Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_718_Библиотеки_им_академика_М_И_Перельмана
.pdf
4.The caudate lobe; It lies posterior to the porta hepatis. To its right is the groove for the inferior
vena cava. Above, it continues into the superior surface on the right of the upper end of the fissure
for the ligamentum venosum.
Fig.80: Lobes of the liver. Source [80].
Functional anatomical divisions:
The liver is divided into eight functional segments, based on the distribution of portal venous
branches in the parenchyma. The liver is divided into four portal sectors by the four main branches
of the portal vein. These are right lateral, right medial, left medial and left lateral.
Fissures of the liver:
1.Main portal fissure (Cantlie’s line); extends from the midpoint of the gallbladder fossa at the
inferior margin of the liver back to the midpoint of the inferior vena cava, and contains the middle
hepatic vein. It separates the liver into right and left hemi-livers.
2.The left portal fissure; extends from the midpoint of the inferior edge of the liver between the
falciform ligament and the left triangular ligament to the point that marks the confluence of the
left and middle hepatic veins, divides the left hemi-liver into medial (anterior) and lateral
(posterior) sectors. It contains the left hepatic vein.
3.The right portal fissure; extends diagonally through the anatomical right lobe from the lateral
end of the inferior border to the termination of the right hepatic vein. The fissure divides the right
anterior sector to its left (segments V and VIII) from the right posterior sector to its right (segments
VI and VII), and contains the right hepatic vein.
4.
The umbilical fissure (fissure for the ligamentum teres); separates segment III from segment IV
within the left medial sector and contains a major branch of the left hepatic vein (the umbilical
fissure vein), the umbilical portion of the left portal vein, segmental bile ducts converging to form
the left hepatic duct, and the terminal branches of the left branch of the hepatic artery.
70
5. The venous fissure (fissure for the ligamentum 67 venosum); is in direct continuity with the
umbilical fissure on the undersurface of the liver and contains the ligamentum venosum (the
obliterated ductus venosus). It lies between the caudate lobe and segment II.
6. The fissure of Gans (Rouvière’s sulcus); lies on the undersurface of the right lobe of the liver
behind the gallbladder fossa.
Sectors of the liver:
The right lateral sector = segments VI and VII.
The right medial sector = segments V and VIII.
The left medial sector = segments III and IV (and part of I).
left lateral sector = segment II.
I: Posterior segment.
II: Lateral segment.
III: Left anterior lateral segment.
IV: Medial segment.
V: Anterior medial segment.
VI: Right anterior lateral segment.
VII: Posterior lateral segment.
VIII: Posterior medial segment.
Fig.81: Segments and fissures of the liver. Source [81].
71
Peritoneal attachments and ligaments of the liver:
Falciform ligament: attaches the liver to the anterior abdominal wall.
The round ligament (ligamentum teres); is the obliterated remnant of the left umbilical vein.
The coronary ligament; attaches the liver and the diaphragm. In-between the two layers of the
coronary ligament lies a large triangular area of liver devoid of peritoneal covering; the Bare area
of the liver.
Triangular ligaments;
The left triangular ligament; Medially, the anterior leaf is continuous with the left layer of the
falciform ligament, and the posterior layer is continuous with the left layer of the lesser omentum.
The right triangular ligament; lies at the right lateral limit of the bare area of the liver.
The lesser omentum; extends between the stomach and the liver and contains the following
ligaments: Lig. Gastrophrenicum, Lig. Gastrosplenicum, Plica presplenica, Lig. Gastrocolicum,
Lig. Phrenicosplenicum, Lig. Splenorenal, Lig. Pancreaticosplenicum, Lig. Pancreaticocolicum,
Lig. Splenocolicum and Lig. Phrenicocolicum.
Ligamentum venosum; The obliterated venous connection that existed in the fetus between the left
branch of the portal vein and the termination of the left hepatic vein.
Fig.82: ligaments of the liver. Source [82].
The porta hepatis:
It is situated between the quadrate lobe anteriorly and the caudate process posteriorly, and contains
the portal vein, hepatic artery and hepatic nervous plexuses as they ascend into the parenchyma of
the liver, and the right and left hepatic ducts and some lymph vessels that emerge from the liver.
All these structures are enveloped within a perivascular sheath of loose connective tissue that is
continuous with the fibrous hepatic capsule (of Glisson).
Surgical importanc of the porta hehapits; Rapid control of the vessels entering the porta hepatis
(the hepatic pedicle) can be obtained by compressing them in the free edge of the lesser omentum;
Pringle’ manœuvre; this is conveniently done by dividing the lesser omentum immediately to the
left of these structures and passing a tape around them through the epiploic foramen.
72
Fig.83: The porta hepatis. Source [83].
The Glisson’s capsule (Valoean sheath’) or (Laenne’s capsule) :
Is a single fibrous condensed sheath around the branches of the portal triad structures as they enter
the liver parenchyma and subdivide into segmental branches.Within each sheath, the portal vein is
surrounded by loose areolar connective tissue.
Fig.84: The Glisson’s capsule. Source [84].
Blood supply of the liver:
1.Hepatic artery:
Origin; The coeliac trunk
Course; passes anteriorly and laterally above the upper border of the pancreas to the upper aspect
of the first part of the duodenum. It ascends anterior to the portal vein and medial to the bile duct
within the free margin of the lesser omentum in the anterior wall of the epiploic foramen.
Divisions;
1.Common hepatic artery, from the coeliac trunk to the origin of the gastroduodenal artery.
73
2. The ‘hepatic artery proper’, from that point to its bifurcation.
3.Right and left branches below the porta hepatis.
Branches;
The common hepatic artery divides into:
1.Right gastric artery.
2. Terminal branches;
A) Proper hepatic artery divides into:
1) Right hepatic artery, which gives the following branches:
1.Cystic artery.
2.Anterior segmental artery to the liver.
3.Posterior segmental artery of the liver.
4. Right artery of the caudate lobe.
2) Left hepatic artery, terminates inside the liver by dividing into medial and lateral segmental
branches.
B) Gastroduodenal artery: Branches.
1. supraduodenal artery.
2. Right gastroepiploic artery.
3. superior pancreaticoduodenal artery.
Fig.85: The hepatic artery. Source [85].
74
2.The portal vein:
Origin:
Is formed behind the neck of the pancreas, from the convergence of the superior mesenteric and
splenic veins at the transpyloric plane.
Course:
Ascends obliquely to the right behind the first part of the duodenum, the common bile duct and
gastroduodenal artery, and anterior to the inferior vena cava. It enters the right border of the lesser
omentum and ascends anterior to the epiploic foramen to reach the right end of the porta hepatis.
Length:
8 cm.
Termination:
Within the liver, it terminates into right and left main branches.
Tributaries:
A) Extrahepatic:
1. The left gastric (coronary) vein.
2. The right gastric vein.
3. The posterior superior pancreaticoduodenal vein.
4. Cystic veins.
5. Splenic vein.
6. Superior mesenteric vein.
7. Inferior mesenteric vein.
B) Intrahepatic:
1. The left portal vein; gives branches to segments I, II, III and IV.
2. The right portal vein; gives branches to segments V or VIII.
3. A right lateral (posterior) sectoral division supplying segments VI and VII.
4. A right medial division may give a branch to segment I
Fig.86: The portal vein. Source [86].
75
3.Hepatic veins:
1.Right hepatic vein:
Beginning:
The right hepatic vein is formed anteriorly near the inferior border of the liver and lies in a
coronal plane through most of its course.
Course:
The right hepatic vein runs in the right portal fissure between the right medial and lateral sectors.
Drains:
It drains the whole of segments VI and VII, and variable proportions of segments V and VIII.
Termination:
It drains into the inferior vena cava near the upper border of the caudate lobe.
2.Middle hepatic vein:
Course:
Lies in the main portal fissure between the right and left hemi-livers.
Drains:
The central part of the liver and receives constant tributaries from segments IV, V and VIII.
Termination:
It joins the left hepatic vein and terminates in the inferior vena cava as a short common trunk
(about 5 mm long).
3.Left hepatic vein:
lies between the left medial and left lateral sectors of the liver.
Drains segments II, III and, occasionally, IV.
4.Minor hepatic veins:
Segment I veins drain directly into the inferior vena cava and vary in number from one to five.
Fig.87: Hepatic veins. Source [87].
76
Lymphatic drainage:
A) Superficial lymphatics; run in subserosal areolar tissue over the surface of the liver and drain
into:
1. Lymphatics from the posterior surface drain into nodes alongside the inferior vena cava.
2. Lymphatics in the coronary and right triangular ligaments pass directly to the thoracic duct.
Lymphatics from the inferior, anterior and superior surfaces drain into the porta hepatis.
B) Deep hepatic lymphatics;
1. Porta hepatis.
2. Some lymphatics pass through the vena caval opening in the diaphragm and drain into
inferior mediastinal nodes.
3. Fine lymphatics within the portal triads and around interlobular veins merge to form larger
vessels.
Fig.88: lymphatic drainage of the liver. Source [88].
Innervation:
Dual innervation:
1.Hepatic parenchyma is supplied by vagal fibers which enter the liver at the porta hepatis.
2.The capsule is supplied by fine branches of the lower intercostal nerves, which also supply the
parietal peritoneum, particularly around the ‘bare area’ and superior surface.
The hepatic plexus;
Receives preganglionic parasympathetic fibers from the anterior and the posterior vagus, and
postganglionic sympathetic fibers via the coeliac and superior mesenteric plexuses.
Multiple fine branches from the plexus supply the extrahepatic bile ducts and gallbladder,
contribute to the supply of the pylorus, proximal duodenum, pancreas and the stomach
77
Fig.89: Innervations of the liver. Source [89].
b
Peritoneal coverings: The liver is covered by peritoneum expect for:
1.The porta hepatis.
2. The dorsal surface adjoining the diaphragm (area nuda) or (bare area).
Skeletopy:
The Skeletopy of the liver (Table15):
Limit Rt.
Paravertebral
line
Superior X rib VIII rib 4th intercostal
Midaxillary
line
Midclavicular
Line
space.
Parasternal
line
Cartilage
of the V rib
Median
line
A little
upwards
of the
Lt.
parasternal
line
th
5
intercostal
space.
xiphoid
process
Inferior
10th
intercostal
space
9th
intercostal
space
asis.
The
midline
between
Cartilage
of the VI
rib.
umbilicus
and
xiphoid
process
Syntopy:
1. Superiorly; The diaphragm
2. Posteriorly; X and XI thoracic vertebra, diaphragmatic crura, aorta, IVC and (bare area) is
related to the posterior abdominal wall.
3. Anteriorly; The diaphragm and the ALAW.
4. Inferiorly; Lesser gastric curvature, first part of the duodenum, superior pole of the rt. Kidney
and adrenal gland and the GB.
78
Fig. 90: Syntopy of the liver. Source [90].
Holotopy:
The liver projects into:
1. Right hypochondriac region.
2. Proper epigastric region.
3. Small part of the left hypochondriac region.
2) The gall bladder:
The gall bladder usually lies in a shallow fossa (the gallbladder bed) on the visceral surface of the
right lobe of the liver. Rarely, the gallbladder is almost completely buried within the liver
(intrahepatic gallbladder), or suspended from the liver by a peritoneal mesentery (when it is at risk
of torsion;), or connected to the duodenum by an extension of the free edge of the lesser omentum
(cystoduodenal ligament).
Parts of the gall bladder:
1.The neck: close to the porta hepatis, has a short peritoneal attachment (mesentery) to the liver,
which contains the cystic artery. The neck usually lies anterior to the second part of the duodenum.
2.The body: The body of the gallbladder normally lies in contact with the visceral surface of the
liver and lies anterior to the second part of the duodenum and the right end of the transverse colon.
3.The fundus: usually projects past the inferior border of the liver to a variable extent. Here, it
frequently lies in contact with the anterior abdominal wall behind the ninth costal cartilage, where
the lateral edge of the right rectus abdominis crosses the costal margin. The fundus commonly lies
adjacent to the transverse colon.
79
Соседние файлы в папке Библиотека им академика М.И. Перельмана