LIVER

ANATOMY

• largest organ

• 1.5 kg

• thin capsule and by visceral peritoneum

• bare area

• two lobes

LIGAMENTS AND PERITONEAL REFLECTIONS

• fixed in the right upper quadrant

• left triangular ligament

• The right triangular ligament

• falciform ligament (remnant of the umbilical vein)

• lesser omentum

BLOOD SUPPLY• coeliac trunk

• along with the splenic artery

• gastroduodenal artery

• right and left hepatic arteries

• right hepatic artery arising from the superior mesenteric artery

• left gastric branch

HILUM OF THE LIVER• bile duct to be within the free edge

• the hepatic artery to be above and medial

• portal vein to lie posteriorly

• common hepatic artery branches at a variable level within the ligament to form two, or often three main arterial branches to the liver

• The right hepatic artery often crosses the bile duct either anteriorly or posteriorly before giving rise to the cystic artery

• portal vein left gastric vein joins just above the pancreas

VENOUS DRAINAGE

• The vena cava lies within a groove in the posterior wall

• The inferior hepatic veins are short vessels

• three large veins

• The right hepatic vein can be exposed fully outside the liver

INTERNAL ANATOMY

• Couinaud, a French anatomist

• eight segments

• branch of the hepatic artery, portal vein and bile duct, and drained by a branch of the hepatic vein

• line between the gall bladder fossa and the middle hepatic vein (Cantlie’s line)

HEPATIC LOBULES• plates of liver cells separated by the hepatic sinusoids, large,

thin-walled venous channels that carry• blood to the central vein, a tributary of the hepatic vein, from

the• portal tracts, which contain branches of the hepatic artery and• portal vein. During passage through the sinusoids, the many

functions• of the liver take place, including bile formation, which is• channelled in an opposite direction to the blood flow to drain

via• the bile duct tributaries within the portal tracts.

TESTS OF LIVER FUNCTION• Bilirubin 5–17 μmol l–1

• Alkaline phosphatase (ALP) 35–130 IU l–1

• Aspartate transaminase (AST) 5–40 IU l–1

• Alanine transaminase (ALT) 5–40 IU l–1

• Gamma-glutamyl transpeptidase (GGT) 10–48 IU l–1

• Albumin 35–50 g l–1

• Prothrombin time (PT) 12–16 s

ULTRASOUND

• bile duct dilatation

• gallstones

• liver tumours

• flow in the hepatic artery, portal vein and hepatic veins

• guiding the percutaneous biopsy

COMPUTERISED TOMOGRAPHY

• triple-phase, multislice, spiral computerised tomography (CT)

• less than 1 cm

• Oral contrast enhancement

• The early arterial phase small liver cancers

• venous phase maps the branches of the portal vein within the liver and the drainage via the hepatic veins

• Inflammatory liver lesions exhibit rim enhancement

• haemangioma late venous enhancement

• density cystic lesion

MAGNETIC RESONANCE IMAGING

• iodine-containing intravenous contrast

• magnetic resonance cholangiopancreatography (MRCP) provides excellent quality, non-invasive imaging of the biliary tract

• Magnetic resonance angiography (MRA) high-quality images of the hepatic artery and portal Vein

• patency of the portal vein and its branches

ENDOSCOPIC RETROGRADECHOLANGIOPANCREATOGRAPHY

• Claustrophobia

• endoscopic intervention

• common bile duct (CBD) stones

• palliative biliary tract stent

• coagulation profile

• Prophylactic antibiotics

• pancreatitis, cholangitis and bleeding or perforation of the duodenum related to sphincterotomy.

PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY

• previous pancreatoduodenectomy

• Pólya gastrectomy

• hilar bile duct tumours

• guide external drainage of the bile ducts to relieve jaundice

• direct stent insertion

ANGIOGRAPHY

• therapeutic intervention

• Prior to liver resection

• anatomy of the hepatic artery

• confirm patency or tumour involvemen of the portal vein

• occlusion of arteriovenous malformations

• embolisation of bleeding sites in the liver and liver tumours (transarterial embolisation, TAE)

NUCLEAR MEDICINE SCANNING

• Iodoida technetium-99m (99mTc)-labelled radionuclide that is administered intravenously

• processed by hepatocytes and excreted in the bile

• gamma camera

• sulphur colloid liver scan Kupffer cell activity

• adenomas and haemangiomas lack Kupffer cells

• 18F-2-fluoro-2-deoxy-D-glucose positron emission tomography (FDG–PET)

• avid uptake of glucose by cancerous tissue

• Deoxyglucose is labelled with the positron emitter fluorine-18 (18FDG)

LAPAROSCOPY AND LAPAROSCOPIC ULTRASOUND

• staging of hepatopancreatobiliary cancers

• peritoneal metastases and superficial liver tumours

• Laparoscopic ultrasound