duct
-Mucosa thrown into spiral fold
[valve of Heister]
-Serves as guide to omental bursa
Cystic duct
- 2- 4 cm long
- Joins common hepatic duct to form
common bile duct
-mucous membrane thrown into
spiral fold
39
Gallbladder
Arterial supply
Cystic art [fr R hepatic
artery]
Venous drainage
Cystic vein [drains into
R branch of portal vein]
Lymphatic drainage
Hepatic LN
Nerve supply
Celiac plexus [symp]
Vagus n [parasymp]
40
The Gallbladder and Biliary System with Pancreas
41
Detailed Anatomy, con’t….
O. Lymphatic drainage of GB
1. Enlarged – [+]malignancy
2. Cystic node at neck of GB
a. Cystic node of Calot
b. Behind is cystic artery
c. Guide for laparoscopic surgeons
3. Other lymph vessels also drain
into hepatic nodes
42
43
Lymph Nodes
N1
Choledochal
Hilar
Cystic duct
N2
Peripancreatic
Retroduodenal
Portal, celiac, or superior
mesenteric vessels
44
Biliary Ducts
Hepatic ducts- drain the
liver
R Hep duct – R lobe
L Hep duct – L Lobe
Common hepatic ducts-
when R and L hd unite
4 cm, in lesser omentum
Common bile duct
- after giving off cystic
duct on right
45
2009 Movies
46
47
Harry Potter and the Half blood Prince
48
49
50
Transformer 2: Revenge of the Fallen
51
52
Common Bile Duct [ CBD ]
8-10 cm long
5-6 mm diameter
in lesser omentum
Passes behind 1st part of
duodenum
Unites w/ main
pancreatic duct to form
hepatopancreatic
ampulla
Opens into descending
or 2nd part of duodenum
53
CBD
Arterial supply
Proximal part – cystic a
Middle part – R hepatic a
Distal part – posterior superior
pancreaticoduodenal a
Venous drainage
Posterior superior
pancreaticoduodenal vein
Lymphatic
Cystic LN
Hepatic LN
Celiac LN
54
III. Gallbladder Diseases
55
Cholelithiasis
56
Gallbladder Diseases, continued …
B. GB Carcinoma
a. US useful in diagnosis
b. mass producing thickening and
irregularity in wall
c. Calculi found frequently
57
Gallbladder Diseases, continued …
C. Polyps of GB
a. Intraluminal echogenic projections
b. Do not change position with patient
c. Must be differentiated from
stones
58
Gallbladder diseases, continued …
59
Cystic artery
Ligated during surgical
removal of gallbladder
[cholecystectomy]
60
Variations in Anatomy of Cystic Duct
61
Anatomy /Histology
Mucosa
Smooth muscle
Serosa
Attachment to liver
Tumors can extend directly
into liver
62
Laparoscopic Cholecystectomy
63
Identify the gallbladder
64
Triangle of CALOT = area formed by the cystic duct, hepatic duct and edge of
liver. The cystic artery will be located in this triangle
65
Isolate and ligate the cystic
artery
66
Isolate and ligate the cystic duct
67
68
Clinical correlation:
Calculous cholecystitis
Diet high in fat produces
cholesterol stones inside GB
After eating GB contracts, it
expels stone w/c lodges at
cystic duct
Trigger inflammation of GB
[cholecystitis]
Pain at RUQ
Diagnosed by:
70
Empyema of gallbladder
Longstanding impaction of
stone at cystic duct
Remaining bile cannot exit the
GB because of impacted stone
Bacteria will set in
Abscess forms inside GB
GB enlarges, wall thickens
Clinical :
Fever, RUQ pain, palpable
GB at RUQ
Common among diabetics and
noncompliant patients
71
Ruptured Cholecystitis
72
National Kidney Institute,East Ave
FEU Medical
Center,Fairview
The end
Aldwin A. Yaneza,MD
General and Laparoscopic Surgery
73
SET A
SET B
Gallbladder
Pear shaped sac
Along R edge of quadrate lobe of
liver in depression called
gallbladder fossa,V
Hangs by stem = cystic duct
Rounded fundus projects beyond
inferior margin of liver
Thin walled greenish
Covered on its posterior and inferior
surfaces by peritoneum
Concentrates and stores bile
secreted by liver
Holds 30-60 ml of bile
76
END
77
Quiz
Set A Set B
Tabulate the 7 Draw and label the 8
differences between Couinauds segments
the jejunum and ileum Tabulate the 7
Draw and label the 8 differences between
surgical segments the jejunum and ileum
Draw and label the Draw and label parts
biliary tree/ tract of gallbladder
78