1

Repeat campaign 2008 A/L

Liver

- Largest gland
Location-intraperitoneal
Right hypochondriac, Epigastric, Left hypochondriac
Structure-
External features- wedge shaped
Surfaces-5
Anterior
posterior
superior
inferior
right
Borders-
Sharp inferior border


Lobes-2 divided by Falciformliga.Liga.TereshepatisLigamentumvenosum
right
left

Portahepatis- R& L divisions of,
Portal vein-posteriorly
Hepatic artery-anterioly, to the left
Hepatic duct- anteriorly, to the right
Histological features

Structural unit hepatic lobule- Hexagonal boundary
Hepatic lobule contain
Sinusoids
Cords of hepatocytes (polyhedral)
Central vein






Portal triad(tract)-arteriole of hepatic artery
Terminal branch of portal vein
Bile ductules
Lymphatics
Sinusoids Blood filled spaces
Sinusoidal lining cells types endothelial cells (fenestrated)
Kuffer cells
Bile canaliculi-spaces between 2 hepatocytes.
Secrete bile
Functional unit- liver acinus ellipsoid mass of hepatocytes centered to a portal tract

Zone 1- receive most oxygenated blood
Zone 2
Zone 3- receive least oxygenated blood

2


Repeat campaign 2008 A/L
Relations
Peritoneal attachments Lesser omentum arise from margins of portahepatis
Ligamentumvenosum
Ligamentumtereshepatis
Falciform ligament
Sup.&Inf.Coronary ligaments
R&L Triangular ligaments
Bare area-. Demarcated by
Right & left triangular ligaments
Upper & lower coronary ligaments

1.Visceral relations- post & inferior surfaces

Posterior surface- groove for IVC
suprarenal gland
diaphragm
esophagus
two crura& aortic opening
celiac trunk

Inferior surface- gastric impression
Pylorus of stomach
1st part of duodenum
groove for gall bladder
hepatic flexure
renal impression
fissure for ligmentumteres

2. Diaphramatic relations- Ant,Sup,Right surfaces

Anterior surface-diaphragm
Pleura
Anterior abdominal wall
xipoid process

Superior surface
Right & left domes of diaphragm
Right surface
(In mid axillary line)
Upper 1/3-lung pleura, diaphragm
Middle 1/3-pleura, diaphragm
Lower 1/3-diaphragm
Blood Supply
Hepatic Artery Portal vein

Segmental vessels -Hepatic segments 8
* No Anastomosis

Mixed blood in sinusoids

2 Functional lobes- dividedby,cysticnotch,groove for IVC,Middle of Caudate lobe,
fossa for gallbladder


3


Repeat campaign 2008 A/L
Venous Drainage
Intersegmental veins hepatic veins


Superficial Phrenic nodes

Lymphatic Drainage

Deep-follow blood vessels hepatic nodes coeliac nodes

Nerve supply
sympathetic T8
Parasympathetic- vagus hepatic plexus
Phrenic


Clinicals
1. Liver biopsy
Needle passes through right 8th intercostal space
2. Liver is normally not palpated in the infra sternal angle due to tone of the recti muscles & the softness of
the liver.
Hepatomegaly-palpable
3. Segmental resection of liver, follow pathway of intersegmental veins
4. Referred pain- T8
Shoulder tip


EXTRA HEPATIC BILIARY SYSTEM

Apparatus consists of Right & left hepatic ducts
Common hepatic duct
Gall bladder
Cystic duct
Bile duct

Arrangement in portahepatis
Behind forwards
R&L divisions of Portal vein
R&L divisions of Hepatic artery
R&L Hepatic ducts


1. Gall bladder
Volume 30- 50ml
Relations Fundus Anterior Anterior abdominal wall
Posterior Transverse colon

Body Posterior Transverses colon,1
st
& 2
nd
parts of duodenum
Superior Attached to liver,not covered by peritoneum
Inferior Covered by peritoneum

Neck Superior Attached to areolar tissue
Inferior - 1
st
part of duodenum
4


Repeat campaign 2008 A/L
Histology
Mucosa epithelium simple columnar epithelium
Submucosa -contains mucous glands
Muscle layer longitudinal, transverse,oblique


Clinical
1. It has dual blood supply
Cystic artery
From liver bed
So gangrene is rare
cystic artery location
Calots triangle
-cystic duct
-common hepatic duct
-inferior surface of liver

2.Stones in gall bladder-cholelithiasis
Spasmodic pain occur(biliary colic)-murphys sign
3.Inflamation of gall bladder-cholecystitis
Refered pain -in the lower border of the scapula - via sympathetics
Stomach- via vagal fibers
Shoulder tip- via phrenic
4.Cholicystectomy- Haemorage during biliary surgery controlled by compressing
hepatic artery at Foramen of Winslow.
5.Gall stone ileus-erosion of gall stones in to duodenum.


2. Bile duct
diameter-6mm
relations
Spraduodenal part
Anterior-liver
Posterior-portal vein,epiploic foramen
Left-hepatic artery
Retro duodenal part
Anterior-1
st
part of duodenum
Posterior-IVC, left gastroduodenal artery
Infraduodenal part
Anterior-head of pancrease
Posterior-IVC


Clinical- 1.Mirizzis syndrome-obstruction of common hepatic duct by a gall stone present in
cystic duct.(can it happen?)




5


Repeat campaign 2008 A/L
Spleen-A Lymphatic organ


Location -intraperitonial
Epigastric + left hypochondriac
Along axis of 10
th
rib
Structure--Wedge shaped
Cup hand
External features
3 borders- Superior, Inferior, Intermediate
2 surfaces-diaphragmatic
Visceral
2 ends - Anterior, Posterior
Hilum - along long axis
Gastrospleniclig.&linorenallig.
Relations
Peritonial Relations
Ligament Extend contents

1.Gastrosplenic Greater curvature of the
stomach to hilum of spleen
Short gastric vessels
Left gastroepiploic vessels
2. Linorenal Hilum of spleen to anterior
surface of kidney
Tail of pancrease
Splenic vessels
Pancreaticosplenic lymph
nodes

Phrenicocolic ligament not attached to spleen ,but supports its anterior end

Visceral surface- Diaphragmatic surface











Blood Supply
Coeliac trunk Splenic vein
superior mesenteric vein
Splenic artery
Portal vein


Lymphatic Drainage
Capsule,traberculae pancreaticospenic nodes coeliac nodes




6


Repeat campaign 2008 A/L

Clinical 1. Blunt trauma
Commonest intra abdominal structure to rupture due to thin tense capsule
2. SpleenomegalyNormal spleen is not palpable, enlarged spleen felt under the left costal
margin
Spleen enlarge along the axis of the 10
th
rib Right iliac fossa
3. Spleenectomy- pancreatic tail can be damaged
4. splenic Puncture- to measure Portal venous pressure
In 9
th
or 10
th
intercostals


Pancrease-exocrine & endocrine gland

Location- retroperitoneal except tail
Neck-transpyloric plane L1
Structure-
External features-elongated J shaped
4 parts Head-unicinate process
Neck
Body-tuber omentale
Tail-in lienorenalliga.
Histological features-collagenous capsule &septae
Endocrine tissue-
Islets of Langerhan-delicate capsule,secretorycells,fenestrated capillaries
Exocrine tissue
Secretory acini-secretory cell

Branched duct system intercalated ducts intralobular ducts
interlobular duct
Herring bone pattern

Major pancreatic duct accessory pancreatic duct
(wirsung) (santorini)

Hepatopancreatic duct
Minor duodenal papilla
Major duodenal papilla (8cm)
(10cm)
2
nd
part of duodenum


Relations Head Anterior Superior mesenteric vessels
Transverse colon
Loops of jejunum

Posterior IVC
Right renal vessels
Bile duct
groove between curvature of duodenum & head
Sup.&inf.pancreaticoduodenal arteries

Neck Anterior - Pylorus

7


Repeat campaign 2008 A/L
Posterior Beginning of portal vein

Body - Anterior Lesser sac & stomach

Posterior Abdominal aorta& sup mesenteric artery commencement
splenic vein
Left renal vessels
Left kidney

Inferior Duodenojejunal flexure
Splenic flexure

Superior b. Splenic artery
Anterior b . Transversemesocolon

Tail - hilum of spleen

Blood supply coeliac trunk splenic artery pancreatic branches (ex- ArteriaPancreatica Magna)

Common hepatic artery sup.Pancreaticoduodenal artery

Superior mesenteric artery inferior pancreaticoduodenal artery

Venous Drainage -Splenic vein

Sup. Pan.duo. vein Portal Vein

Inf. Pan.duo vein Sup mesenteric


Lymph Drainage - To the left of the neck pancreaticsplenic nodes
Upper part of head coeliac nodes
Lower part of head Superior mesenteric nodes


Nerve Supply- Sympathetic T6- T10
Parasympathetic - Vagus



Clinical 1. Neoplasm of head of the pancreas - obstruction of the bile duct
Portal venous obstruction
IVC obstruction
2. Pseudocyst of pancreas caused by acute pancreatitis or posterior gastric
Ulcerations
3. Splenectomy-Tail can be damaged( high in islets of Langerhan)
4. Gastric cancer/Posterior duodenal ulcer erode pancreas
5. Lesser sac between stomach & pancreas fill with fluid in posterior gastric
ulcer/acute pancreatitis