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Chapter 1

Anatomy and physiology


R. Sutcliffe & O. Tucker
Liver segmental anatomy 2 Hepatic artery anatomy 6 Liver resection planes 7 Liver physiology 8 Gallbladder anatomy 10 Biliary anatomy 13 Pancreatic anatomy 14 Pancreatic physiology 15

CHAPTER 1

Anatomy and physiology

Liver segmental anatomy


The liver is the largest solid organ (weight 1.21.6kg), and lies in the right upper quadrant of the abdomen below the right hemidiaphragm. Peritoneal attachments: falciform ligament, coronary ligament, and left and right triangular ligaments (see Fig. 1.3). The Glissonian capsule is a brous covering over the liver, except the bare area, where the liver is in direct contact with the diaphragm.

Liver segments
Anatomical divisions are based on vascular and biliary anatomy not surface markings (see Figs 1.1 and 1.2). The arterial supply to the liver is via the common hepatic artery (branch of coeliac axis), which usually runs to the left of the common bile duct, before dividing into left and right branches. There is considerable anatomical variation of the hepatic arteries (Hepatic artery anatomy b p. 6). The mid-plane of the liver separates the right lobe (supplied by right hepatic artery and right portal vein) from the left lobe (supplied by left hepatic artery and left portal vein). The principal plane (see Fig. 1.1) intersects the gallbladder fossa anteriorly and the inferior vena cava fossa posteriorly. The left and right hepatic ducts (rst-order ducts) drain bile into the common hepatic duct from each lobe. Second-order ducts and arteries divide each lobe into two sections. right lobe => anterior and posterior sections; left lobe => medial and lateral sections. The left intersectional plane corresponds to the umbilical ssure and the attachment of the falciform ligament to the liver. The right intersectional plane does not have a surface marking. Third-order divisions of the liver are also known as Couinauds segments. right anterior section => segments 5 and 8 right posterior section => segments 6 and 7; left lateral section => segments 2 and 3; left medial section => segment 4. The caudate lobe is distinct from the left and right lobes, and is also referred to as segment 1. It lies between the porta hepatis and the inferior vena cava. It receives a blood supply from both left and right hepatic arteries, and bile drains into both left and right hepatic ducts.

LIVER SEGMENTAL ANATOMY

2 7 8 4 3

Principal plane

Fig. 1.1 Principal plane.

RHV

LHV

2 7 8 4 3

5 MHV

LHV Left hepatic vein MHV Middle hepatic vein RHV Right hepatic vein

Fig. 1.2 Liver segments. LHV: left hepatic vein, MHV: middle hepatic vein, RHV:
right hepatic vein.

CHAPTER 1

Anatomy and physiology

The portal vein drains blood from the gastrointestinal tract (from lower oesophagus to rectum), pancreas, and spleen. It is formed by the union of the splenic and superior mesenteric veins posterior to the neck of the pancreas. The inferior mesenteric vein invariably drains into the splenic vein. The right portal vein supplies the right lobe and its branches correspond to those of the right hepatic artery. The left portal vein is initially horizontal and changes direction at the ligamentum venosum to become vertical (umbilical portion, in the umbilical ssure). The vertical portion is a remnant of the umbilical vein, and gives branches to segment 4 (to its right), and segments 2 and 3 (to its left). The hepatic veins drain blood from the liver into the inferior vena cava, and lie between sections or lobes: left hepatic vein between s2 and s3 then left intersectional plane; middle hepatic vein mid-plane (between s4 and s5/8); right hepatic vein right intersectional plane (between s5/8 and s6/7). 10% of patients have a large inferior right hepatic vein in addition to a superior right hepatic vein. The caudate lobe drains blood directly into the IVC, via several small veins. See Fig. 1.3.

LIVER SEGMENTAL ANATOMY

Anterior view

IVC

LTL L R FL

Posterior view UC BA PH

LC

RTL Fig. 1.3 Peritoneal attachments of the liver. G: gallbladder, FL: falciform ligament, LTL: left triangular ligament, IVC: inferior vena cava, R: right lobe, L: left lobe, PH: porta hepatis, BA: bare area, UC: upper layer of coronary ligament, LC: lower layer of coronary ligament, RTL: right triangular ligament.

CHAPTER 1

Anatomy and physiology

Hepatic artery anatomy


An accessory artery indicates that the proper hepatic artery (left, right, or common) is also present. A replaced artery indicates that the proper artery is absent. An accessory or replaced left hepatic artery arises from the left gastric artery and runs in the lesser omentum. An accessory or replaced right hepatic artery arises from the superior mesenteric artery, and passes behind the common bile duct to run along its right posterolateral border into the liver.

LIVER RESECTION PLANES

Liver resection planes


Anatomical liver resections follow anatomical planes (Fig. 1.4). Transection through umbilical ssure/falciform ligament (left intersectional plane): left lateral sectionectomy (or segmentectomy); extended right hepatectomy. Transection through mid-plane: left hepatectomy; right hepatectomy. Transection through right intersectional plane: extended left hepatectomy; right posterior sectionectomy.

Right hepatectomy Left hepatectomy

Extended right hepatectomy Left lateral segmentectomy

Fig. 1.4 Resection planes.

CHAPTER 1

Anatomy and physiology

Liver physiology
The liver parenchyma is arranged into lobules, which contain several acini. An acinus is arranged around terminal branches of the hepatic artery and portal vein. Hepatocytes receive their blood supply via the hepatic sinusoids, which are fenestrated capillaries lined by endothelial cells. Sinusoids are lined by Kupffer cells (part of reticulo-endothelial system), hepatic stellate cells, and liver-associated lymphocytes. Bile canaliculi drain bile from hepatocytes into a network of cholangioles and larger ducts, before entering the common hepatic duct

Liver function
The liver has substantial reserve capacity, which allows signicant damage (e.g. cirrhosis) to occur before symptoms develop. A signicant volume of liver (up to 60%) can be resected safely, without patients developing liver failure, provided that the future liver remnant is of good quality and an adequate volume (see Complications after liver resection, Early, Smallfor-size syndrome b p. 190). Metabolism: carbohydrates (gluconeogenesis, glycogenesis, glycogenolysis); protein; lipids; bilirubin; hormones; haemoglobin; drugs; lactate. Synthesis: albumin; clotting factors (brinogen, prothrombin, V, VII, IX, XI, protein C, protein S, antithrombin); cholesterol; triglycerides; bile; lipoproteins; caeruloplasmin; transferrin; complement; glycoproteins. Storage glycogen; vitamin B12; iron; copper. Foetal erythropoiesis.

LIVER PHYSIOLOGY

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CHAPTER 1

Anatomy and physiology

Gallbladder anatomy
The gallbladder is a hollow organ that concentrates and stores bile. It lies in the gallbladder fossa on the inferior aspect of the right lobe. It has a rounded fundus, a body, and an infundibulum. Gallstones may become impacted in Hartmanns pouch. The presence of fat in the duodenum stimulates the release of cholecystokinin (CCK), which causes contraction of the gallbladder and secretion of bile through the cystic duct, common bile duct, and into the duodenum. Calots triangle is bordered by the gallbladder, the common hepatic duct and the liver (Fig. 1.5). The peritoneal covering of the gallbladder extends onto the anterior and posterior aspects of Calots triangle and onto the portal structures. The arterial supply of the gallbladder is via the cystic artery, which usually arises from the right hepatic artery and lies within Calots triangle. Occasionally, the cystic artery has anterior and posterior branches before entering the gallbladder. The cystic duct joins the common hepatic duct to form the common bile duct, usually about 5cm above the duodenum. Rarely, an accessory cystic duct (duct of Luschka) drains bile intrahepatically through the gallbladder fossa, and is susceptible to injury during cholecystectomy (Fig. 1.6). Venous drainage of the gallbladder occurs via multiple small veins that enter the portal vein, either through the gallbladder fossa or Calots triangle

GALLBLADDER ANATOMY

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PH

CD

CA

CHD

Fig. 1.5 Calots triangle. PH: porta hepatis, R: right lobe of liver, G: gallbladder, L: liver, CD: cystic duct, CHD: common hepatic duct, CA: cystic artery.

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CHAPTER 1

Anatomy and physiology


RHD LHD CHD

GB CD

CBD (a) (b)

(c)

(d)

Fig. 1.6 Gallbladder anatomical variation. (a) Normal (GB: gallbladder; CD: cystic duct; CBD: common bile duct; CHD: common hepatic duct; RHD: right hepatic duct; LHD: left hepatic duct). (b) Cystic duct draining into RHD. (c) Right posterior sectoral duct draining into gallbladder. (d) Short or absent cystic duct.

BILIARY ANATOMY

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Biliary anatomy
The left and right hepatic ducts unite at the base of segment 4, anterior to the portal vein bifurcation. The common hepatic duct passes inferiorly in the right edge of the hepatoduodenal ligament, to the right of the common hepatic artery, and joins the cystic duct to become the common bile duct. The common bile duct (diameter 37mm) passes behind the rst part of the duodenum, enters the head of the pancreas, and terminates at the ampulla of Vater. Many anatomical variants of biliary anatomy have been described (Fig. 1.7). The blood supply of the biliary tree is derived principally from the hepatic artery, which explains the presence of biliary complications that develop after hepatic artery thrombosis in liver transplant recipients.
RA LHD RP RP RA LHD

(a)

(b)

RA RA LHD RP RP LHD

(c)

(d)

Fig. 1.7 Hepatic duct anatomical variation. (a) Normal anatomy (RA: right anterior sectoral duct, RP: right posterior sectoral duct, LHD: left hepatic duct). (b) Right anterior and posterior sectoral ducts drain directly into conuence (c) Right posterior sectoral duct drains into left hepatic duct. (d) Right anterior sectoral duct drains into common hepatic duct.

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CHAPTER 1

Anatomy and physiology

Pancreatic anatomy
The pancreas is a retroperitoneal organ, which is separated from the stomach anteriorly by the lesser sac. It consists of a head, neck, body and tail. The head of the pancreas lies within the C-shaped duodenum. The neck lies at the level of the rst lumbar vertebra (transpyloric plane of Addison), anterior to the conuence of the portal, superior mesenteric and splenic veins, and connects to the body and tail. The tail of the pancreas is closely related to the splenic hilum within the lienorenal ligament. The uncinate process of the pancreas originates from the embryological dorsal pancreas and fuses with the pancreatic head (ventral pancreas). It lies posterior to the superior mesenteric artery and vein. Exocrine secretions (see Fig.1.8) enter the pancreatic duct (diameter 1-3mm) that joins with the accessory pancreatic duct and the common bile duct to form a common channel that terminates at the ampulla of Vater (postero-medial border of the second part of the duodenum). The arterial supply of the pancreas is via branches of the coeliac axis (gastroduodenal artery => superior pancreatico-duodenal artery), superior mesenteric artery (inferior pancreatico-duodenal artery) and branches directly from the splenic artery. Venous drainage is via tributaries into the splenic, portal and superior mesenteric veins. Lymphatic drainage of the pancreas occurs via lymph nodes located along the arterial supply (coeliac axis and superior mesenteric artery).

HA Aorta S CBD PV PD DJ CA LGA SA

SMV

SMA

Fig. 1.8 Anatomical relationships of the pancreas. D: duodenum, S: spleen, CBD: common bile duct, PD: pancreatic duct, DJ: duodeno-jejunal exure, PV: portal vein, SMV: superior mesenteric vein, HA: hepatic artery, SA: splenic artery, SMA: superior mesenteric vein, CA: coeliac axis.

PANCREATIC PHYSIOLOGY

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Pancreatic physiology
Exocrine: acinar cells secrete bicarbonate (regulated by secretin) and inactive pro-enzymes (regulated by CCK), which are activated in the duodenum (e.g. trypsin, amylase, lipase, chymotrypsin). Bicarbonate neutralizes gastric acid, and enzymes digest dietary proteins, lipids, and carbohydrate to allow absorption. Lipid absorption is facilitated by bile acids (secreted in bile). Endocrine: Islets of Langerhans consist of alpha, beta, delta, and PP cells, which secrete glucagon, insulin, somatostatin, and pancreatic polypeptide, respectively.

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