Download Liver

The abdomen Ⅲ
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Department of anatomy and
neurobiology
O:65985626
Go over peritoneum and
esophagus
Stomach & duodenum : parts,
position , arteries ,ligaments ,
Liver and biliary ducts
Greater omentum & Lesser
omentum
Hepato-gastric ligament
Hepato -duodenal ligament
Gastro-phrenic ligament
Gastro-splenic ligament
Gastro-colic ligament
Omental (epiploic)foramen
The omental bursa
communicates with the
greater sac only through
the (epiploic) omental
foramen.
The boundary:
Anteriorly --- the hepatoduodenal ligament,
Posteriorly---IVC & the right crus of diaphragm
Superiorly--- liver
Inferiorly --- 1st part of the duodenum
Digestive system
Digestive tube
Mouth
Pharynx
Esophagus
Stomach
Small
Duodenum
intestine Jejunum
Ileum
Large intestine
Cecum ， Vermiform
appendix ,Colon ,rectum,
Anal canal
Digestive glands
• Major salivary glands
• Liver
• Pancreas
Function: Ingestion - selective intake of food.
Digestion – mechanical and chemical breakdown of food
into a form the body can use.
Absorption – uptake of nutrients into blood and lymph.
Compaction – absorption of water and consolidation of
wastes into fecal mass.
Defecation – the elimination of the fecal mass.
Esophagus
（position and division
three parts:
Cervical parts：5cm;
Thoracic parts: 18-20 cm;
Abdominal parts : only 1-2cm.
3 constrictions of the esophagus:
:
narrows
position
distance from middle inscior
first
beginning
second
in front of left branchus
third
esophageal hiatus
15cm
25cm
40cm
7
Ⅱ. Three constrictions



beginning, lies at level of C6, the
narrowest part
crossed by left main bronchus,
25cm from incisors, lies at level of
intervertebral disc between T4 and
T5.
passes through the esophageal
hiatus of diaphragm, 40cm from
incisors, at level of T10
Carcinoma of esophagus
stomach
Shape:
Location:
digestion
gastric juice---chyme
Peristalsis
Enzymatic digestion
PH: 2
Peristaltic movement
ring-like movements
of esophagus contracting then
relaxing to move food
downward.
Z-line: at the junction
Two wall
Anterior wall
Cardial
notch
Posterior wall
Two curvature
Lesser curvature
Greater curvature
4 parts:
Cardia
cardia
fundus
fundus
Pyloric canal
Lesser
curvature
angula
notch
body
body
pyloric part—
Pyloric canal
and Pyloric antrum
Greater
curvature
11
Pyloric antrum
Relations of the stomach


Anteriorly:
 Live (right part)
 Diaphragm (left upper part)
 Anterior abdominal wall (left
lower part)
Posteriorly－separated by
peritoneum of lesser sac from
the following (“stomach-bed”)
 Pancreas
 Left suprarenal gland
 Left kidney
 Spleen
 Transverse colon and
transverse mesocolon
Abdominal Aorta and branches
Celiac trunk
Left branch
Right branch
Cystic a.
Common
hepatic a.
Left gastric a.
Short gastric a.
Splenic a.
Right gastric a.
Proper hepatic a.
Gastroduodenal a.
Splenic branches
Left gastroepiploic a.
Right gastroepiploic a.
Superior pancreaticoduodenal a.
Arteries of stomach

Left and right gastric
arteries


Arise from celiac trunk and
proper hepatic artery,
respectively.
These two vessels run in
lesser omentum along lesser
curvature , and anastomose
end-to-end.
Arteries of stomach

Right and left gastro-omental
arteries


Arise from the gastroduodenal and
splenic artery.
These two vessels pass into the
greater omentum, run parallel to
the greater curvature, and
anastomose end-to-end.
Arteries of stomach

Short gastric arteries




Branches of splenic artery
through the gastrosplenic
ligament
Supply the fundus of stomach.
Posterior gastric artery (72%)


Arise from the splenic artery
through the gastrophrenic
ligament and supply the
posterior wall of fundus of
stomach.
Venous drainage of stomach



Right and left gastric veins
empty directly into hepatic
portal vein.
Left gastroepiploic and short
gastric veins drain into hepatic
portal vein via the splenic vein.
Right gastroepiploic vein drain
into superior mesenteric vein.
Lymph drainage of stomach

Accompany the A. along the 2
curvatures
Right and left gastric LN

Right and left gastroomental LN
drain into

pancreaticosplenic ,

pyloric LN,
pancreaticoduodenal LN
finally to the celiac LN.
lymphatic metastasis

Nerve supply of stomach

Parasympathetic innervation




The left vagus N→The anterior vagal
trunk → anterior gastric
hepatic branches
The right vagus N → The posterior
vagal trunk → posterior gastric
celiac branches
“crow’s foot” → supply the pyloric
part
Sympathetic innervation


Mainly from celiac plexus
Afferent and efferent fibers derives
from thoracic segments (T5 －L1)
Lie anterior to vertebral column and near
the arteries


Celiac ganglion and plexus


Superior mesenteric ganglion
and plexus
gastrectomy
1.BillrothⅠ 1881
1.Billroth Ⅰ Ⅰ ：1885
Laparoyomy :
Laparoscopy :
Paracentesis:
Question 2
1. What are the four parts, five ligaments and arterial supply
of the stomach?
2. What’s the bed of stomach?
3. The lesser omentum is divided into __________ and
_______________ ligaments.
4. The __________ foramen connects the omental bursa with
the peritonial cavity( the great sac).
5. The __________ recess (pouch of morison) is the lowest point
of the peritoneal cavity in a supine patient.
If you do not learn to think
when you are young,you may
never learn.
---Thomas Edison
The liver
Wedge-shaped,largest single organ ,1,500g,
Function :
1.The largest metabolic organ ,nutrients absorbed from the digestive
tract are initially conveyed to the liver by the portal vein;
2.The largest gland ,secrete bile---yellowish ,brown fluid aids in the
emulsification of fat;
3.The pirimary site for detoxification;
4.The large lymph-producing organ,
5.produce RBC prenatally .
Liver

★ Position


Most lies in the right
hypochondrium and
epigastric region
less part extends into the
left hypochondrium
Liver
★ Surface projection
Upper border
the right midclavicular line --5th rib process
Lower border
the right lobe extends just
beneath the costal margin,
median line ,lower border
crosses a point about 3~5cm
below the xiphoid
In children, larger, extends
below the costal arch within in
2cm
Liver

Diaphragmatic surface


Convex and smooth
Divided into right and left
lobes by falciform lig.
superiorly

coronary lig. of liver

Bare area ：Posteriorly
Visceral surface of liver
left lobe
right lobe
caudate lobe
quadrate lobe
Caudate lobe
left lobe
Quadrate
lobe
31
Right
lobe
Liver

★ Visceral surface
Covered with peritoneum,
H-shaped fissures and grooves

Anterior (inferior) border –thin and
sharp


Notch for gallbladder
Notch for ligamentum teres
hepatis (round ligament of
liver)
Liver
1.Left sagittal fissure
Anteriorly
fissure for round ligament
(remnant of umbilical V )
Posteriorly
fissure for ligamentum venosum
(remnant of Ductus venosus)
2.Right sagittal fissure
Anteriorly

fossa for gallbladder
Posteriorly

Sulcus for IVC (inferior vena cava
Liver
★ transverse fissure --Porta hepatis
5 cm long, transversely across the under surface
of the liver,
 Contents
 Right and left hepatic ducts
 Left and right branches of proper hepatic
artery
 Left and right branches of hepatic portal
vein
 Nerves and lymphatic vessels
 These structures are surrounded by connective
tissue and called
“hepatic pedicle”
vessels of liver(4)
Blood supply of liver:
1.proper hepatic artery( ← hepatic A←celiac trunk)
2.hepatic portal vein
A dual supply,the venous supply for75%(dominant) ,
The arterial supply account for 25%(lesser)

Hepatic portal vein
General features

the union of superior mesenteric vein
SMV and splenic vein

passing through the lesser omentum to
the porta hepatis, divides into right and
left branches

Has no valves in hepatic portal system

Drains blood from GI tract from the
lower end of oesophagus to the upper
end of anal canal, pancreas, gall bladder,
bile ducts and spleen
2.Hepatic portal vein
Tributaries of hepatic portal v.
1. Superior mesenteric v. SMV
2. Inferior mesenteric v. IMV
3. Splenic v.
4. Left gastric v.
5. Right gastric v.
6. Cystic v.
7. Paraumbilical v.
Portal- Caval venous anastomoses
1. Site at the esophagus
left gastric vein → esophageal venous plexus →
esophageal vein → hemiazygos vein → superior vena
cava
Esophageal varices,---bleeding
2. At rectum
splenic vein → inferior mesenteric vein → superior
rectal vein → rectal venous plexus → inferior rectal
and anal veins → internal iliac vein → inferior vena
cava
Hemorroid ---Hemorrage
Portal hypertension

Portal- Caval venous anastomoses
3. At paraumbilical venous rete
paraumbilical vein→periumbilical venous rete→
thoracoepigastric and superior epigastric vein →intercostal vein--superior vena cava
Caput medusa
4.retroperitoneal anastomosis
the retroperitoneal branches of the colic veins
pancreaticoduodenal veins -----the lumbar veins,, twigs of
colic veins (portal) anastomosing with systemic
retroperitoneal veins
Intestinal bleeding
pancreaticoduodenal veins
3 Intrahepatic bile duct

4 hepatic veins
Liver

The segments of the liver


The segments of the liver, bases
upon the principal divisions of the
proper hepatic artery and
accompanying hepatic ducts and
hepatic portal vein－Glisson system.
The hepatic vein do not follow the
same pattern : their main tributaries
tend to run rather intersegmental of
the three ducts .

Couinaud segments
by controversial
8
Peritoneal Relations of the Liver
The falciform ligament
attaches the liver to the
anterior abdominal wall
Coronary ligaments attach the
liver to the diaphragm
Peritoneal relations of
the liver
-Bare area
-Subphrenic recess
Subhepatic space
Ligaments
Ligaments of liver

Falciform ligament of liver
from anterior abdominal wall
(umbilicus) to liver
 Free border contains
round ligament of liver



Coronary ligament
Left and right
triangular ligaments －
formed by left and right
extremity of coronary
ligament



Hepatorenal recess
－lies between the right
lobe of liver, right kidney,
and right colic flexure, and
is the lowest parts of the
peritoneal cavity in supine
position
Morrison ‘s pouch
Hepatorenal recess
Paracolic gutters are formed
by the ascending and
descending colons
Transplantation of liver
1
2
Cirrhosis (or cancer )of liver
3
Relations of liver

Diaphragmatic surface

Visceral surface
－
separated by diaphragm from the
following
 Right costodiaphramatic recess
and lung
 Cardiac base


Left lobe is related to the
stomach and abdominal part of
esophagus
Right lobe is related to the right
colic flexure anterioly,
gallbladder and superior
duodenal flexure medially, right
kidney, superarenal gland
posteriorly
★ Biliary duct and gallbladder

★ Consists of




Gallbladder,
Left and right hepatic ducts
Common hepatic duct
Common bile duct
★ Gallbladder


★ Position
 Lies in fossa for gallbladder on visceral
surface of liver
★ Four parts
1. Fundus of gallbladder
protrude below the inferior margin of the
liver, behind the point where the lateral
margin of the right rectus abdominis
meets the costal arch(Murphy ’ point).

2.Body of gallbladder
3.Neck of gallbladder
4. Cystic duct
Function: stores and concentrates bile
★ Biliary duct system



Left and right hepatic ducts
unite outside of liver to form
common hepatic duct
common hepatic duct
Cystic duct joins common
hepatic duct to form common
bile duct
★ Biliary duct system

Hepatopancreatic ampulla (Vater)

Common bile duct and pancreatic duct run
obliquely through the wall of the descending
part of duodenum ,unite to form the
hepatopancreatic ampulla --- rounded by
sphincter of hepatopancreatic
ampulla (Oddi), has sphincteric for
regulating flow, opens at the major
duodenal papilla
Obstruction of the biliary system results in the
clinic condition of jaundice (yellow skin) .
Cystohepatic triangle
Calot’s Triangle

Boundaries




Common hepatic duct on the
left
Cystic duct on the right
Liver superiorly
Content: cystic artery
Divisions and relations of common bile duct
Divisions




Supraduodenal segment
Retroduodenal segment
Pancreatic segment
Intraduodenal segment
★ Bile circulation
Biliary ductuli
Bile is secreted by the liver cells
Common hepatic duct
Cystic duct
Right and left hepatic
ducts
Gallbladder (store, concentrate)
When fat enters small intestine,
gallbladder contracts, sphincter of
hepatopancreatic ampulla relax
Common bile duct
Main
Pancreatic
duct
the hepatopancreatic ampulla
Major duodenal papilla
Duodenal cavity
Magnetic resonance cholangiopancreatogram.
Pancreas

Function



The pancreas is both an exocrine and an endocrine
gland
The exocrine portion of the gland produces a secretion
that contains enzymes that are capable of hydrolyzing
proteins, fats, and carbohydrates
The endocrine portion of the gland, the pancreatic islet,
produces the hormones insulin and glucagons that play
a key role in carbohydrate metabolism
★ Pancreas

Shape


A soft yellowish lobulated gland
★ Position


Lies in epigastric and left
hypochondriac regions, behind
the peritoneum on the
posterior abdominal wall,
roughly at the level of of L1~L2
★ Pancreas

★ Four parts
 Head--Lies within the C-shaped curvature of duodenum.
 Uncinate process A projection to the left from the lower part of
the head behind the superior mesenteric vessels.
 Neck--narrow part, overlies the superior mesenteric vessels and
beginning of the portal vein
 Body--triangular in cross section, passes upward ang to the left
across the midline
 Tail--extends to the hilum of spleen in the splenorenal ligament
Pancreas

Pancreatic duct

Main Pancreatic duct

Begins at tail and throughout gland

Joins common bile duct before entering descending part of
duodenum at major duodenal papilla

Accessory pancreatic duct

When present, drains head of pancreas separately

Opens 2cm above main duct at lesser duodenal papilla
Blood supply of pancreas

Arteries
1.Mainly from splenic A
2.Superior pancreaticoduodenal
a.(from gastroduodenal A)
 Inferior pancreaticoduodenal
a.(from SMA)

Veins－ draining into superior
mesenteric and splenic veins –
potal vein.
CT scan of pancreas.
Vessels of pancreas
1,
2,
The Small Intestine


About 5-7m long,
Divided into



Duodenum
Jejunum
Ilium
Duodenum
Ilium
1. The major part of digestion occurs ,
extends from the pylorus to the
ileocecal junction .
2. permanent circular folds and villi
Jejunum
duodenum
Features:
1. 25cm long,the widest
and fixed part of
small intestine.
2. Pursue a C-shaped
course around the
head of pancreas.
3. Has 4 parts
Four parts
Duodenum
Superior part 1st
5cm,L1 vertebrae

Superior duodednal flexure
Descending part 2nd
7~10cm, L2~3
Inferior part
3rd
6~8cm,L3 to the left
Ascending part 4th


duodenojejunal flexure
Ligament of tretz


Suspensory muscle of duodenum (ligament of Treitz), is composed
of a skeletal muscle from diaphragm, and a fibromuscular band of
smooth muscle from the duodenum.
a surgical landmark, descends from the right crus of diaphragm to
duodenal termination.
duodenum
superior part

Anteriorly
 Quadrate lobe of live
 Gallbladder
Duodenal cap
(radiography )
2cm,intraperitoneal,mobile
Site of duodenal ulcer
duodenum
Relations of descending part


Medially
 Head of pancreas
 Common bile duct and
pancreatic duct
Laterally
 Right colic flexure
1.Major duodenal
papilla(opening)
Hepatopancreatic ampulla
(Vater ampulla)--united of the bile and pancreatic
ducts
2.Minor duodenal papilla
duodenum
Relations of horizontal part

Anteriorly
 Root of mesentery
 Superior mesenteric a. and v.
ascending part
Right — Head of pancreas and abdominal
aorta
Left — left kidney and ureter
Blood supply of duodenum

Arteries



Superior pancreaticoduodenal
a.
Inferior pancreaticoduodenal a.
Veins－follow arteries, draining
directly into superior mesenteric
and hepatic portal veins

Lymph drainadge
follow the arteries to celiac LN

Nerve innervation:
superior mensenteric plexus
celiac plex
Jejunum and ilium
The jejunum and ileum
lies free in the abdomen.
They are attached to the
posterior abdominal wall
by the mesentery .
Intraperitoneum
76
Jejunum and ileum
jejunum is shorter , emptier, more vascular (redder in vivo), more thickly walled .
Jejunum and ileum
Characteristic
Jejunum
Ileum
Position
Upper 2/5
Lower 3/5
caliber
2~4cm
2~3cm
Wall
Thicker and heavy
Thin and light
Circular folds
Large, tall and large
villi
low，sparse, less
abundant villi
Vascularity
Greater
Less
Colour
Deeper red
Paler
vasas recta
Arcades
Fat in
mensentery
Long
A few large loops
less
Short
Many short loops
more
78
Mesentery
The mensentery -
suspends the small
intestine from the
posterior abdominal wall
-Broad and a fan-shaped;
vasculature vessels are
between the two layers
of peritoneum.

Root of mesentery


15 cm long
Directly obliquely run
from left side of L2 to
right sacroiliac joint
Middle colic a.
Inf. pancreaticodudenal a.
Right colic a.
Ileocolic a.
Appendicular a.
Superior
Mesenteric v.
Superior
mesenteric a.
Jejunal and ileal a.
large intestine
• Approximately 1.5m long,
• Five parts:
– Cecum
– Vermiform appendix
– Colon
– Rectum
– Anal Canal
formation, transport, and evacuation of
feces . the absorption of water and the
secretion of mucus
81
Paracolic gutters are formed
by the ascending and
descending colons
Features of ：
1. Teniae coli: 3 longitudinal smooth muscles
2. haustra : sacculation
3. Omental appendices: small fatty projections
haustra
of colon
Teniae coli
omental
appendices
83
（一）Cecum
first part of large intestine, Lies in right iliac
fossa.Free and has no mensentery--- mobile
cecum
The
ileum enters the cecum obliquely, and partly
invaginates into it, forming the ileocecal valve－consists of
two folds.
ileocecal
valve
84
Appendix
a blind diverticulum
mesoappendix
the base of appendix ：
Lies deep to a point that 1/3 of
the way along the oblique line
joining the right anterior
superior iliac spine to the
umbilicus .(Mcburney’s point)
The
base of the appendix lies
at the point of convergence of
three teniae coli
85
（二）vermiform appendix
is a narrow blind tube, usually 6 ~
8cm long. It opens into the cecum 。
position: very variable in position,
frequently lies in the retrocecal
recess or extend into the lesser pelvis.
orifice
appendix
86
colon
1、asccending colon
2、transverse colon
3、descending colon
4、sigmoid colon
right colic flexure
left colic flexure
87
Inferior mesenteric v.
Inferior mesenteric a.
Left colic a.
Sigmoid a.
Superior rectal a.


Hepatogastric ligament
Hepatoduodenal
ligament
Relations of common bile duct
Supraduodenal segment



Descends along the right margin of
hepatoduodenal lig.
To the right of proper hepatic a.
Anterior to hepatic portal v.
Retroduodenal segment



Behind the superior part of duodenum
Anterior to the vena cava
To the right of the hepatic portal v.
Relations of common bile duct
Pancreatic segment

Lies in a groove between
posterior surface of head of
pancreas and duodenum
Intraduodenal segment


Enters the wall of descending
part of duodenum obliquely
where jions the pancreatic duct
to form the hepatopancreatic
ampulla
Opens at the major duodenal
papilla
spleen

Diaphragmatic surface

Visceral surface



Anteriorly－fundus of
stomach
Posteriorly－left suprarenal
gland and kidney
Inferiorly－tail of pancreas
and left colic flexure
Ligaments of spleen

Gastrosplenic ligament －connects the fundus of
stomach to hilum of spleen. the short gastric and
left gastroepiploic vessels pass through it.
Splenorenal
ligament －extends
between the hilum of spleen and
left kidney.
The splenic vessels tail of pancreas
Phrenicosplenic ligament
Splenocolic ligament
★You must identify follow structures！
Liver

Falciform lig. of liver

ligamentum teres hepatic(round
ligament )

porta hepatis

Coronary ligament

Nothch for gallbladder
Gallbladder

Fundus of gallbladder

Body of gallbladder

Neck of gallbladder

Cystic duct

Right and left hepatic ducts

Common hepatic duct

Common bile duct
Pancreas

Head

Uncinate process

Neck

Body

Tail
Peritoneum

Lessor omentum

Omental foramen

Greater omentum

Mesentery

Mesoappendix

Gastrosplenic ligament

rectovesical pouch

Rectouterine pouch

Vesicouterine pouch
1.What is the extension of the root of the mesentery?
1. The mesentery extends about 15 cm downward and to the right from the
duodenojejunal flexure to the ileocolic junction . The intestinal border is
many times longer (6 or 7 m.) than the root of the mesentery; hence the
mesentery is pleated.
2 Where are the junctions between the foregut and midgut and
between the midgut and hindgut?
The foregut-midgut and celiac-superior mesenteric junction is at the middle of the
duodenum, superior to the major duodenal orifice. The midgut-hindgut and
superior-inferior mesenteric junction is near the left end of the transverse colon.
3. How is the liver maintained in position?
The liver is maintained in position by being (1) joined to the posterior abdominal
wall by veins (hepatic and caval) and ligaments (coronary and triangular), (2)
supported inferiorly by viscera (e.g., the right kidney and colic flexure), and (3)
suspended by ligaments (falciform and teres)