Liver, Gallbladder and

Biliary Tree
Dr. Aldwin A. Yaneza
Dept of Anatomy

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 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

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 SURFACES
 A. Diaphragmatic
 Smooth and dome shaped
 Recesses
 Subphrenic – bet diaphragm &
liver
 Hepatorenal – bet liver and R
kidney

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 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

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 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

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 Visceral surface
 Structures:
 IVC
 Portal triad
 Hepatic artery
 Portal Vein
 Hepatic duct
 Caudate lobe
 Quadrate lobe

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 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]

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 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

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 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

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Portal v

Hepatic art
Hepatic duct

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 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

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 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

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 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%

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 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%

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 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

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16
17
 I-back
Posterior
IVa II
superior

III

VIII
VII
IVb

V
VI
Posterior
inferior P A Me La

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 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

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P A Me La

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 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

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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.

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 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.
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 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

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25
 Nerve Supply
 Hepatic Nerve Plexus
 Largest derivative of celiac plexus
 Accomp branches of p. triad to liver

 Consists of sympathetic and parasym fibers

 Function: Vasoconstriction

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Variations in LIVER

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The Dark Knight ,2008
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GALLBLADDER and BILIARY
DUCTS
Bile
 Produced by hepatocytes
 Yellow fluid

 Stored in GB

 Passes to via bile ducts duodenum

 Emulsifies fat

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Gallbladder

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 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
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General Information, con’t.

C. Fundus slants inferiorly, to the right

D. Attached to liver by loose (areolar)
connective tissue
E. Peritoneum covers free surfaces

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Introduction, continued …

F. Normal measurements:
7-10 cm long
4 - 6 cm diameter
30 – 60 cc bile
G. Function:Stores and concentrates bile

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 II. Detailed Anatomy
A. Fundus of GB:

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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

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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

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 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

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 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]

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The Gallbladder and Biliary System with Pancreas

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 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
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 Lymph Nodes
 N1
 Choledochal
 Hilar
 Cystic duct

 N2
 Peripancreatic
 Retroduodenal
 Portal, celiac, or superior
mesenteric vessels

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 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

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Harry Potter and the Half blood Prince

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Transformer 2: Revenge of the Fallen

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 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

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 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

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 III. Gallbladder Diseases

A. Cholelithiasis & Cholecystitis

1. Cholecystitis = inflammation of GB
2. Cholelithiasis = Stone(s) in GB

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 Cholelithiasis

 GB shows likely sites

of stone
formation/deposition

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Gallbladder Diseases, continued …

B. GB Carcinoma
a. US useful in diagnosis
b. mass producing thickening and
irregularity in wall
c. Calculi found frequently

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Gallbladder Diseases, continued …

C. Polyps of GB
a. Intraluminal echogenic projections
b. Do not change position with patient
c. Must be differentiated from
stones

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Gallbladder diseases, continued …

D. Viscid Bile, “sludge”

a. Due to intermittent obstruction of
CBD or cystic duct
b. Seen in patients with bile stasis
c. Produces linear, echogenic
interface within GB

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 Cystic artery
 Ligated during surgical
removal of gallbladder
[cholecystectomy]

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Variations in Anatomy of Cystic Duct

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 Anatomy /Histology
 Mucosa
 Smooth muscle
 Serosa

 Attachment to liver
 Tumors can extend directly
into liver

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Laparoscopic Cholecystectomy

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Identify the gallbladder

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Triangle of CALOT = area formed by the cystic duct, hepatic duct and edge of
liver. The cystic artery will be located in this triangle

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Isolate and ligate the cystic
artery

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Isolate and ligate the cystic duct

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 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:

-History, PE and ultrasound

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 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

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Ruptured Cholecystitis

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 National Kidney Institute,East Ave

FEU Medical
Center,Fairview

The end

Aldwin A. Yaneza,MD
General and Laparoscopic Surgery

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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

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END

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 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

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