Anatomy of the Liver, Pancreas and Spleen (M.D. Program 2024) PDF

Anatomy of the Liver, Pancreas and Spleen M.D. Program 2024 Presented by: SEAN LAL  Liver, Pancreas and Spleen Learning outcomes: To understand the location and relationship of the liver including its peritoneal relationships To dra...

Anatomy of the Liver, Pancreas and Spleen M.D. Program 2024 Presented by: SEAN LAL  Liver, Pancreas and Spleen Learning outcomes: To understand the location and relationship of the liver including its peritoneal relationships To draw the liver labeling external features, peritoneal attachments and structural and functional lobes To describe the blood supply of the liver and name the structures that pass through the porta hepatis To describe and draw the extrahepatic biliary system and its significant relationships To draw and describe the pancreas, its external features, ducts and relationship to the greater and lesser sacs. To describe the location, features and relationships of the spleen  The Liver Riedel’s lobe (on palpation may be mistaken for kidney or gallbladder) Just below nipple on right, about fingerbreadth below left Fundus of Gallbladder Variations in size and shape Netter, F., Interactive Atlas of Anatomy on CD, Basmajian, J.V., Primary Anatomy, Ceiba-Geogy Corporation, New Jersey. 8th Edn, Williams and Wilkins, Baltimore. The liver is the largest organ in the body (1.5 kg); wedge-shaped; dark reddish brown (reflects its vascularity) Contains thin fibrous capsule (of Glisson) Location: right hypochondrium, epigastrium & into left hypochondrium Normally not palpable as it is covered by the ribcage, or in midline by the rectus abdominis muscle Relationships liver to pleural cavity Netter, F. (1995), Interactive Atlas of Anatomy on CD, Ceiba- Geogy Corporation, New Jersey. in midaxillary line Pleura Lung Liver Rib 6 Lung Rib 7 Rib 10 Rib 11 Costodiaphragmatic recess of pleural cavity Pleural cavity Through the diaphragm, the liver is related to the right & left pleural cavities, the lungs and the pericardium of heart A penetrating wound may lacerate the liver ( intra-abdominal bleeding) and penetrate pleura ( pneumothorax, haemothorax) Liver biopsy (interest only): Should be performed at the level of 10th intercostal space  below level of pleura Breathe out fully  diaphragm rises and reduces the costodiaphragmatic recess and the risk of damaging pleural cavity or lung  Diaphragmatic & Visceral Surfaces Liver Diaphragm Superior Post Liver K D Inferior border (sharp edge, soft regular margin) Sagittal Diaphragmatic surface has right, superior, anterior and posterior parts with no defined demarcation Visceral surface is in contact with viscera & faces down and back. Diaphragmatic and visceral surfaces meet anteriorly at a sharp inferior border – not normally palpable. May become palpable with deep inspiration or liver enlargement or in patients with emphysema (diaphragm at lower resting level) Rosse, C. & Gaddum-Rosse, P, Hollinhead’s Textbook Of Moore, K.L. & Dalley, A.F., Clinically Oriented Anatomy, 5th Edn, Lippincott Williams & Wilkins, Philadelphia. Anatomy, 5th Edn, Lippincott-Raven Publishers, Philadelphia.  Visceral Surface of the Liver Oesophagus IVC Bare area Right suprarenal gland Stomach Right kidney Pylorus of stomach Duodenum Transverse Gallbladder Right colic flexure colon Posterior-Inferior view with visceral relationships Visceral surface of liver is related to oesophagus, stomach, duodenum, transverse colon, right colic flexure, right suprarenal gland & right kidney Images from Scheunke, M et al, Thieme Atlas of Anatomy: Neck and Internal Organs, Thieme, Stuttgart Modified from Basmajian, J.V., Primary Anatomy, 8th Edn, Williams and Wilkins, Baltimore.  Liver – External Features – Anterior Ligamentum teres Umbilicus Falciform ligament - demarcates left and right anatomical lobes - double layer of peritoneum reflecting from liver to diaphragm and anterior abdominal wall to level of umbilicus Ligamentum teres is a thickening in lower free edge of falciform ligament (fibrous remnant of umbilical vein) Moore, K.L. & Dalley, A.F., Clinically Oriented Anatomy, 5th Edn, Lippincott Williams & Wilkins, Philadelphia. Snell, R.S. 1995, Clinical Anatomy For Medical Students, 5th Edn, Little, Brown and Company, Boston.  Liver – External Features – Posteroinferior Groove for IVC H C Q Porta hepatis (hilum) Fissure for ligamentum venosum Fissures Fossa for Fissure for ligamentum teres gallbladder Drake, R et al,, Gray’s Anatomy for Students, Elsevier Inc. H-shaped region postero-inferiorly formed on left side by fissures for ligamentum teres and ligamentum venosum and on right side by groove for IVC and fossa for gallbladder Cross-bar of H is porta hepatis (region where vessels, nerves and ducts enter or leave) Above cross bar is caudate lobe, below is the quadrate lobe  Functional / Physiological Lobes Left Bailey and Love’s Right functional Short Practice of Surgery, 25th edn 2004 functional lobe lobe Portal triad Netter, F. (1995), Interactive Atlas of Anatomy on CD, Ceiba-Geogy Corporation, New Jersey. Segments of the liver Proper hepatic artery Common hepatic Portal vein Gray’s Anatomy, 40th Edn, Standring, S Editor, Churchill Livingstone duct Left & right functional lobes: Approximate line of division through IVC and gallbladder (more equal in mass than anatomical lobes) Receive left and right branches of proper hepatic artery & portal vein (bile from each functional lobe drains to left & right hepatic ducts) Eight liver segments: 4 sectors - based on branches of portal vein Then each sector is sub-divided into segments (usually two) based on their supply by tertiary divisions of the portal triad  Peritoneal Relationships of Liver Anterior coronary ligament Attachment of lesser omentum (to fissure for ligament venosum and porta hepatis Hepatorenal recess (pouch of Morrison) - Commonly infected space in abdominal cavity - Communicates with right subphrenic space, lesser sac and right paracolic gutter Drake, R et al, Gray’s Anatomy for Students, Elsevier Inc. Liver is “intraperitoneal” and covered by peritoneum, except at bare area & attachments of lesser omentum and fossa for gallbladder Anterior and posterior coronary ligaments reflect from liver to diaphragm; between them is the bare area of the liver Lymph vessels from bare area pass through diaphragm to thoracic nodes, remainder pass via porta hepatis to coeliac nodes  cysternal chyli  Key Points The liver contains a thin fibrous capsule (of Glisson) and is located at the right hypochondrium, epigastrium and left hypochondrium. In the mid-axillary line, the liver extends from ribs 6 to 11. Its diaphragmatic and visceral surfaces meet at the inferior margin, which may just be palpable below the right costal margin. The visceral surface of the liver is related to the stomach, duodenum, right colic flexure, right suprarenal gland & right kidney. Ligamentum teres (fibrous remnant of the umbilical vein) is a thickening in the lower free edge of the falciform ligament. The falciform ligament divides the liver into the left and right anatomical lobes. There is a H-shaped region postero-inferiorly on the liver, which is formed on the left side by fissures for ligamentum teres and ligamentum venosum and on the right side by the groove for the IVC and the fossa for the gallbladder. The crossbar of the H is the porta hepatis (hilum). Above the cross bar is the caudate lobe and below it is the quadrate lobe. The liver is “intraperitoneal” and covered by peritoneum, except at the bare area & at the attachments of the lesser omentum and fossa for gallbladder. The anterior and posterior coronary ligaments meet at the left and right triangular ligaments.  Extrahepatic Biliary System Tank, PW, Grant’s Dissector, 14th Edn, Lippincott, Williams and Wilkins Extrahepatic biliary system is the part of the biliary system outside the liver. It comprises of the gallbladder, cystic duct, left & right hepatic ducts, common hepatic duct and bile duct. Bile duct joins main pancreatic duct  forms hepatopancreatic ampulla (ampulla of Vater) and is surrounded by hepatopancreatic sphincter (sphincter of Oddi). It opens into duodenum at the major duodenal papilla. Course of bile duct: 1. supraduodenal – in hepatoduodenal ligament, 2. retroduodenal - behind 1st part of duodenum, 3. infraduodenal - within or behind head of pancreas, 4. intraduodenal - in wall of 2nd part of duodenum. Causes of obstruction of the bile duct with jaundice, include gallstones and cancer of head of pancreas.  Pancreas – Ducts (of Santorini) (of Wirsung) Drake, R et al, 2005, Gray’s Anatomy for Students, Elsevier Inc. Sphincter Gallstone in of Oddi hepatopancreatic ampulla (of Vater) Opening on major duodenal papilla Main pancreatic duct joins bile duct, forms hepatopancreatic ampulla and opens at tip of major (greater) duodenal papilla Accessory pancreatic duct opens at tip of minor (lesser) duodenal papilla (2 cm superior & anterior to major duodenal papilla) Narrowest point along bile duct is opening into duodenum  obstruction by gallstone  backflow of bile into main pancreatic duct  activation of pancreatic enzymes  autodigestion (acute pancreatitis) http://www.nim.nih.gov/medlineplus/ency/article/003893.htm Skandalakis, J.E. et. al, Surgical Anatomy: The Embryonic and Anatomic Basis of Modern Surgery. McGraw Hill, New York  Pancreas IVC Spleen Portal vein Bile duct Left kidney Duodenum Main pancreatic duct Accessory pancreatic duct SMA SMV Uncinate process Hepatopancreatic ampulla Gray’s Anatomy, 40th Edn, Standring, S Editor, Churchill Livingstone The Pancreas is the largest of the digestive glands; it has a firm lobulated, surface Pancreas is associated mainly with foregut  epigastric pain Function: endocrine & exocrine Pancreas is also retroperitoneal  refers pain to back Pancreas is retroperitoneal, except for the tail, which lies within the splenorenal ligament Located on the posterior abdominal wall between duodenum and spleen Head is within the curve of the 1st to 3rd parts of the duodenum, to the right of the midline Uncinate process is the part of the head posterior to SMV (and SMA) The body passes up and to the left, anterior to the splenic vein and left renal vein Pancreas curves around vertebral column and passes posteriorly as it ascends towards spleen (it is not in a straight plane)  Revise: Venous drainage IVC Hepatic vein Liver Spleen Portal vein Sinusoids of liver Portal vein SMV Splenic vein Splenic vein IMV Faiz, O et al, 2002, Anatomy at a Glance, IMV Blackwell Science Part of pancreas resected to show the formation of SMV the portal vein posterior the neck of the pancreas Netter, F., Interactive Atlas of Anatomy on CD, Indicates variations in termination of IMV Ceiba-Geogy Corporation, New Jersey. Nutrients and products absorbed by the GIT drain first to the liver for processing. The gastrointestinal tract drains by the portal vein to the liver. The liver in turn drains by 2-3 hepatic veins to the inferior vena cava (IVC). Venous drainage of parts of the gut is similar to the arterial supply (with some exceptions): Foregut-derived structures drain via splenic vein Midgut-derived structures drain via superior mesenteric vein Hindgut-derived structures drain via inferior mesenteric vein Exceptions to the rule: Some foregut structures drain to the superior mesenteric vein or drain directly into the portal vein. The liver (a foregut-associated organ) drains to the IVC via hepatic veins.  1. left gastric, 2. coeliac trunk, 3. splenic a., 4. SMA, 5. jejunal brs, 6. right colic, 7. inferior pancreaticoduodenal a., 8. common hepatic, 9. middle colic, 10. SMA (giving off jejunal branches to the left), 11. IMA, 12. left colic, 14 13. sigmoidal, 14. superior rectal, 15. SMA (giving off ileal branches), 16. ileocolic, 17. R colic, 18. inferior pancreatic duodenal Corporation, New Jersey. Atlas of Anatomy on CD, Ceiba-Geogy Modified from Netter, F., Interactive 5 6 4 7 15 13 8 16 12 17 11 18 3 2 1 10 9 Test yourself - name these arteries Revise: Arterial supply  Pancreas – relationship to vessels Coeliac trunk Posterior view Portal vein SMA Sagittal Splenic vein Splenic Coeliac trunk artery Splenic artery Splenic Splenic vein posterior to vein Bile duct pancreas SMA originating posterior to pancreas Inferior mesenteric vein Pancreatico- duodenal arteries Uncinate process Left renal vein Commencement of Duodenum (3rd part) SMA passing anterior SMA SMA passing anterior posterior to pancreas SMV portal vein behind neck of pancreas Splenic artery runs a tortuous course to the spleen, superior to body of pancreas to the spleen Netter, F. (1995), Interactive Atlas of Anatomy on CD, SMA originates from aorta, behind pancreas but then passes anterior to uncinate process Ceiba-Geogy Corporation, Pancreaticoduodenal arteries in the head of pancreas supply pancreas & duodenum. New Jersey. Splenic vein runs posterior to tail and body and joins SMV behind neck of pancreas to form portal vein IMV (usually) joins splenic vein behind body of pancreas Pancreatitis may cause thrombosis of nearby veins  Key Points The left & right hepatic ducts form the common hepatic duct, which together with the cystic duct (from the gallbladder) form the bile duct. The bile duct joins the main pancreatic duct to form the hepatopancreatic ampulla (ampulla of Vater), which opens into the duodenum at the major duodenal papilla. The pancreas is retroperitoneal (secondarily retroperitoneal), except for the tail, which lies within the splenorenal ligament. It is located on the posterior abdominal wall. The head of the pancreas is within the curve of the 1st to 3rd parts of the duodenum, to the right of the midline. The uncinate process is the part of the head posterior to the SMV (and SMA). The splenic artery runs a tortuous course to the spleen, superior to the body of the pancreas. The splenic vein runs posterior to the tail and body of the pancreas and joins the SMV behind neck of pancreas to form the portal vein. The IMV (usually) joins the splenic vein behind the body.  Spleen Images from Scheunke, M et al,, Thieme Diaphragmatic surface Visceral surface with impressions Atlas of Anatomy: Neck and Internal Organs, Thieme, Stuttgart The spleen is part of the lymphatic system but is described with GIT because of common blood supply. Function: blood filter, reservoir for RBCs & platelets, production of lymphocytes & antibodies, removal of old RBCs Soft, red, has thin fibroelastic capsule, easily ruptured especially if enlarged (e.g., sudden increase in intraabdominal pressure in MVA) Located in left hypochondrium, posterior to midaxillary line Related to ribs 9, 10, 11 through diaphragm; long axis of spleen is oblique and parallel to rib 10  Spleen – Visceral surface Posterior end Superior border Gastrosplenic (gastrolienal) ligament (containing short gastric and left gastroepiploic vessels) Splenorenal (lienorenal) ligament Inferior (containing tail of border pancreas and splenic vessels) Anterior end Moore, K.L. & Dalley, A.F., Clinically Oriented Anatomy, 5th Edn, Basmajian, J.V. & Slonecker, C.E., Grant’s Method Of Lippincott Williams & Wilkins, Philadelphia. Anatomy, 11th Edn, Williams & Wilkins, Baltimore. The spleen is intraperitoneal (it is almost completely invested in peritoneum) The superior border is notched, and when the spleen is enlarged, the notch between the anterior and superior borders may be palpable The visceral surface has a hilum (where peritoneal ligaments attach) & impressions made by stomach, colon and left kidney (gastric, colic & renal impressions); the tail of the pancreas is close to, or in contact with, the spleen at the hilum, and within the splenorenal ligament  Spleen – Visceral surface Gastric impression Images from Scheunke, M et al, 2010, Thieme Atlas of Anatomy: Neck and Internal Organs, Thieme, Stuttgart Visceral surface: stomach (gastric impression): left colic flexure (colic impression), left kidney (renal impression), +/- tail of pancreas  Clinical Anatomy Full expiration Neutral respiratory position Inspiration (liver moves vertically with breathing) Liver & spleen palpable in infant Inferior margin of liver Images from Moore, K.L. & Dalley, A.F. 2006, Clinically Oriented Anatomy, 5th Edn, Lippincott Williams & Wilkins, Philadelphia, except line diagram from Snell, R.S. 1995, Clinical Anatomy For Medical Students, 5th Edn, Little, Brown and Company, Boston. Middle image: Eizenberg, N., Briggs, C, Adams, C. & Ahern, G. (2007) General Anatomy: Principles and Applications, Anatomedia, McGraw-Hill, Sydney Supine  diaphragm higher, liver may be felt with deep inspiration Notched border of spleen palpable beyond left costal margin if enlarged by about 1.5-3 times Murphy’s sign – patient breathes out; examiner’s hand presses under right costal margin; patient instructed to breathe in; patient Spleen moves obliquely towards umbilicus with catches breath on inspiration if gallbladder is inflamed inspiration (left kidney move vertically)  Key Points The spleen is intraperitoneal and located in the left hypochondrium, posterior to the midaxillary line. It is related to ribs 9, 10, 11 through the diaphragm with its long axis parallel to rib 10. The superior border of the spleen is notched, and when the spleen is enlarged, the notch between the anterior and superior borders may be palpable. The spleen moves obliquely towards the umbilicus with inspiration (left kidney moves vertically) The visceral surface has a hilum (where peritoneal ligaments attach), in addition to impressions made by the stomach, colon and left kidney (gastric, colic & renal impressions respectively). The gastrosplenic ligament contains the short gastric and left gastroepiploic vessels. The splenorenal ligament contains the tail of the pancreas and the splenic vessels. The following slides are for clinical interest…..  Spleen – surface anatomy Spleen Lungs and pleura Lung Spleen Left Kidney Parietal Stomach Spleen pleura Left Kidney Left Ureter Left colic flexure L & middle image: Moore, K.L. & Dalley, A.F. 2006, Clinically Oriented Midaxillary line Anatomy, 5th Edn, Lippincott Williams & Wilkins, Philadelphia. Eizenberg, N., Briggs, C, Adams, C. & Ahern, G. (2007) General Anatomy: Principles and Applications, Anatomedia, McGraw-Hill, Sydney Located in left hypochondrium, posterior to midaxillary line Relationships of spleen: Visceral surface: stomach, left colic flexure, left kidney, and in some cases, tail of pancreas Diaphragmatic surface: diaphragm, and through the diaphragm, the left pleural cavity and ribs 9-11  Accessory Spleen & Splenectomy Stomach Accessory spleen present in 10% of population (splenunculus) Spleen Left kidney © University of Sydney, 2006, Photographer Roland Smith Clinical significance for splenectomy: Patient should be assessed presurgically for the presence of an accessory spleen(s). If undetected, an accessory spleen can enlarge after a therapeutic splenectomy.  (embryology) Romanes, GJ, 2010, Cunningham’s Manual of Practical Anatomy, Vol 2, 15th Edn, Oxford Medical Publications. Schematic diagram of the developing liver, Moore, K.L. & Dalley, A.F. 2006, Clinically Oriented Anatomy, 5th Edn, Lippincott Williams & Wilkins, Philadelphia. showing umbilical cord and umbilical vein in the lower free edge of falciform ligament Ligamentum teres & ligamentum venosum are the fibrous remnants of umbilical vein & ductus venosus of foetus respectively. They are continuous with each other & connect to the left branch of portal vein at porta hepatis. In the foetus, the umbilical vein brought oxygenated blood from the placenta to liver. The ductus venosus was a shunt by which oxygenated blood in umbilical vein bypassed the liver & passed directly to IVC then right atrium.  Abscess in spaces related to Liver Fluid may collect, or abscesses may form, in peritoneal spaces related to the liver Prior to the introduction of ultrasound and CT it was difficult to determine the location of an abscess Symptoms of abscess include swinging pyrexia Examples of abscesses on right side Skandalakis, J.E. et. Al, 2004, Surgical Anatomy: The Embryonic and Anatomic Basis of Modern Surgery. McGraw Hill, New York Examples of abscesses on left side  Hepatic veins are in rigid canals that cannot contract to Blood Supply to Liver stem bleeding when liver is Hepatic veins drain into IVC In congestive heart lacerated failure, blood can flow back into IVC  hepatomegaly Liver segments (8)  segmentectomy, lobectomy Central vein Sinusoids Portal Triad Common Proper hepatic artery Fibrous capsule hepatic duct Portal vein (of Glisson) extends into liver around Toxic vessels portal triad effects Hepatocyte Oxygen Liver has a dual blood supply: damage deprivation 1. proper hepatic artery (oxygenated blood to liver) 2. portal vein (poorly oxygenated blood, nutrients & toxins absorbed from GIT) All images from Netter, F. (1995), Interactive Atlas of Anatomy on CD, Ceiba-Geogy Corporation, The venous drainage of the liver is by 2-3 large hepatic veins into the IVC New Jersey.  Metastatic spread to the Liver umbilicus 2. Portal Hypertension 1. Metastatic Spread to Liver a. Oesophageal varices (danger of rupture  upper GI bleed) Liver Spleen IVC Aorta Stomach Tumours may metastasize to the liver liver via the portal vein, eg. cancer of spleen pancreas or stomach, or colorectal cancer Portal hypertension (increased b. Splenomegaly pressure in portal vein, eg liver (due to congestion cirrhosis) may lead to oesophageal varices, splenic enlargement, caput of splenic vein) medusa (visibly enlarged veins radiating from umbilicus) and haemorrhoids Upper L image, http//:www3.hku.hk/surgery/ugi.php Upper R images from Moore, K.L. & Dalley, A.F. 2006, Clinically Oriented Anatomy, 5th Edn, Lippincott Williams Netter, F. (1995), Interactive Atlas of & Wilkins, Philadelphia. Lower R image Anatomy on CD, Ceiba-Geogy http://www.hemorrhoids.org/bleeding-hemorrhoids.html Corporation, New Jersey. c. Caput Medusae Splenomegaly image: Bailey and Love’s Short Practice of d. Haemorrhoids Surgery, 25th edn 2004  Portosystemic Shunts http//:nim.nih.gov/medlineplus/ency/impagepages/19859.htm (liver cirrhosis) Portal vein Splenic vein L. Renal vein IVC Both veins are located posterior to pancreas Portal vein is anterior to IVC at epiploic foramen TIPS (Trans jugular intrahepatic portasystemic shunt) – stent inserted via right internal jugular vein  SVC  r. atrium  IVC  Moore, K.L. & Dalley, A.F. 2006, Clinically Oriented Anatomy, 5th Edn, Lippincott Williams & Wilkins, Philadelphia. hepatic vein in liver The diagrams above show how surgeons use the knowledge of anatomical relationships to create portosystemic shunts Complications of severe liver disease caused by portal hypertension include: bleeding from oesophageal varices and accumulation of fluid in the abdomen (ascites). The pressure in the portal system may be relieved by creating a ‘portasystemic’ shunt to the IVC or its tributaries. For example: the portal vein may be anastomosed to the IVC or the splenic vein anastomosed to the left renal vein (both are close to each other behind the pancreas) or an intrahepatic shunt - hepatic vein connected to an intrahepatic branch of portal vein (TIPS) via a stent Following bowel perforation with pneumoperitoneum, the liver outline is visible on plain radiographs (outlined by gas) Lateral decubitus, right side up Supine http://www.imagingpathways.health.wa.gov.au Extrahepatic Biliary System - Variations Variations in ducts Phrygian cap (folded fundus) Skandalakis, J.E. et. Al, 2004, Surgical Anatomy: The Embryonic and Anatomic Basis of Modern Surgery. McGraw Hill, New York Hartman’s pouch (pathological) Mulholland, MW, et al (editors), 2006, Greenfield’s Surgery, Bile duct within or behind head of pancreas 4th edn, Lippincott, Williams and Wilkins Bile duct Long cystic duct running parallel to Duodenum common hepatic (2nd part) duct, short bile duct Head of pancreas Skandalakis, J.E. et. Al, 2004, Surgical Anatomy: The Embryonic and Anatomic Basis of Modern Surgery. McGraw Hill, New York Moore, K.L. & Dalley, A.F. 2006, Clinically Oriented Anatomy, 5th Edn, Lippincott Williams & Course of bile duct has implications wrt to jaundice e.g., blockage of bile duct from Wilkins, Philadelphia. gallstone or cancer of head of pancreas GB Surgery – many variations in blood supply Moore, K.L. & Dalley, A.F. 2006, Clinically Oriented Anatomy, 5th Mulholland, MW, et al (editors), 2006, Greenfield’s Surgery, 4th edn, Lippincott, Williams and Wilkins Edn, Lippincott Williams & Wilkins, Philadelphia. (above& top R)  Gallbladder Surgery – Calot’s Triangle Liver Cystic artery Cystic duct Haemorrhage during gallbladder surgery may be stemmed by compressing proper Common hepatic duct hepatic a. in free edge of lesser omentum. Moore, K.L. & Dalley, A.F. 2006, Clinically Oriented Anatomy, 5th Bile duct Edn, Lippincott Williams & Wilkins, Philadelphia. Identify on Netter image: Coeliac trunk L gastric artery Splenic artery Common hepatic artery Property hepatic artery L & right brs of proper hepatic artery Portal vein Gastroduodenal artery Superior pancreaticoduodenal aa (ant & post brs) Netter, F. (1995), Interactive Inferior pancreaticoduodenal artery (ant & post brs) Atlas of Anatomy on CD, Ceiba- Superior mesenteric artery & vein (anterior to uncinate process) Geogy Corporation, New Jersey. Calot’s triangle (hepatocystic triangle) – bordered by cystic duct, common hepatic duct and liver. Contains: cystic artery (ligated in cholecystectomy). Significance: boundaries are identified in gallbladder surgery. Cystic artery (usually) arises in triangle – identified and ligated, together with cystic duct in cholecystectomy. Important not to damage common hepatic duct or bile duct during gallbladder removal. Errors may arise from lack of appreciation of the many anatomical variations of biliary system & its blood supply. Lymph node (of Lund) that drains gallbladder is located here and may be removed during cholecystectomy.  Blockage of Bile Duct ERCP (Endoscopic Retrograde CholangioPancreatography) A gallstone lodged in hepatopancreatic ampulla (gives direct line of vision, can inject dye / remove stone) may also block the main pancreatic duct  pancreatitis Series of diagrams from http://www.nim.nih.gov/medline plus/ency/article/003893.htm Bile duct blocked by cancer of head of pancreas Sphincterotomy enlarges the opening  allow stone to pass through – stent inserted to hold bile duct open  Pancreas – Development Pancreas develops as a dorsal and ventral pancreatic bud which later join. Developmental anomaly: pancreas may come to surround the duodenum  annular pancreas  duodenal obstruction Uncinate process (ventral bud) comes to lie posterior to the superior mesenteric vessels. Pancreas becomes secondarily retroperitoneal (except tail). Note the avascular plane of fusion. Annular Pancreas Stomach Annular portion of Pancreas pancreas Duodenum http://www.nim.nih.gov/medlineplus/ency/article/001142.htm Skandalakis, J.E. et. Al, 2004, Surgical Anatomy: The Embryonic and Anatomic Basis of Modern Surgery. McGraw Hill, New York Forms Ventral bud Dorsal bud the uncinate Skandalakis, J.E. et. Al, process 2004, Surgical Anatomy: The Embryonic and Anatomic Basis of Early development Late Modern Surgery. McGraw Hill, New York Basmajian, J.V. & Slonecker, C.E. 1989, Grant’s Method Of Anatomy, 11th Edn, Williams & Wilkins, Baltimore.  Pancreas & ducts Neck Cystic duct Right hepatic Body duct Lipid rich food in duodenum Left hepatic duct promotes CCK secretion into Right lobe liver bloodstream  gallbladder contracts & Fundus of sphincters around distal gallbladder bile & pancreatic ducts Spleen relax  bile and pancreatic enzymes pass into Accessory pancreatic duct duodenum (of Santorini) Normal absorption of fat requires 1. bile (via bile duct  Minor duodenum) Body Tail duodenal papilla 2. pancreatic enzymes (via Bile duct Neck pancreatic ducts  Second part duodenum duodenum) 3. normal intestine. Uncinate process Major duodenal papilla Main pancreatic duct Fat malabsorption  (of Wirsung) steatorrhoea (passage of pale, Head of pancreas bulky, malodorous stools) Modified from Snell, R.S. 1995, Clinical Anatomy For Medical Students, 5th Edn, Little, Brown and Company, Boston R image,. Pancreas – Variations in duct system Bailey and Love’s Short Practice of Surgery, 25th edn 2004 Ellis, H, 2006, Clinical Anatomy, 11th Edn, Blackwell publishing The pancreas develops as two parts that later join. The ducts of each part may join in a variable fashion. Note that the lesser duodenal papilla may sometimes be absent (b, d)  Intrahepatic Biliary System Bile canaliculi Tank, PW, 2009, Grant’s Dissector, 14th Edn, Lippincott, Williams and Netter, F. (1995), Interactive Atlas of Anatomy on CD, Ceiba- Wilkins Geogy Corporation, New Jersey. Faiz, O & Moffat, D, 2002, Anatomy at a Glance, Blackwell Science  COMMONWEALTH OF AUSTRALIA Copyright Regulation WARNING This material has been reproduced and communicated to you by or on behalf of the University of Sydney pursuant to Part VB of the Copyright Act 1968 (the Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of this material by you may be the subject of copyright protection under the Act. Do not remove this notice