Functional & Applied Anatomy of the

Liver, Gall Bladder & Pancreas

MUHAMMAD ALBAHADILI
2022-2023
objectives
• At the end of lecture we able to
• Locate the liver, pancreas or gallbladder in abdominal cavity
• Explain their relation to GIT
• Differentiate clinical problem related each organ
Liver
 • Largest glandular organ, roughly triangular, lies mainly in the
right hypochondrium & extends into the epigastrium & left
Liver hypochondrium, covered by a fibrous capsule (Glisson capsule)
• what is the largest organ in the body?
❖Covered by peritoneum except a small
area (bare area) on its posterior surface
where its is in contact with the inferior
vena cava
❖Protected by the rib cage;
❖Superior, lateral, anterior & posterior surface in contact with the diaphragm;
❖inferior (visceral) surface in contact with parts of the GI tract
❖Not palpable in normal position; lower edge palpable in deep inspiration
❖Visceral surface contains the porta
hepatis – for structures entering &
leaving the liver
 Fixation of the liver in its position
• By ligaments • By vascular connection to IVC
•Coronary ligament
•Triangular ligament
•Falciform ligament
•Ligamentum teres (hepatis)
•Lesser omentum
Ligaments of the liver
 Falciform ligament & round ligament
falciform ligament(flap of ventral mesentery attaches the liver to the ant.
abdominal wall); contains the obliterated left umbilical vein (ligamentum teres)
❖ Falciform ligament covers the liver &
is reflected on the superior surface as
the coronary ligament which fixes it
to the diaphragm
Triangular ligament: fixes the liver to the diaphragm
Lesser omentum
 Anatomical Liver Lobes
❖ Divided into right & left lobes
by the falciform ligament
anteriorly;
❖ By ligamentum venosum
poseriorly
❖ The right lobe is further subdivided by the right
sagittal fissure into three parts: the main right
lobe & the caudate & quadrate lobes; the
caudate lobe is bounded by the inferior vena
cava & the ligamentum venosum (remnant of
ductus venosus – bypass for placental
oxygenated blood to IVC during development)
❖ The quadrate lobe bounded by the bed of the
gallbladder & the round ligament
FUNCTIONAL SUBDIVISION OF LIVER
Functional & surgical divisions of the liver are based on the distribution
of vascular & biliary elements

• Each part receives its own primary

branch of the hepatic artery and
hepatic portal vein and is drained by
its own hepatic duct.
• The caudate lobe may in fact be
considered a third liver; its
vascularization is independent of the
bifurcation of the portal triad (it
receives vessels from both bundles)
and is drained by one or two small
hepatic veins, which enter directly
into the IVC
• The liver can be further subdivided into
four divisions and then into eight
surgically resectable hepatic segments,
each served independently by a
secondary or tertiary branch of the
portal triad, respectively
• Segments of Liver: Except for the
caudate lobe (segment I), the liver is
divided into right and left livers based
on the primary (1°) division of the
portal triad into right and left branches,
the plane between the right and the left
livers being the main portal fissure in
which the middle hepatic vein lies
• On the visceral surface, this plane is
demarcated by the right sagittal fissure.
The plane is demarcated on the
diaphragmatic surface by extrapolating an
imaginary line (the Cantlie line) from the
notch for the fundus of the gallbladder to
the IVC
• The right and left livers are subdivided
vertically into medial and lateral divisions
by the right portal(no external mark) and
umbilical fissures, in which the right and
left hepatic veins lie
• Each of the four divisions receives a
secondary (2°) branch of the portal triad
A transverse hepatic plane at the level of the
horizontal parts of the right and left branches
of the portal triad subdivide three of the four
divisions (all but the left medial division),
creating six hepatic segments, each receiving
tertiary branches of the triad.
 Liver – Vascular & Biliary
■ Elements
The liver has a dual blood supply consisting of:
Hepatic artery (20-30%),
Hepatic Portal Vein (70-80%) drain of the intestine!
■ Each of them gives 50% of liver oxygenation;
.left or right hepatic artery ligation leads to a physiologically healthy liver
.Rt. Hepatic A. may arise from sup. Mesenteric A
.Lt. hepatic A. may arise from Lt. gastric A
Blood & Bile Flow in the Liver
❖Arterial blood & portal venous blood mix
together in the liver sinusoids.
❖Sinusoidal blood drains into central veins >
hepatic veins > inferior vena cava;
❖Direction of flow determined by relatively
high pressure of blood in the portal vein vis-
à-vis central vein.
Blood from the liver is drained by Hepatic veins > Inferior vena cava
 Liver – Vascular & Biliary Elements
❖ Right branches of the portal vein &
hepatic artery distribute to the right
lobe of the liver (5-8 segments)
❖ Left branches distribute to the
caudate, quadrate & left lobe of the
liver (2-4 segments)
❖ Right hepatic bile duct drains 5-8
segments
❖ Left hepatic duct drains 2-4
segments
❖ The third liver (caudate, 1) receives
dual blood from the right & left
portal triad
❖Bile secreted flows in the opposite
direction to the blood flow.
❖Bile secretory system begins as bile
canaliculi between adjacent
hepatocytes; Bile canaliculi > bile
ductules; ductules converge to form
intra- & interlobular biliary ducts
which converge to form right & left
hepatic ducts.
❖Outside the liver, hepatic ducts form
the common hepatic duct.
❖Common hepatic duct join cystic duct
form common bile duct.
 Nerve supply of liver
• The nerves of the liver are derived from the hepatic
plexus the largest derivative of the celiac plexus. The
hepatic plexus accompanies the branches of the
hepatic artery and the hepatic portal vein to the liver.
This plexus consists of sympathetic fibers (T6-T9) from
the celiac plexus and parasympathetic fibers from the
anterior and posterior vagal trunks. Nerve fibers
accompany the vessels and biliary ducts of the portal
triad. Other than vasoconstriction, their function is
unclear.
Lymphatic drainage of the liver
• superficial lymphatics in the sub-peritoneal fibrous capsule of the liver
• deep lymphatics in the connective tissue,
• Most lymph is formed in the perisinusoidal spaces (of Disse) and drains to the
deep lymphatics in the surrounding intralobular portal triads.
• Superficial lymphatics from the anterior aspects of the diaphragmatic and
visceral surfaces of the liver, and deep lymphatic vessels accompanying the
portal triads, converge toward the porta hepatis.
• The superficial lymphatics drain to
the hepatic lymph nodes scattered
along the hepatic vessels and ducts
in the lesser omentum.
• Efferent lymphatic vessels from the
hepatic nodes drain into celiac
lymph nodes
• Superficial lymphatics from the
posterior aspects of the
diaphragmatic and visceral surfaces
of the liver drain toward the bare
area of the liver. Here they drain
into phrenic
 Liver – Microstructure
• Main unite of liver is lobule
Hepatomegaly (enlarged liver) can be caused by:
• blood engorgement may be due to rise in central venous pressure
(lack of valves in IVC & hepatic veins), congestive heart failure,
• bacterial & viral diseases (hepatitis) or parasite (hydatid cyst),
• tumours & metastatic carcinoma - 2° from organs drained by the
hepatic portal system)
percussion
 Alcoholic Cirrhosis & Portal Hypertension
• Liver vulnerable to cellular damage &
consequent scarring; replaced by
fibrous tissue.
• Fibrous tissue surrounds intra-hepatic
vessels & bile ducts > restriction of
blood flow > ↑ pressure in HPV >
portal hypertension
• Blood flow into systemic circulation
via venous sites (porto-systemic
anastomoses); vessels become
varicosed and may rupture
(haemorrhage).
Complications portal hypertension:
• oesophageal varices: portal = left gastric
veins & systemic = Oesophageal veins > via
the azygos vein
• Ano-rectal varices (haemorrhoids): portal =
superior rectal vein & systemic = middle and
inferior rectal veins
• caput medusae: portal = paraumbilical vein &
systemic = epigastric veins
• Retrocolic: portal = superior and inferior
mesenteric veins tributaries & systemic =
retroperitoneal vessels

;Rx
TIPS = Shunt: Transjugular Intrahepatic
Portosystemic Shunt
gallbladder
• The gallbladder is a pear-shaped, hollow structure
located under the liver and on the right side of the
abdomen,
• about 7 to 10 cm long an average capacity of 30 to
50 ml
• located in a fossa on the inferior border of the liver,
• the body of the gall- bladder lies anterior to the
superior part of the duodenum, and its neck and
cystic duct are immediately superior to the
duodenum
• Peritoneum surrounds the fundus of the gallbladder
and binds its body and neck to the liver. The hepatic
surface of the gallbladder attaches to the liver by
connective tissue of the fibrous capsule of the liver.
 Gallbladder
❖ Gall bladder has a fundus, body & neck > cystic duct
• Fundus: the wide blunt end that usually projects from the
inferior border of the liver at the tip of the right 9th costal
cartilage in the MCL
• Body: the main portion that contacts the visceral surface of the
liver, transverse colon, and superior part of the duodenum.
• Neck: narrow, tapering end, directed toward the porta hepatis;
The cystic duct (3–4 cm long) connects the neck of the gallbladder
to the common hepatic duct
The mucosa of the cystic duct spirals into the spiral fold (spiral
valve) the spiral fold helps keep the cystic duct open.
 bile ducts
❖ Right & left hepatic ducts leaving the
porta hepatis to join to form the
common hepatic duct (4 cm)
❖ Joined on the right by the cystic duct
from the bile duct; which lies in the
free border of the lesser omentum
 Gall bladder & bile ducts
❖ Opens into the 2nd part of the
duodenum with the main pancreatic
duct through sphincter of Oddi
• blood supply – cystic artery (br. Right hepatic art-
RHA.); RHA also supplies part of the common bile
duct
• Venous drainage fellows the artery
 Gall bladder & bile ducts
• Lymphatic: The lymphatic vessels of the gall bladder (subserosal and
submucosal) drain into the cystic lymph node of Lund (the sentinel lymph node),
which lies in the fork created by the junction of the cystic and common hepatic
ducts. Efferent vessels from this lymph node go to the hilum of the liver, and to
the coeliac lymph nodes.
• The subserosal lymphatic vessels of the gall bladder also connect with the
subcapsular lymph channels of the liver, and this accounts for the frequent
spread of carcinoma of the gall bladder to the liver.
 Nerve supply of Gall bladder & bile ducts
❖ Nerve supply to the gall bladder
& cystic duct from the coeliac
plexus sympathetic (sensory)
visceral afferent pain fibres)
❖ and from the Vagus nerve
parasympathetic (motor)
❖ Parasympathetic stimulation >
contraction of gall bladder &
relaxation of the sphincter of
Oddi; these responses are also
stimulated by the hormone
(cholecystokinin (CCK)
produced by the duodenum upon
the arrival of food (fat) in the
duodenum
❖ Somatic (afferent) to right
phrenic n.
❖ Gall bladder stores, concentrates
bile & secretion of mucus;
biliary ducts convey bile to the
duodenum; released
intermittently
❖ Mucosa of the neck spirals into
spiral fold – keeps the cystic
duct open; allows the gall
bladder to fill up when the distal
end of the common bile duct is
closed off by its sphincter at the
lower end.
Clinical condition: Gall stones
• Bile produce by the liver and
excreted in bile canaliculi is
within 500 to 1000 ml
• Composed of water, electrolytes,
bile salts, protein, cholesterol
and bile pigments
• Stone formed as a result of
solids settling out of solution
• The major organic solutes are
bile salts, bile pigments,
phospholipid and cholesterol
Causes of gallstone
• Too much absorption of water
from of bile
• Too much absorption of bile
acids from of bile
• Too much cholesterol in bile
• Too much bile pigment in bile
• Inflammation of epithelium of
gallbladder
 Gall stone
• Gallstones can be divided into three main types: cholesterol, pigment (brown/black)
or mixed stones.
• Effects and complications of gallstones
• Biliary colic
• Acute cholecystitis
• Chronic cholecystitis
• Empyema of the gall bladder
• Mucocoele
• Perforation
• Biliary obstruction
• Acute cholangitis
• Acute pancreatitis
• Intestinal obstruction (gallstone ileus)
❖ Cholecystitis (inflammation of gall bladder)
due to bile accumulation > pain in the
epigastrium or the right hypochondrium; gall
bladder derivative of the foregut
(sympathetic innervation from T5 – T9 &
pain fibres return to T7 – T9 segments of the
spinal cord; pain felt along 7th – 9th
intercostal spaces (from inf. angle of scapula
to epigastrium)
❖Pain referred to the tip of the right shoulder (C3
- C5)
❖Cholecystectomy (removal of the gall bladder)
presents surgical challenges because of
variations in the anatomy & blood supply of the
biliary system.
Pancreas
 Pancreas
▪ The name ‘pancreas’ is derived from
the Greek ‘pan’ (all) and ‘kreas’ (flesh).
For a long time, its glandular function
was not understood, and it was
thought to act as a cushion for the
stomach.
▪ It’s a retroperitoneal organ
▪ Parts of the pancreas:
▪ Head
▪ Neck
▪ Body
▪ Tail
▪ Uncinate process
Pancreas: anteriorly is the lesser sac
 Pancreas: Anatomy
• The head lies within the curve of the
duodenum, overlying the body of the second
lumbar vertebra.
• The pancreatic head rests posteriorly on the
IVC, right kidney hilum, to the right of the
superior mesenteric vessels just inferior to
the transpyloric plane.
• It firmly attaches to the medial aspect of the
descending and horizontal parts of the
duodenum.
• the bile duct lies in a groove on the
posterosuperior surface of the head or is
embedded in its substance
• The neck of the pancreas is short (1.5–2 cm) and
overlies the superior mesenteric vessels, which form
a groove in its posterior aspect.
• The anterior surface of the neck, covered with
peritoneum, is adjacent to the pylorus of the
stomach.
• The SMV joins the splenic vein posterior to the neck
to form the hepatic portal vein
• uncinated process of the pancreas Coming off the
side of the pancreatic head and passing to the left
and behind the superior mesenteric vein.
• The body of the pancreas continues from the neck
and lies to the left of the superior mesenteric
vessels, passing over the aorta and L2 vertebra,
continuing just above the transpyloric plane
posterior to the omental bursa.
• The anterior surface of the body of the pancreas is
covered with peritoneum
• The posterior surface of the body is devoid of
peritoneum and is in contact with the aorta, SMA,
left suprarenal gland, left kidney, and renal vessels
• The tail of the pancreas lies
anterior to the left kidney, where
it is closely related to the splenic
hilum and the left colic flexure.
The tail is relatively mobile and
passes between the layers of the
splenorenal ligament with the
splenic vessels
 Pancreas: blood supply
superior mesenteric Pancreas: blood
Gastroduodenal splenic
artery supply

anterior superior anterior inferior

posterior superior posterior inferior Inferior pancratic Greater pancreatic Dorsal pancreatic To the tail
pancreaticoduodenal pancreaticoduodenal
Venous drainage of pancreas.
LYMPHATIC DRAINAGE OF THE PANCREAS
▪ Diffuse and widespread
▪ The pancreatic lymphatic vessels follow the
blood vessels
▪ Most vessels end in the pancreatic-splenic
lymph nodes, which lie along the splenic artery.
▪ Some vessels end in the pyloric lymph nodes.
Efferent vessels from these nodes drain to the
superior mesenteric lymph nodes or to the
celiac lymph nodes via the hepatic lymph
nodes.
▪ Communicate with lymph nodes in transverse
mesocolon and mesentery
• Pancreas is:
• (mixed gland); exocrine secretions (acinar
cells pancreatic juice) > duodenum via
main & accessory ducts;
• endocrine secretions ( islets of
Langarhans) > blood
• Main pancreatic duct together with the
common bile duct form the
(hepatopancreatic ampulla of Vater) and
open into the 2nd part of the duodenum
at the major duodenal papilla
• An accessory pancreatic duct drains the upper (superior) part of
the head of the pancreas and opens in the duodenum at the
minor duodenal papilla 2 cm anterosuperior to the major papilla
The main duct is lined by columnar
epithelium, which becomes cuboidal in
the ductules. Acinar cells are clumped
around a central lumen, which
communicates with the duct system.
Clusters of endocrine cells, known as islets
of Langerhans, are distributed throughout
the pancreas.
Islets consist of different cell types: 75 per
cent are B cells (producing insulin); 20 per
cent are A cells (producing glucagon); and
the remainder are D cells (producing
somatostatin) and a small number of
pancreatic polypeptide cells.

Within an islet, the B cells form an inner core surrounded by the other cells. Capillaries
draining the islet cells drain into the portal vein, forming a pancreatic portal system.
Pancreas - Microstructure
 Pseudocyst of pancreas
• formed when disruption of the main pancreatic duct or its branches, either
from inflammation or direct injury, causes extravasation of pancreatic
enzymes into the parenchyma and eventually forms a distinct collection.
• Pseudocysts arise as a complication of pancreatitis.
• It appears that alcohol-related pancreatitis is the major cause of pancreatic
pseudocyst The remaining causative factors are biliary stones, trauma, or
idiopathic.
• A pseudocyst is formed following an episode of acute pancreatitis, often
within 4 to 6 weeks of that episode, with a well-defined wall lined by
granulation or fibrous tissue.
• They are filled with amylase rich fluid. About one-third of pseudocysts are
located near the head of the gland, and the remaining two-thirds occur in
the tail.
 Pancreas: clinical correlates
• Impaction (gallstone) of the hepatopancreatic ampulla) > secretions
from the gall bladder & pancreas blocked - interruption of pancreatic
juice flow > pancreatitis
- interruption of bile flow > ‘post-hepatic (obstructive) jaundice’
• Pancreatic cancer (head) > extrahepatic obstruction of biliary ducts >
enlargement of gall bladder > obstructive jaundice