Anatomy of liver, biliary tract and portal venous system

1. 3000268Alimentary System I
Anatomy of the Liver, Biliary Tract, and
PortalVenous System
TanatTabtieang
MD, DipThai Board (Diagnostic Radiology)
Fellowship of the Royal College of Radiologists ofThailand
Department of Anatomy
Faculty of Medicine
Chulalongkorn University
Tanat.T@chula.ac.th

2. Objectives
Students should be able to describe
• The surface anatomy of the liver and the gallbladder.
• The anatomical and functional lobes and segments of the
liver.
• The peritoneal relations of the livers.
• The blood supplies of the liver and the gallbladder.
• The divisions of the gallbladder and the biliary tract.
• The portal venous system and its collateral circulations.

3. Liver

4. Liver
• Intraperitoneal organ
• The largest gland in the body
– Weight 1500 gm
– About 2.5% of body weight in adult
• Lies mainly in right upper
quadrant
– Occupies most of the right
hypochondrium and upper
epigastrium and extends into the
left hypochondrium.

5. Liver
• Surface projection
– Uppermost: Right midinguinal line
// Right 5th rib
– Right lowermost: Right midaxillary
line // Right 10th costal cartilage
– Left lowermost: Left midinguinal
line // Left 5th intercostal space
(ICS)

6. Surface of the liver
• Diaphragmatic surface
– Anterosuperior surface
– Convex surface
– Relate to inferior surface of
diaphragm
• Visceral surface
– Posteroinferior surface
– Concave surface
– Relate to abdominal organ

7. Diaphragmatic surface

8. Visceral surface of the liver
• H-shaped structures
1. Porta hepatis
– Hepatic artery, Portal vein, Bile duct, Nerves and Lymphatic vessels
2. Ligamentum teres hepatis (round ligament of liver)
– Remnant of umbilical vein
3. Ligamentum venosum
– Remnant of ductus venosus
4. Gallbladder
5. Inferior vena cava

9. Visceral surface of the liver

10. Visceral surface of the liver

11. Peritoneal relations
• “Glisson’s capsule”
– Capsule of the liver
– Dense layer of fibrous
connective tissue
• Visceral peritoneum covers
the liver, except “bare
areas”

12. Ligaments of the liver
Peritoneal ligaments
• Lesser omentum
• Falciform ligament
• Coronary ligaments
• Triangular ligaments
Vascular remnants
• Round ligament of the liver
(remnant of umbilical vein)
• Ligamentum venosum
(remnant of ductus venosus)

13. Lesser omentum
• Hepatoduodenal ligament
– Between porta hepatis and superior aspect of 1st part of duodenum
– Enclosing portal triad
• Hepatogastric ligament
– Between groove for
ligamentum venosum and
lesser curvature of stomach

18. Potential spaces
• Subphrenic recess
– Between diaphragm and the
anterior and superior aspects of
the diaphragmatic surface of the
liver
• Subhepatic space
– Peritoneal cavity immediately
inferior to the liver
• Hepatorenal recess
(Rutherford-Morrison pouch)
– Between the right part of the
visceral surface of the liver and the
right kidney and adrenal gland
– Gravity-dependent space

20. Normal hepatorenal recess Free fluid in hepatorenal recess

21. Bare areas of the liver
• Between anterior & posterior coronary ligaments
• Fossa for gallbladder
• Porta hepatis
• Fissure for round ligament of the liver
• Fissure for ligamentum venosum
• Fossa for IVC

24. Lobes and segments of the liver
• Anatomical lobation (Falciform ligament)
– Right lobe
– Left lobe
– Caudate lobe
– Quadrate lobe

25. Lobes and segments of the liver
• Functional lobation (Imaginary line passing through
gallbladder fossa to IVC: “Cantlie’s line”)
– Right lobe
– Left lobe
– Caudate lobe (segment I)

26. Lobes and segments of the liver
• Bismuth-Couinaud system for liver segmental nomenclature
– 8 surgically resectable hepatic segments
– Each served independently by a branch of the portal triad
Claude Couinaud
1922-2008

31. Vascular system of the liver
• Blood supplies: Dual blood supplies
– Right and left hepatic arteries (25%)
• Oxygenated blood
– Hepatic portal vein (75%)
• Carries almost all nutrients from GI tract
• Venous drainage
– Hepatic veins drain venous blood to IVC
• Left hepatic vein
• Middle hepatic vein
• Right hepatic vein

32. Celiac trunkCommon hepatic a.
Splenic a.
Gastroduodenal a.
Left gastric a.
Proper hepatic a.
(in hepatoduodenal lig.)
Right
hepatic a.
Left
hepatic a.

33. Splenic v.
Superior
Mesenteric v.
(SMV)
Portal v.
Inferior
Mesenteric v.
(IMV)
Right
portal v.
Left
portal v.

34. Nerve supplies of the liver
• Derived from the hepatic plexus
• Autonomic nerves
– Sympathetic: Greater splanchnic
nerves
– Parasympathetic: Anterior and
posterior vagal trunks
• Accompany the vessels and biliary
ducts of the portal triad.

35. Lymphatic drainage
• Anterior surfaces of the liver and deep lymphatics along portal triads:
drain via porta hepatis to the hepatic nodes & celiac nodes
• Posterior surfaces of the liver: drain toward the bare area into phrenic
nodes

37. Gallbladder and biliary tract

38. Gallbladder
• Pear shape
• 7-10 cm in length
• Up to 5o mL
• In the gallbladder fossa on the
visceral surface of the liver
• Surface projection of fundus:
– Right linear semilunaris // right costal
margin = Murphy’s point

39. Parts of gallbladder
• Fundus
• Body
• Neck
– Infundibulum (Hartmann’s pouch)

40. Blood supply of gallbladder
• Cystic artery
– Commonly arises from the right hepatic artery
– In the triangle between the common hepatic duct, cystic duct, and
visceral surface of the liver = Calot’s triangle
Jean-François Calot
(1861 – 1944)

41. Biliary system
• Gallbladder
• Biliary tract
– Right and left hepatic ducts
– Common hepatic duct
– Cystic duct
– Common bile duct

42. Hepatopancreatic ampulla (ofVater)
• Second part of duodenum
Sphincter of Oddi

43. Imaging of biliary tract
Endoscopic retrograde
cholangiopancreatography
(ERCP)
Magnetic resonance
cholangiopancreatography
(MRCP)

44. Imaging of biliary tract
Cholangioscopy
Photo courtesies of Asst. Prof. Dr.Phonthep Angsuwatcharakon

45. Imaging of biliary tract
Cholescintigraphy or
hepatobiliary scintigraphy

46. Gallstones

47. Portal venous system

48. Portal venous system
Tributaries
• Cystic vein
• Paraumbilical vein
• Right and left gastric veins
• Splenic vein
• Superior mesenteric vein
• Posterior superior
pancreaticoduodenal vein

50. Portal hypertension

51. Portal hypertension with splenomegaly
Hepatic cirrhosis
Cirrhosis with splenomegaly
representing portal hypertension

52. Portal-systemic anastomoses
Left gastric vein
Esophageal vein
Azygos vein
SVC

53. Esophageal
varices
Gastric varices
Photo courtesies of Asst. Prof. Dr.Phonthep Angsuwatcharakon

54. Portal-systemic anastomoses
Superior rectal vein
Rectal venous plexus
Middle & inferior
rectal vein

55. Internal hemorrhoids
Rev Gastroenterol Disord. 2009Winter;9(1):16-26.

56. Portal-systemic anastomoses
Paraumbilical vein
Superficial epigastric
veins
External iliac vein
IVC
Caput medusae

57. Portal-systemic anastomoses
Colic vein
Retroperitoneal
veins
IVC

58. Q&A session
This presentation is dedicated to the memory of
Dr. Natavuth Plodpiyakun,
our beloved anatomy teacher