DM Lecture 3 - Stomach, Liver, and Gallbladder Anatomy PDF

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All year-1 course materials, whether in print or online, are protected by copyright. The work, or parts of it, may not be copied, distributed, or published in any form, printed, electronic, or otherwise. As an exception, students enrolled in year 1 of St. George’s University School of Medicine and their faculty are permitted to make electronic or print copies of all downloadable files for personal and classroom use only, provided that no alterations to the documents are made and that the copyright statement is maintained in all copies. ‘View only’ files, such as lecture recordings, are explicitly excluded from download, and creating copies of these recordings by students and other users is strictly illegal. The author of this document has made the best effort to observe current copyright law and the copyright policy of St. George's University. Users of this document identifying potential violations of these regulations are asked to bring their concerns to the attention of the author.  Your Objectives will show here! Foregut Structures Describe the following ligaments, their embryonic origin, peritoneal coverings and their function: falciform, round ligament of the liver (ligamentum teres hepatis), coronary, triangular, median, medial and lateral SOM.MK.1.BMP2.3.DM.1.ANAT.1125 umbilical, greater omentum, gastrocolic, gastrosplenic, splenorenal ligaments, lesser omentum (hepatoduodenal and hepatogastric ligaments) and suspensory ligament of the duodenum (Treitz). SOM.MK.1.BMP2.3.DM.1.ANAT.1126 Describe the abdominal esophagus, its blood supply and lymphatic drainage. SOM.MK.1.BMP2.3.DM.1.ANAT.1127 Describe the nerve pathways for pain in a patient with gastroesophageal reflux disease. SOM.MK.1.BMP2.3.DM.1.ANAT.1129 Describe sliding and paraesophageal hiatal hernia SOM.MK.1.BMP2.3.DM.1.ANAT.1130 Describe the anatomy of the stomach and identify its parts and curvatures. Describe the relationships of the stomach to the spleen, pancreas, liver, ascending and descending SOM.MK.1.BMP2.3.DM.1.ANAT.1131 colon. SOM.MK.1.BMP2.3.DM.1.ANAT.1132 Describe the blood supply and the venous and lymphatic drainage of the stomach. SOM.MK.1.BMP2.3.DM.1.ANAT.1159 Describe the location of the liver and its relationship to surrounding structures. SOM.MK.1.BMP2.3.DM.1.ANAT.1160 Describe the four anatomical lobes of the liver. SOM.MK.1.BMP2.3.DM.1.ANAT.1161 Describe the functional (physiological) lobes of the liver. SOM.MK.1.BMP2.3.DM.1.ANAT.1162 List the structures entering / leaving the liver at the porta hepatis. SOM.MK.1.BMP2.3.DM.1.ANAT.1163 Describe the contents of the hepatoduodenal ligament which will be gripped during a Pringle maneuver. SOM.MK.1.BMP2.3.DM.1.ANAT.1164 Describe the “the bare area” of the liver. SOM.MK.1.BMP2.3.DM.1.ANAT.1165 Describe the blood supply, venous and lymphatic drainage to the liver. SOM.MK.1.BMP2.3.DM.1.ANAT.1166 Describe the contents of a liver segment and its importance in surgery of the liver. SOM.MK.1.BMP2.3.DM.1.ANAT.1167 Describe the location of the gall bladder and its relationship to the liver. SOM.MK.1.BMP2.3.DM.1.ANAT.1168 Describe the anatomy of the biliary tree. SOM.MK.1.BMP2.3.DM.1.ANAT.1169 Describe the arterial supply, venous and lymphatic drainage of the gall bladder and cystic duct. List the borders of the triangle of Calot and state the importance of this triangle when performing SOM.MK.1.BMP2.3.DM.1.ANAT.1172 laparoscopic surgery for gallbladder disease  Drake, Vogl, Mitchell. Grays Anatomy for Students. 5th ed. Elsevier Churchill Livingstone. Online Textbook: Chapter 4: Click here Abdominal Viscera Abdominal Organs Esophagus, Stomach Liver, Gallbladder Pay special attention to the green (print text)/blue (ebook)“In the Clinic” boxes for the clinical correlations for this topic Begins at the abdominal esophagus and ends proximal to the major duodenal papilla. Esophagus Stomach Liver /Biliary apparatus Pancreas Spleen (developed in dorsal mesogastrium) ½ Duodenum (proximal to the major papilla) Arterial supply: Celiac Trunk Venous drainage: Portal Venous System Lymphatic drainage: Celiac Nodes  SOM.MK.1.BMP2.3.DM.1.ANAT.1126 Part of foregut 25cm long Location-neck, thorax & abdomen Musculature of esophagus : Skeletal – upper 1/3 Mixed – middle 1/3 Smooth – lower 1/3 Pierces the diaphragm at the level of T10 Below the diaphragm, is covered by peritoneum.  SOM.MK.1.BMP2.3.DM.1.ANAT.1126 1 1. Upper Esophageal Sphincter 2. Arch of the 2 Aorta 3 3. Left Main Bronchus 4 4. Diaphragmatic hiatus Lower Esophageal LES Sphincter (LES)  SOM.MK.1.BMP2.3.DM.1.ANAT.1126 Esophagus Vagus n.  SOM.MK.1.BMP2.3.DM.1.ANAT.1126, 1127 Blood Supply Esophageal arteries (thoracic aorta, L. gastric a.) Esophageal veins (drain into left gastric vein) Lymphatic Drainage Posterior mediastinal + Left gastric nodes Nervous Supply Esophageal complex (esophageal branches from vagal trunks + sympathetic trunks) Visceral afferents (vagus, sympathetics, splanchnic nerves) Pain in GERD Visceral afferents that pass through sympathetic trunks  SOM.MK.1.BMP2.3.DM.1.ANAT.1129 At the level of the esophageal hiatus Lax in diaphragm  fundus (stomach) herniates into posterior mediastinum Sliding hernia (more common): Esophagus and stomach slide up into chest Gastroesophageal junction displaced upward Associated with GERD Paraesophageal hernia Gastroesophageal junction remains in normal position Fundus of stomach slides up into chest next to (-para) esophagus https://drvasudevgastroenterologist.com/hiatal-hernia/  SOM.MK.1.BMP2.3.DM.1.ANAT.1130 Parts Cardia Fundus Body Pyloric region Antrum Canal Sphincter Curvatures Lesser curvature Greater curvature  SOM.MK.1.BMP2.3.DM.1.ANAT.1131, 1125 Lesser Omentum Hepatogastric L ligament Hepatoduodenal G ligament G – Gallbladder L – Liver S RC – Right colic flexure RK – Right kidney D D – Duodenum RK LC TC – Transverse colon (behind to greater omentum) S – Spleen RC LC – Left colic flexure TC  SOM.MK.1.BMP2.3.DM.1.ANAT.1130 Rugae Musculature 1. Outer longitudinal 2. Middle circular 3. Innermost oblique 1 Pyloric Sphincter Thickened ring of circular muscle 2 3  SOM.MK.1.BMP2.3.DM.1.ANAT.1132 6 1 2 4 1. Celiac trunk 2. Left gastric 3. Splenic 4. Short gastrics 5. L. gastro-omental 6. Common hepatic 7 7. Proper hepatic 8. Right gastric 9. Gastroduodenal 10. R. gastro- omental Gastro-omental = Gastroepiploic 9 10 8 3 5 Study tip: Draw your own flow diagram  SOM.MK.1.BMP2.3.DM.1.ANAT.1132 5 4 3 1 8 1. Short gastric 2. L. gastro-omental 7 3. Splenic 4. Right gastric 5. Left gastric 6. R. gastro-omental 7. Superior mesenteric 6 3 2 8. Hepatic portal vein  SOM.MK.1.BMP2.3.DM.1.ANAT.1132 Arteries: Left gastric: Branch of the celiac trunk. Supplies the lower part of the esophagus and upper left part along the lesser curvature of the stomach. Right gastric: Arises from the hepatic artery and runs along the lesser curvature of the stomach (lower right part). Short gastric: Arises from the splenic artery. Supplies the fundus. Left gastroepiploic: Arises from the splenic artery then passes forward to supply the upper (left) part of the greater curvature of the stomach Right gastroepiploic: Arises from the gastroduodenal branch of the common hepatic artery. Supplies right lower part of stomach along the greater curvature Veins: Veins all eventually drain into the portal system Left and right gastric drain into the portal vein directly The short gastrics and left gastroepiploic veins drain into the splenic vein Right gastroepiploic vein drains into the superior mesenteric vein Lymphatic channels from the stomach will first drain to the celiac group of lymph nodes located around the celiac trunk. SOM.MK.1.BMP2.3.DM.1.ANAT.1141, 1178  SOM.MK.1.BMP2.3.DM.1.ANAT.1159 Right hypochondrium and epigastric and (left hypochondrial) regions. Enclosed in lower portion of rib cage - trauma can be caused by Fractures of lower ribs. Penetrating wounds (thorax or upper abdomen) All can be associated with severe hemorrhage G L LO Sp St RK TC GO L – Liver; RK – Right Kidney; TC – Transverse colon; G – Gallbladder; St – Stomach; Sp - Spleen; LO – Lesser Omentum; GO – Greater Omentum  SOM.MK.1.BMP2.3.DM.1.ANAT.1159, 1160 D CI G QL RL LL RI GI CL IVC G Anterior view: RL – Right lobe; LL – Left Visceral view: CL – Caudate Lobe; QL Quadrate Lobe; GI – Lobe; D – Diaphragm; G - Gallbladder Gastric Impression; RI – Renal Impression; CI – Colic Impression; Circle – Porta Hepatis; G – Gallbladder The liver has two surfaces: Diaphragmatic: anterior, superior, posterior Visceral surface: inferior and covered with visceral peritoneum (except the fossa for gallbladder + porta hepatis) Subphrenic space: between diaphragm and liver Hepatorenal recesses: [between right kidney & liver] is the gravity dependent part of the peritoneal cavity in supine position  SOM.MK.1.BMP2.3.DM.1.ANAT.1125, 1164 CL LT RT RL FL RL FL RL BA CL Anterior view: FL – Falciform Ligament; RL – Visceral view: BA – Bare Area; RL Round ligament (ligamentum teres hepatis); – Round ligament; Triangle – LT; Left Triangular Ligament; RT – Right Triangular ligament; CL – Coronary Triangular Ligament; CL – Coronary Ligament Ligament Falciform Ligament – attaches liver to anterior abdominal wall (ventral mesentery) Round Ligament – posterior free margin of falciform ligament (obliterated umbilical vein) Bare area of liver – triangular area on diaphragmatic surface devoid of peritoneal covering Coronary Ligaments – (anterior & posterior) attach the liver to the diaphragm Triangular Ligaments – (right & left) attach the liver to the diaphragm Umbilical ligaments – median, medial (2), lateral (2) Review MSK  SOM.MK.1.BMP2.3.DM.1.ANAT.1125, 1164 Falciform Ligament – attaches liver to anterior abdominal wall (ventral mesentery) Coronary Ligaments – (anterior & posterior) attach the liver to the diaphragm Triangular Ligaments – (right & left) attach the liver to the diaphragm Bare area of liver – triangular area devoid of peritoneal covering, related to the diaphragm  SOM.MK.1.BMP2.3.DM.1.ANAT.1160, 1161 Divided into Left and Right Lobes by Falciform ligament Caudate lobe posterior visceral surface between ligamentum venosum fissure + IVC groove Quadrate lobe anterior visceral surface between ligamentum teres fissure + gallbladder fossa Right anatomic lobe: right anatomic lobe + caudate lobe + quadrate lobe Left anatomic lobe: only of left lobe LEFT RIGHT QL RIGHT LOBE LOBE LOBE LEFT LOBE CL Anatomically, right lobe larger with caudate & quadrate lobes  SOM.MK.1.BMP2.3.DM.1.ANAT.1160, 1161 Divided into Left and Right Lobes by the Principal plane (Cantlie’s line) Principal Plane (Cantlie’s line) Imaginary line that runs through the midline of the gallbladder fossa and IVC Middle hepatic vein runs in this plane Right functional lobe: only of the right anatomic lobe Left functional lobe: left anatomic lobe + caudate lobe + quadrate lobe LEFT RIGHT QL RIGHT LOBE LOBE LOBE LEFT LOBE CL Functionally, more equal left lobe contains caudate & quadrate lobes  SOM.MK.1.BMP2.3.DM.1.ANAT.1161, 1166 Subdivision of FUNCTIONAL (Portal) Lobes Liver is divided into 8 segments based on the main branches of right & left hepatic arteries, portal vein & hepatic ducts [hepatic veins → intersegmental] Branches of the right & left hepatic arteries, ducts and portal vein do not communicate significantly. [hepatic lobectomy / segmentectomy can be performed]  SOM.MK.1.BMP2.3.DM.1.ANAT.1160, 1161, 1166 Anatomically, the liver can be divided into four lobes: right ,left, caudate and quadrate. In this classification the quadrate and caudate lobes are considered part of the right liver. Functionally, it can be divided into independent right and left livers i.e., portal lobes. This functional division is produced by the sagittal plane passing through the gall bladder fossa and the fossa of the IVC on the visceral surface of the liver, and an imaginary line over the diaphragmatic surface that runs from the surface of the gall bladder to the IVC. The left liver now includes anatomic quadrate and caudate lobes. This functional division results in the liver having a slightly larger right lobe. These “portal lobes” will have their own blood supply from the hepatic artery, portal veins, their own venous (hepatic veins) and biliary drainage. The (2) portal lobes of the liver are further divided into 8 segments. The segmentation is based on the principal branches of the right and left hepatic arteries, hepatic portal veins and hepatic ducts. Each segment is supplied by the corresponding branch of the right or left hepatic artery, portal vein and drained by a branch of the left or right hepatic duct. Moore, K. L., Agur, A. M., & Dalley, A. F. (2002). Essential clinical anatomy (Vol. 469). Philadelphia: Lippincott Williams & Wilkins.  SOM.MK.1.BMP2.3.DM.1.ANAT.1162, 1163 Porta hepatis [circle] – structures enter / leave the liver (except hepatic veins) 1 ENTER: Hepatic arteries + Portal vein EXIT: Hepatic bile ducts 2 Pringle maneuver: manually compress/clamp hepatoduodenal ligament (which contains vessels of the porta hepatis) 3 anterior to omental foramen to control bleeding to/from liver QL LEFT RIGHT LOBE LOBE CL  SOM.MK.1.BMP2.3.DM.1.ANAT.1165 Arterial supply – hepatic arteries Hepatic artery (proper) (2) [30%] Right (3) and Left (4) hepatic a. 3 4 5 Portal vein (5) [70%] to the liver Veins – hepatic & portal* 2 Hepatic veins open into IVC Left, Right, Middle hepatic veins Liver produces large amount of lymph  mainly to celiac nodes *1. Common hepatic artery 1 SOM.MK.1.BMP2.3.DM.1.ANAT.1141, 1178  SOM.MK.1.BMP2.3.DM.1.ANAT.1167 Pear shaped, in its fossa on the inferior surface of liver 3 Parts 1. Fundus: rounded end [projects beyond the inferior 2 margin of liver  located at the tip of the right 9th costal cartilage mid-clavicular line], 2. Body: major part, against TC and D 3. Neck: narrow part  leads to cystic duct 1 Receives bile from the liver (concentrates & stores it) L LO D G TC P AC L – Liver; G – Gallbladder; TC – transverse colon; AC – Ascending colon; D – Duodenum; P – Pancreas; LO – Lesser Omentum  SOM.MK.1.BMP2.3.DM.1.ANAT.1168 Right (1) & left (2) hepatic ducts join to 4 1 form the common hepatic duct (3); 2 Joined by the cystic duct (4) to form the [common] bile duct [BD] (5) BD passes posterior to the 1st part of duodenum 3 Joins the pancreatic duct (6) to open into the major duodenal papilla (7) 5 G 1. Right hepatic duct 2. Left hepatic duct 3. Common hepatic duct 6 4. Cystic duct 5. [Common] Bile duct D 6. Main pancreatic duct 7. Hepato-pancreatic Ampulla of Vater 7 G – Gallbladder; D - Duodenum  SOM.MK.1.BMP2.3.DM.1.ANAT.1169, 1172 1 2 Arterial Cystic artery from R hepatic a. Venous Cystic veins (portal v.) Lymphatics Celiac trunk nodes Triangle of Calot Boundaries: Superior – Liver Lateral – Cystic duct Medial – Common hepatic duct Contents: Cystic artery