Liver and Bile ducts pdf - Abdomen

Basic Anatomy

The

ductus venosus close and become fibrous cords.

joins the inferior vena cava. At birth, the umbilical vein and

liver in the ductus venosus (ligamentum venosum) and

teres). The greater proportion of the blood bypasses the

is brought to the liver in the umbilical vein (ligamentum

cava (Figs. 5.8 and 5.22). In the fetus, oxygenated blood

face of the liver to be attached above to the inferior vena

portal vein and ascends in a fissure on the visceral sur

is attached to the left branch of the

ductus venosus,

of the

a fibrous band that is the remains

ligamentum venosum,

portal vein in the porta hepatis (Figs. 5.9 and 5.22). The

ceral surface of the liver and joins the left branch of the

passes into a fissure on the vis

ligamentum teres

The

(Fig. 5.8).

bare area of the liver

of liver devoid of peritoneum. Such an area is referred to as

the coronary ligament are widely separated, leaving an area

liver. It should be noted that the peritoneal layers forming

of the

right triangular ligament

ligament is known as the

(Fig. 5.8). The right extremity of the coronary

lar ligament

left triangu

the left layer forms the upper layer of the

ment;

coronary liga

The right layer forms the upper layer of the

superior surfaces of the liver and then splits into two layers.

falciform ligament passes on to the anterior and then the

the ligamentum teres, the remains of the umbilical vein. The

(Fig. 5.8). It has a sickle-shaped free margin that contains

the peritoneum, ascends from the umbilicus to the liver

which is a two-layered fold of

falciform ligament,

The

Peritoneal Ligaments of the Liver

and esophagus and fundus of the stomach

of the colon, duodenum, gallbladder, inferior vena cava,

Diaphragm, right kidney, hepatic flexure

Posteriorly:

costal angle

xiphoid process, and anterior abdominal wall in the sub

right and left pleura and lower margins of both lungs,

Diaphragm, right and left costal margins,

Anteriorly:

Important Relations

into the central vein.

and drains

sinusoids

between the liver cells by means of

duct (portal triad). The arterial and venous blood passes

of the hepatic artery, portal vein, and a tributary of a bile

which contain branches

portal canals,

the lobules are the

is a tributary of the hepatic veins. In the spaces between

of each lobule

central vein

The

liver lobules.

made up of

sule but only partially covered by peritoneum. The liver is

The liver is completely surrounded by a fibrous cap

lymph nodes.

and gallbladder and send their efferent vessels to the celiac

A few hepatic lymph nodes lie here; they drain the liver

sympathetic and parasympathetic nerve fibers (Fig. 5.47).

and left branches of the hepatic artery, the portal vein, and

margins. In it lie the right and left hepatic ducts, the right

of the free edge of the lesser omentum is attached to its

and quadrate lobes (Figs. 5.8 and 5.9). The upper part

the posteroinferior surface and lies between the caudate

or hilum of the liver, is found on

porta hepatis,

The

two sides overlap very little.

quadrate plus caudate lobes), respectively. Apparently, the

ducts, are distributed to the right lobe and the left lobe (plus

hepatic artery and portal vein, and the right and left hepatic

lobe of the liver. Thus, the right and left branches of the

quadrate and caudate lobes are a functional part of the left

tum venosum. Experiments have shown that, in fact, the

teres, the inferior vena cava, and the fissure for the ligamen

presence of the gallbladder, the fissure for the ligamentum

by the

caudate lobe

and a

quadrate lobe

divided into a

the falciform ligament (Fig. 5.8). The right lobe is further

by the attachment of the peritoneum of

left lobe

a small

right lobe

The liver may be divided into a large

nal gland, and the gallbladder.

num, the right colic flexure, the right kidney and suprare

abdominal part of the esophagus, the stomach, the duode

is therefore irregular in shape; it lies in contact with the

is molded to adjacent viscera and

visceral surface,

rior,

posteroinfe

surface of the domes of the diaphragm. The

convex upper surface of the liver is molded to the under

197

-
-

and

■

hepatis.

into right and left terminal branches that enter the porta

The hepatic artery, a branch of the celiac artery, divides

Arteries

passes down to the lesser curvature of the stomach (Fig. 5.10).

hepatis and the fissure for the ligamentum venosum and

arises from the edges of the porta

lesser omentum

Blood Supply

plicae circulares

jejunum

small intestine

ileum

colon

Peyer's patch

smooth mucous membrane

teniae coli

appendices
epiploicae

teniae coli

large intestine

sacculations

FIGURE 5.50

Some external and internal differences

between the small and large intestine.

198

CHAPTER 5

it lies in a groove on the posterior surface of the head of the

troduodenal artery (Fig. 5.4). In the third part of its course,

first part of the duodenum (Fig. 5.7) to the right of the gas

In the second part of its course, it is situated behind the

portal vein and on the right of the hepatic artery (Fig. 5.11).

the lesser sac. Here, it lies in front of the right margin of the

margin of the lesser omentum in front of the opening into

long. In the first part of its course, it lies in the right free

The bile duct (common bile duct) is about 3 in. (8 cm)

gallbladder to form the bile duct (Fig. 5.29).

tum. It is joined on the right side by the cystic duct from the

and descends within the free margin of the lesser omen

is about 1.5 in. (4 cm) long

common hepatic duct

The

hepatic duct (Fig. 5.29).

short course, the hepatic ducts unite to form the common

left lobes of the liver in the porta hepatis (Fig. 5.47). After a

The right and left hepatic ducts emerge from the right and

lobe.

left duct drains the left lobe, caudate lobe, and quadrate

right hepatic duct drains the right lobe of the liver and the

porta hepatis, form the right and left hepatic ducts. The

to form progressively larger ducts and, eventually, at the

the bile canaliculi. The interlobular ducts join one another

are situated in the portal canals of the liver; they receive

The smallest interlobular tributaries of the bile ducts

cystic duct.

and the

gallbladder,

bile duct,

mon hepatic duct,

com

the

left hepatic ducts,

and

right

liver consist of the

it is delivered to the duodenum. The bile ducts of the

bile is stored and concentrated in the gallbladder; later,

40 mL per hour. When digestion is not taking place, the

Bile is secreted by the liver cells at a constant rate of about

branch, which passes directly to the liver.

plexus. The anterior vagal trunk gives rise to a large hepatic

Sympathetic and parasympathetic nerves form the celiac

Nerve Supply

to the posterior mediastinal lymph nodes.

pass from the bare area of the liver through the diaphragm

The efferent vessels pass to the celiac nodes. A few vessels

the liver and enter several lymph nodes in the porta hepatis.

third to one half of all body lymph. The lymph vessels leave

The liver produces a large amount of lymph—about one

Lymph Drainage

directly into the inferior vena cava.

and these leave the posterior surface of the liver and open

The central veins drain into the right and left hepatic veins,

the central vein of each liver lobule by the liver sinusoids.

tinal tract. The arterial and venous blood is conducted to

digestion, which have been absorbed from the gastrointes

the portal vein brings venous blood rich in the products of

hepatic artery brings oxygenated blood to the liver, and

are the hepatic artery (30%) and portal vein (70%). The

The blood vessels (Fig. 5.47) conveying blood to the liver

Blood Circulation through the Liver

the liver and drain into the inferior vena cava.

(three or more) emerge from the posterior surface of

veins

hepatic

that enter the porta hepatis behind the arteries. The

The portal vein divides into right and left terminal branches

Veins

The Abdomen: Part II—The Abdominal Cavity

Bile Ducts of the Liver

the

Hepatic Ducts

Bile Duct

Liver Supports and Surgery

nied by a loss of liver dullness caused by the accumulation of gas

dull on percussion. Perforation of a gastric ulcer is often accompa

the peritoneal surfaces. The anterior surface of the liver is normally

abnormal accumulation of gas or fluid is necessary for separation of

potential spaces only, and the peritoneal surfaces are in contact. An

are described on page 163. Under normal conditions, these are

The important subphrenic spaces and their relationship to the liver

hepatic arteries, and portal vein are distributed in a segmental

or upper abdomen are common causes of liver injury. Blunt trau

surgically because even if the peritoneal ligaments are cut, the

cava. The peritoneal ligaments and the tone of the abdominal

cavity by the attachment of the hepatic veins to the inferior vena

The liver is held in position in the upper part of the abdominal

muscles play a minor role in its support. This fact is important

liver can be only slightly rotated.

Liver Trauma

The liver is a soft, friable structure enclosed in a fibrous cap-

sule. Its close relationship to the lower ribs must be emphasized.

Fractures of the lower ribs or penetrating wounds of the thorax

matic injuries from automobile accidents are also common, and

severe hemorrhage accompanies tears of this organ.

Because anatomic research has shown that the bile ducts,

manner, appropriate ligation of these structures allows the sur-

geon to remove large portions of the liver in patients with severe

traumatic lacerations of the liver or with a liver tumor. (Even

large, localized carcinomatous metastatic tumors have been

successfully removed.)

Liver Biopsy

Liver biopsy is a common diagnostic procedure. With the patient

holding his or her breath in full expiration—to reduce the size of

the costodiaphragmatic recess and the likelihood of damage to

the lung—a needle is inserted through the right 8th or 9th inter-

costal space in the midaxillary line. The needle passes through

the diaphragm into the liver, and a small specimen of liver tissue

is removed for microscopic examination.

Subphrenic Spaces

over the anterior surface of the liver and in the subphrenic spaces.

C L I N I C A L N O T E S

Basic Anatomy

cle around the distal end of the bile duct and the ampulla is

gallbladder to contract. At the same time, the smooth mus

denum; the hormone then enters the blood, causing the

from the mucous membrane of the duo

cholecystokinin

the duodenum. The fat causes release of the hormone

mechanism is initiated by the entrance of fatty foods into

traction and partial emptying of the gallbladder. This

Bile is delivered to the duodenum as the result of con

microvilli on their free surface.

ance. The columnar cells lining the surface have numerous

each other, giving the surface a honeycombed appear

membrane is thrown into permanent folds that unite with

and secretes mucus. To aid in these functions, the mucous

absorbs bile salts, keeping the bile acid; excretes cholesterol;

The gallbladder concentrates bile; stores bile; selectively

remains closed and bile accumulates in the gallbladder.

When digestion is not taking place, the sphincter of Oddi

Function of the Gallbladder

ond parts of the duodenum (Fig. 5.29)

The transverse colon and the first and sec

Posteriorly:

rior surface of the liver (Fig. 5.2)

The anterior abdominal wall and the infe

Anteriorly:

Relations

face of the liver.

gallbladder and binds the body and neck to the visceral sur

The peritoneum completely surrounds the fundus of the

(Fig. 5.29).

to join the common hepatic duct, to form the bile duct

with the cystic duct, which turns into the lesser omentum

becomes continuous

neck

backward, and to the left. The

with the visceral surface of the liver and is directed upward,

lies in contact

body

tip of the 9th right costal cartilage. The

contact with the anterior abdominal wall at the level of the

below the inferior margin of the liver, where it comes in

is rounded and projects

fundus

dus, body, and neck. The

absorbing water. The gallbladder is divided into the fun

of 30 to 50 mL and stores bile, which it concentrates by

face of the liver (Figs. 5.8, 5.9, and 5.29). It has a capacity

The gallbladder is a pear-shaped sac lying on the undersur

Location and Description

Figure 5.52.

common variations of this arrangement are shown in

pancreatic ducts open separately into the duodenum. The

(Fig. 5.51). Occasionally, the bile and

(sphincter of Oddi)

sphincter of the hepatopancreatic ampulla

known as the

ducts and the ampulla are surrounded by circular muscle,

(Fig. 5.51). The terminal parts of both

duodenal papilla

major

of the duodenum by means of a small papilla, the

The ampulla opens into the lumen

(ampulla of Vater).

hepatopancreatic ampulla

the duodenal wall, called the

atic duct, and together they open into a small ampulla in

length (Fig. 5.51). It is usually joined by the main pancre

the second part of the duodenum about halfway down its

The bile duct ends below by piercing the medial wall of

with the main pancreatic duct.

pancreas (Fig. 5.29). Here, the bile duct comes into contact

199

Gallbladder

■

plicae
circulares

major
duodenal
papilla

sphincter of Oddi
(sphincter of the
hepatopancreatic ampulla)

bile duct

accessory pancreatic duct

main pancreatic duct

FIGURE 5.51

Terminal parts of the bile and pancreatic ducts

as they enter the second part of the duodenum. Note the

sphincter of Oddi and the smooth muscle around the ends

of the bile duct and the main pancreatic duct.

combined ducts

bile duct

main pancreatic duct

sphincter of Oddi

major duodenal papilla

separate ducts

ampulla of
Vater

bile duct

main pancreatic duct

sphincter of Oddi

separate ducts

ampulla
Vater

FIGURE 5.52

Three common variations of terminations of the bile and main pancreatic ducts as they enter the second part of

the duodenum.

200

CHAPTER 5

form a spiral fold that is continuous with a similar fold in

The mucous membrane of the cystic duct is raised to

free margin of the lesser omentum.

S-shaped and descends for a variable distance in the right

to form the bile duct (Fig. 5.29). It usually is somewhat

the neck of the gallbladder to the common hepatic duct

is about 1.5 in. (3.8 cm) long and connects

cystic duct

The

food from the stomach.

mucous membrane of the duodenum on the arrival of fatty

the hormone cholecystokinin, which is produced by the

celiac plexus. The gallbladder contracts in response to

Sympathetic and parasympathetic vagal fibers form the

artery and then to the celiac nodes.

pass to the hepatic nodes along the course of the hepatic

the neck of the gallbladder. From here, the lymph vessels

situated near

cystic lymph node

The lymph drains into a

Lymph Drainage

veins also run between the liver and gallbladder.

directly into the portal vein. Several very small arteries and

drains

cystic vein

(Fig. 5.47), supplies the gallbladder. The

a branch of the right hepatic artery

cystic artery,

The

digestion and absorption.

emulsifying the fat in the intestine and in assisting with its

the duodenum. The bile salts in the bile are important in

relaxed, thus allowing the passage of concentrated bile into

The Abdomen: Part II—The Abdominal Cavity

Blood Supply

Nerve Supply

Cystic Duct

Gallstones

Sonograms can now be used to demonstrate the gallbladder

bladder rarely becomes gangrenous. In addition to the cystic

rise to referred pain over the shoulder, because the skin in this

irritation of the subdiaphragmatic parietal peritoneum, which is

pancreatic duct is subject to considerable variation. The type of

arrangement of the terminal part of the bile duct and the main

greater splanchnic nerves to the thoracic segments of the spinal

Gallstones are usually asymptomatic; however, they can give

rise to gallstone colic or produce acute cholecystitis.

Biliary Colic
Biliary colic is usually caused by spasm of the smooth muscle

of the wall of the gallbladder in an attempt to expel a gallstone.

Afferent nerve fibers ascend through the celiac plexus and the

cord. Referred pain is felt in the right upper quadrant or the epi-

gastrium (T7, 8, and 9 dermatomes).

Obstruction of the biliary ducts with a gallstone or by com-

pression by a tumor of the pancreas results in backup of bile in

the ducts and development of jaundice. The impaction of a stone

in the ampulla of Vater may result in the passage of infected bile

into the pancreatic duct, producing pancreatitis. The anatomic

duct system present determines whether infected bile is likely to

enter the pancreatic duct.

Gallstones have been known to ulcerate through the gallblad-

der wall into the transverse colon or the duodenum. In the former

case, they are passed naturally per the rectum, but in the latter

case, they may be held up at the ileocecal junction, producing

intestinal obstruction.

Acute Cholecystitis

Acute cholecystitis produces discomfort in the right upper quad-

rant or epigastrium. Inflammation of the gallbladder may cause

supplied in part by the phrenic nerve (C3, 4, and 5). This may give

area is supplied by the supraclavicular nerves (C3 and 4).

Cholecystectomy and the Arterial Supply

to the Gallbladder

Before attempting a cholecystectomy operation, the surgeon

must be aware of the many variations in the arterial supply to

the gallbladder and the relationship of the vessels to the bile

ducts (Fig. 5.53). Unfortunately, there have been several reported

cases in which the common hepatic duct or the main bile duct

have been included in the arterial ligature with disastrous con-

sequences.

Gangrene of the Gallbladder

Unlike the appendix, which has a single arterial supply, the gall-

artery, the gallbladder also receives small vessels from the vis-

ceral surface of the liver.

(Fig. 5.54).

C L I N I C A L N O T E S

right hepatic artery

cystic artery

left hepatic artery

hepatic artery

bile duct

FIGURE 5.53

Some common variations of blood supply to the gallbladder.