1. LIVER, BILIARY SYSTEM, PANCREAS AND SPLEEN Ass. Prof. Dr. Saif Ali Ahmed Ghabisha

2. LIVER AND BILIARY SYSTEM

3. LIVER DEFINITION: It is the largest gland in the body SURFACE ANATOMY: It occupies the whole right hypochondrium, a part of epigastrium & a part of left hypochondrium

4. Liver- Position

5. The largest gland in the body Weighs approximately 1500 g (approximately 2.5% of adult body weight). Lies mainly in the right hypochondrium and epigastrium and extends into the left hypochondrium. Protected by the thoracic cage and diaphragm, lies deep to ribs 7-11 on the right side and crosses the midline toward the left nipple. Moves with the diaphragm and is located more inferiorly when one is erect because of gravity. Liver

6. LOBES OF LIVER ANATOMICAL DIVISION: The liver is divided into a smaller left & a larger right lobe by: 1.Falciform ligament: anteriorly 2.Fissure for ligamentum venosum: posteriorly 3.Fisssure for ligametnum teres: inferiorly

7. –Largest lobe - Occupies the right hypochondrium - Divided into anterior and posterior sections by the right hepatic vein - Reidel’s Lobe extend as far caudally as the iliac crest Rt. Lobe Left Lobe Varied in size Lies in the epigastric and left hypochondriac regions Divided into lateral and medial segments by the left hepatic vein

8. Caudate Lobe present in the posterior surface from the Rt. Lobe Two processes 1- c- process 2- papillary process Relations: - Inf.  the porta hepatis - The right  the fossa for the inferior vena cava - The left  the fossa for the lig. venosum.

9. Quadrate lobe Present on the inferior surface from the Rt. Lobe. Relation: - Ant.  anterior margin of the liver - Sup.  porta hepatis - Rt.  fossa for the gallbladder - Lt.  by the fossa for lig. teres

10. Separation of the four lobes of the liver: Right sagittal fossa - groove for inferior vena cava and gall bladder left sagittal fissure - contains the Ligamentum Venosum and round ligament of liver Transverse fissure (also porta hepatis) - bile ducts, portal vein, hepatic arteries

11. LOBES OF LIVER FUNCTIONAL DIVISION: The liver is divided into a nearly equal left & right lobes by a plane passing through groove for IVC & gall bladder fossa. The caudate & quadrate lobes are included in the left lobe (because they are supplied by left branches of hepatic artery & portal vein)

12. Normal biliary anatomy

14. ANTERIOR SURFACE OF LIVER

15. LIVER SURFACES: ANTERIOR: related to diaphragm & anterior abdominal wall. The diaphragm separates it from pleurae & lungs SUPERIOR: related to diaphragm separating it from pericardium & heart (in the middle) & pleurae & lungs (on each side)

16. POSTERIOR SURFACE OF LIVER

17. SURFACES: POSTERIOR: formed of (from right to left): 1.Bare area: triangular area related to diaphragm. Its base is formed by groove for IVC; its sides are formed by upper & lower layers of coronary ligaments that meet at the apex to form the right triangular ligament 2.Groove for IVC

18. 4. Caudate lobe: related to diaphragm, projects downwards to form a process separating IVC from porta hepatis & forming upper boundary of epiploic foramen. 5. Fissure for ligamentum venosum (obliterated ductus venosus) 6. Esophageal notch POSTERIOR SURFACE OF LIVER

19. BARE AREAS OF LIVER TRIANGULAR DIAPHRAGMATIC AREA GROOVE FOR IVC GALL BALDDER FOSSA PORTA HEPATIS FISSURE FOR LIGAMENTUM VENOSUM

20. INFERIOR SURFACE OF LIVER

22. SURFACES: INFERIOR: 1.Related to the following viscera: right kidney, right suprarenal gland, right colic flexure, 2 nd part of duodenum, fundus & body of stomach 2.Formed of (from right to left): Gall bladder fossa Quadrate lobe: related to pylorus, 1 st part of duodenum & transverse colon Fissure for ligamentum teres (obliterated left umbilical vein)

23. LIVER ACCORDING TO ITS RELATIONS, THE LIVER IS DIVIDED INTO: 1.DIAPHRAGMATIC SURFACE: includes superior, anterior & most of posterior surface 2.VISCERAL SURFACE: includes inferior & a part of posterior surface

24. 1 - The Falciform ligament of liver 2 - The Ligamentum teres hepatis 3 - The coronary ligament 4 - The right triangular ligament 5 - The left triangular ligament 6 - The Hepatogastric ligament 7 - The hepatoduonedenal ligament 8 - The Ligamentum Venoosum The ligaments of the liver

25. LIGAMENTS OF LIVER PERITONEAL LIGAMENTS FALCIFORM LIGAMENT: a triangular fold formed of two layers (right & left) with: 1.Anterior border: attached to diaphragm 2.Posterior border: attached to anterior & superior surfaces of liver 3.Lower free border: extending from liver to umbilicus & enclosing ligamentum teres & paraumbilical veins

26. LIGAMENTS OF LIVER PERITONEAL LIGMENTS LEFT TRIANGULAR LIGAMENT: to the left of falciform ligament, the peritoneum is reflected from the diaphragm to the upper surface of the liver to form the anterior layer of left triangular ligament (continuous with left layer of falciform ligament). The peritoneum then covers anterior, inferior & posterior surfaces & is reflected to the diaphragm to form the posterior layer of left triangular ligament

27. LIGAMENTS OF LIVER PERITONEAL LIGMENTS RIGHT TRIANGULAR LIGAMENT: to the right of falciform ligament, the peritoneum is reflected from the diaphragm to the upper surface of the liver to form the upper layer of coronary ligament (continuous with right layer of falciform ligament). The peritoneum then covers anterior & inferior surfaces then becomes reflected to the front of right kidney to form the lower layer of coronary ligament. The right extremity of both layers meet to form the right triangular ligament

28. LIGAMENTS OF LIVER PERITONEAL LIGMENTS LESSER OMENTUM: 1.It is attached to the margins of porta hepatis & fissure for ligamentum venosum 2.It extends to lesser curvature of stomach & upper border of 1 st inch of 1 st part of duodenum

29. LIGAMENTS OF LIVER LIGMENTUM TERES: Represents the obliterated left umbilical vein that originally joins the branch of portal vein.

30. LIGMENTUM M TERES

31. LIGAMENTS OF LIVER LIGAMENTUM VENOSUM: Represents the obliterated ductus venosus that originally connects IVC with left branch of portal vein

32. Coronary ligament: the area between upper and lower layer of the coronary ligament is the bare area of liver which contract with the diaphragm. Left and right triangular ligaments formed by left and right extremity of coronary ligament LIGAMENTS OF LIVER

33. Blood Circulation through the Liver

34. The blood vessels conveying blood to the liver are the hepatic artery (30%) and portal vein (70%). The hepatic artery brings oxygenated blood to the liver, The portal vein brings venous blood rich in the products of digestion, which have been absorbed from the gastrointestinal tract. The arterial and venous blood is conducted to the central vein of each liver lobule by the liver sinusoids. The central veins drain into the right and left hepatic veins, and these leave the posterior surface of the liver and open directly into the inferior vena cava.

35. BLOOD SUPPLY OF LIVER HEPATIC ARTERY: brings oxygenated blood to the liver (30% blood reaching the liver) PORTAL VEIN: brings blood absorbed from GIT to the liver (70% blood reaching the liver) ALL BLOOD PASS TO HEPATIC SINUSOIDS Blood leave the liver through HEPATIC VEINS

36. Blood supply of the liver Proper hepatic artery  The right and left hepatic arteries enter the porta hepatis. The right hepatic artery usually gives off the cystic artery, which runs to the neck of the gallbladder.

37. PORTA HEPATIS: It is the hilum of liver It lies in the inferior surface of liver Structures passing through it: right & left hepatic ducts, right & left branches of hepatic artery & portal vein (DAV, from before backwards)+ lymphatics, lymph nodes & autonomic fibers

38. PORTA HEPATIS

40. LYMPHATIC DRAINAGE : Mainly into hepatic lymph nodes in porta hepatis. Efferent vessels pass to celiac lymph nodes. NERVE SUPPLY: Hepatic plexus of autonomic fibers derived from celiac plexus SUPPORT: 1.Hepatic veins (main support): suspend liver from IVC & have no extrahepatic course 2.Peritoneal folds. 3.Surrounding organs 4.Tone of anterior abdominal wall LYMPHATIC DRAINAGE and NERVE SUPPLY

42. BILIARY SYSTEM 1.BILIARY DUCTS 2.GALL BLADDER

43. Bile is secreted by the liver cells at a constant rate of about 40 ml per hour. When digestion is not taking place, the bile is stored and concentrated in the gallbladder; later, it is delivered to the duodenum. The biliary system consists of the liver, gallbladder & bile ducts that are involved in the production, storage & transportation of bile. Biliary System

44. The bile ducts consist of: Bile canaliculi Interlobular ducts Intrahepatic ducts Right and left hepatic ducts Common hepatic duct Gallbladder & Cystic duct Common bile duct (Bile duct) The Bile Ducts

45. The liver cells secrete bile The bile canaliculi carry this bile to the interlobular ducts. The interlobular ducts join one another to form progressively larger ducts and, eventually, at the porta hepatis form the right and left hepatic ducts.

46. The right hepatic duct drains the right lobe of the liver The left hepatic duct drains the left lobe, the caudate lobe, & quadrate lobe. After a short course, the hepatic ducts unite to form the common hepatic duct The common hepatic duct is about 1.5 in. (4 cm) long It descends within the free margin of the lesser omentum It is joined on the right side by the cystic duct from the gallbladder to form the common bile duct COMMON HEPATIC DUCT

47. COMMON BILE DUCT

48. Common Bile Duct The common bile duct is about 3 inches (8 cm) long. course: First it lies in the free margin of lesser omentum along with portal vein and hepatic artery. Then it runs behind the first part of the duodenum. Then it lies in a groove on the posterior surface of the head of the pancreas. Here, the bile duct comes into contact with the main pancreatic duct The common bile duct is about 3 inches (8 cm) long. course: First it lies in the free margin of lesser omentum along with portal vein and hepatic artery. Then it runs behind the first part of the duodenum. Then it lies in a groove on the posterior surface of the head of the pancreas. Here, the bile duct comes into contact with the main pancreatic duct

49. The bile duct ends below by piercing the medial wall of the second part of the duodenum about halfway down its length. It is usually joined by the main pancreatic duct, and together they open into a small ampulla in the duodenal wall, called the hepatopancreatic ampulla (ampulla of Vater). The ampulla opens into the lumen of the duodenum by means of a small papilla, the major duodenal papilla. Occasionally, the bile and pancreatic ducts open separately into the duodenum. The terminal parts of both ducts and the ampulla are surrounded by circular muscle, known as the sphincter of the hepatopancreatic ampulla (sphincter of Oddi). Common Bile Duct Sphincter of Oddi

51. GALLBLADDER

52. A pear-shaped sac lying on the undersurface of the liver. It has a capacity of 30 to 50 ml and stores bile, which it concentrates by absorbing water. The gallbladder is divided into the fundus, body, and neck. The fundus is rounded and projects below the inferior margin of the liver, where it comes in contact with the anterior abdominal wall at the level of the tip of the ninth right costal cartilage. The body lies in contact with the visceral surface of the liver and is directed upward, backward, and to the left. The neck becomes continuous with the cystic duct, which turns into the lesser omentum, joins the common hepatic duct, to form the bile duct Gallbladder

53. The peritoneum completely surrounds the fundus of the gallbladder and binds the body and neck to the visceral surface of the liver. Function of the Gallbladder When digestion is not taking place, the sphincter of Oddi remains closed and bile accumulates in the gallbladder. The gallbladder concentrates bile; stores bile; selectively absorbs bile salts, keeps the bile acid; excretes cholesterol; and secretes mucus. To aid in these functions, the mucous membrane is thrown into permanent folds that unite with each other, giving the surface a honeycombed appearance. Relations Anteriorly: The anterior abdominal wall and the inferior surface of the liver Posteriorly: The transverse colon and the first and second parts of the duodenum Gallbladder

54. The cystic artery is a branch of the right hepatic artery. The cystic vein drains directly into the portal vein. Several very small arteries and veins also run between the liver and gallbladder. The cystic artery is a branch of the right hepatic artery. The cystic vein drains directly into the portal vein. Several very small arteries and veins also run between the liver and gallbladder. Blood Supply

58. Lymph Drainage The lymph drains into a cystic lymph node situated near the neck of the gallbladder. From here, the lymph vessels pass to the hepatic nodes along the course of the hepatic artery and then to the celiac nodes. Lymph Drainage The lymph drains into a cystic lymph node situated near the neck of the gallbladder. From here, the lymph vessels pass to the hepatic nodes along the course of the hepatic artery and then to the celiac nodes. Nerve Supply Sympathetic and parasympathetic vagal fibers form the celiac plexus. The gallbladder contracts in response to the hormone cholecystokinin, which is produced by the mucous membrane of the duodenum on the arrival of fatty food from the stomach. Nerve Supply Sympathetic and parasympathetic vagal fibers form the celiac plexus. The gallbladder contracts in response to the hormone cholecystokinin, which is produced by the mucous membrane of the duodenum on the arrival of fatty food from the stomach.

60. The cystic duct is about 1.5 in. (3.8 cm) long and connects the neck of the gallbladder to the common hepatic duct to form the bile duct. It usually is somewhat S-shaped and descends for a variable distance in the right free margin of the lesser omentum. The cystic duct is about 1.5 in. (3.8 cm) long and connects the neck of the gallbladder to the common hepatic duct to form the bile duct. It usually is somewhat S-shaped and descends for a variable distance in the right free margin of the lesser omentum. Cystic Duct The mucous membrane of the cystic duct is raised to form a spiral fold that is continuous with a similar fold in the neck of the gallbladder. The fold is commonly known as the “spiral valve.” The function of the spiral valve is to keep the lumen constantly open.

61. Cystic Duct

62. The Pancreas

65. Chapter 19 The Pancreas

66. It is exocrine gland secrete enzymes for protein, fats & carbohydrates hydrolyzing. It is endocrine gland that produce the hormones insulin & glucagon by pancreatic islets (islets of Langerhans) It lies in epigastrium & left upper quadrant, crosses transpyloric plane (L1 vertebra). It lies on the post.abd.wall behind the peritoneum (retroperitoneal)

67. The Pancreas

68. Head Neck Body Tail Parts of pancreas

69. The head lies in the concavity of duodenum. The uncinate process arises from the lower part of the head and lies behind sup.mesenteric vessels. The neck lies in front of the beginning of portal vein. The body Continues from the neck and lies to the left of the superior mesenteric vessels, passing over the aorta and L2 vertebra. The tail passes in the splenico-renal ligament to end in the hilum of spleen. Parts of pancreas

71. The Relation of Pancreas Anteriorly: from right to left…. Transverse colon & mesocolon,lesser sac & stomach. Posteriorly: from right to left…. Bile duct, portal vein, superior mesenteric vessels, splenic vein -- I.V.C., aorta., Left psoas muscle. Left kidney., Left suprarenal and hilum of spleen.

72. Posterior view of duodenum/pancreas

73. Pancreatic Ducts

74. The main pancreatic duct begins in the tail of pancreas and opens into middle of 2 nd part of duodenum by major duodenal papilla after joining the bile duct or drains separetely into the duodenum. The accessory duct: when present, drains the upper part of head and opens into the duodenum by minor duodenal papilla, a short distance above the main duct, frequently connects with the main duct.

75. Blood supply, lymph drainage and innervation of Pancreas The arteries are: Splenic artery, superior & inferior pancreatico- duodenal arteries. The veins: as arteries, drain into the portal system. Lymph nodes: lie along the arteries and drain into celiac & sup. mesenteric L.Ns. Nerve supply: by symp.& parasymp.(vagal) N.Fs.

76. Blood supply

77. SPLEEN

79. Position of spleen Largest single mass of lymphoid tissue and It is reddish in color Spleen is oval-shaped and has a notched anterior border lies in the left hypochondrium between the stomach and diaphragm. It has two ends, three borders and two surfaces.

80. LOCATION It lies beneath the left cupolae of diaphragm close to the 9 th, 10 th and 11 th ribs. It's long axis lies along the shaft of the 10 th rib and it's lower pole extends to the midaxillary line. Lower pole extends forward as far as the midaxillary line Normal size spleen can not be palpated on clinical examination It lies beneath the left cupolae of diaphragm close to the 9 th, 10 th and 11 th ribs. It's long axis lies along the shaft of the 10 th rib and it's lower pole extends to the midaxillary line. Lower pole extends forward as far as the midaxillary line Normal size spleen can not be palpated on clinical examination

81. LOCATION

82. Measurements: 1 inch (thickness) x 3 inches (Breadth) x 5 Inches (length). Weight: 875 gram (7 ounces). 3 borders, 2 ends, 2 surfaces. A. Ends 1) lateral end (Broad) 2) medial end (tapering) B. Borders Upper(Anterior) border: Sharp & notched Lower (Posterior)border: (Broad) Intermediate border: thick, incomplete. Extends from the medial end till the hilum).

83. Surface anatomy It lies parallel to the ribs number 9, 10, and 11 on the left side. The long axis of the spleen lies parallel to the 10th rib. Its medial end lies 1 1/2 inches from the spine of T. 10, while the lateral end lies just behind the mid-axillary line.

84. Diaphragmatic surface: Convex, Related to the diaphragm which separates it from 3 structures: Lower part of left pleura, Base of left lung, Left 9, 10, 11 ribs. Surfaces

85. Visceral surface: Concave, irregular, directed to the abdominal cavity. Contains the hilum and impressions for 4 abdominal organs: 1- Gastric impression (related to posterior wall of fundus of stomach). 2- Renal impression. 3- Colic impression (left colic flexure). 4- Pancreatic impression (tail of pancreas). Surfaces

86. PERITONEAL CONNECTIONS The spleen is surrounded by peritoneum of the greater sac which passes in front of the hilum as the gastrosplenic ligament to the greater curvature of the stomach, carring inside the short gastric and the left gastroepiploic vessels. It is also connected to the left kidney as the splenicorenal ligament (carrying the splenic vessels and the tail of the pancreas).

87. Peritoneal Reflections/Ligaments

88. CONTENTS The gastrosplenic ligament contains: - Short gastric vessels - Left gastroepiploic vessels - Lymph nodes The lieno-renal ligament contains: - Splenic vessels - Tail of pancreas - Lymph nodes

89. RELATIONS ANTERIORLY Stomach, Tail of pancres, Left colic flexure. Left kidney (lies along its medial border). POSTERIORLY Diaphragm, Left pleura Left costodiaphragmatic recess, Left lung; 9 th, 10 th and 11 th ribs. ANTERIORLY Stomach, Tail of pancres, Left colic flexure. Left kidney (lies along its medial border). POSTERIORLY Diaphragm, Left pleura Left costodiaphragmatic recess, Left lung; 9 th, 10 th and 11 th ribs.

90. BLOOD SUPPLY Splenic artery - the biggest branch of the celiac artery. It has a tortuous course and runs along the superior border of the pancreas. Before entering the hilum of spleen, it divides into 6 branches. Splenic vein leaves the hilum of the spleen and runs behind the body of the pancreas. Behind the neck of the pancreas it joins the superior mesenteric vein to form the portal vein.

91. LYMPH DRAINAGE The lymph vessels emerge from the hilum and pass through a few lymph nodes (pancreaticosplenic nodes) along the course of the splenic artery and then drain into the celiac nodes.

92. NERVE SUPPLY The nerves accompany the splenic artery and are derived from the celiac plexus.