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Or, get it for Kobo Super Points! See if you have enough points for this item. Considers all worldwide opinions and approaches to management, and includes key data on surgical outcomes to better inform your clinical decision-making. Covers exactly what you need to know, balancing basic science with information on clinical practice. Presents cutting edge guidance on pathology, diagnostics, surgery and non-operative intervention of the liver, biliary tract, and pancreas in a single, comprehensive reference. Covers the most recent non-surgical therapies for pancreatic cancer, microwave ablation, and other emerging technologies. Brings you up to date with recent developments in transplantation, minimally invasive surgery, percutaneous devices, pre- and post-care, blood transfusion, and surgical techniques for the spleen.

The liver is divided into three main scissurae by the right, middle, and left hepatic vein branches. The intrahepatic branching of the right and left hepatic ducts, arteries and portal veins shown in the horizontal plane of the liver divides the liver into eight separate segments.

The caudate lobe Segment I is nei- ther part of the right or left lobe. Rather the caudate lobe receives venous and arterial branches from both the right and left side of the liver, and drains directly into the inferior vena cava. Aberrant segmental anatomy of the liver is uncommon. The presence of a di- minutive left lobe is the most common anomaly reported and is important only because it may serve as a limitation to the performance of extended right hepatecto- mies.

Hepatic Veins OUTFLOW The three major hepatic veins the right, middle and left comprise the main outflow tract for the liver, although additional veins of varying size are always present as direct communications between the vena cava and the posterior surface of Essential Hepatic and Biliary Anatomy for the Surgeon 5 Fig. Uniquely, the caudate lobe Segment I drains principally through direct communication with the retrohepatic cava. The hepatic veins lie within the three major scissurae of the liver dividing the parenchyma into the right anterior and posterior sectors, and the right and left lobes.

Anatomically, the main scissura separates the liver into right and left lobes. The left hepatic vein lies within the left scissura or the left segmental fissure in line with or just to the right of the falciform ligament. The right hepatic vein drains directly into the suprahe- 1 patic cava, while the middle and left hepatic veins coalesce to form a short common trunk prior to entry. The umbilical vein represents an additional alternative site of venous efflux.

It is located beneath the falciform ligament and eventually terminates in the left hepatic vein, or less commonly in the confluence of the middle and left hepatic veins.

Although the outline above should suffice as cursory knowledge of hepatic venous anatomy, it is far from exhaustive. For example, large accessory right hepatic veins are commonly found, and an appreciation of these structures on axial imaging can be important for operative planning.

If a large accessory right hepatic vein is present, it may be possible to divide all three major hepatic veins in the performance of an extended left hepatectomy. Most importantly, the surgeon embarking on hepatic resection should have a thorough knowledge of the internal course of the hepatic veins, as the danger posed by hepatic venous bleeding cannot be overestimated.

An accessory hepatic artery refers to a vessel that supplies a segment of liver that also receives blood supply from a normal hepatic artery. An aberrant he- patic artery is called a replaced hepatic artery as it represents the only blood supply to a specific hepatic segment. Precise knowledge of normal hepatic arterial anatomy is necessary to appreciate abnormal anatomy and will be the focus of this section.

The celiac artery arises from the aorta shortly after it emerges through the dia- phragmatic hiatus. The celiac trunk itself is typically very short and divides into the left gastric, splenic, and common hepatic arteries shortly after its origin. The common hepatic artery typically passes forward for a short distance in the retroperitoneum where it then emerges at the superior border of the pancreas and left side of the common hepatic duct.

After arising from the celiac axis, the common hepatic artery turns upward and runs lateral and adjacent to the common bile duct. The gastroduodenal artery that supplies the proximal duodenum and pancreas is typically the first branch of the common hepatic artery. The right gastric artery takes off shortly thereafter and con- tinues within the lesser omentum along the lesser curve of the stomach.

At this point the common hepatic artery is referred to as the proper hepatic artery. The proper hepatic artery courses towards the hilum and soon divides into the right and left hepatic arteries. Prior to the bifurcation, a small cystic artery branches off to provide blood supply to the gallbladder. While coursing through the hepatoduodenal ligament the hepatic artery proper, common bile duct, and portal vein are enveloped Essential Hepatic and Biliary Anatomy for the Surgeon 7 Fig.

Caudate lobe anatomy. The caudate lobe is situated to the left of the inferior vena cava IVC. The ligamentum venosum, a rem- nant of the fetal umbilical vein, courses across the anterior surface of the caudate lobe to enter the left hepatic vein. Small venous tributar- ies drain the caudate lobe directly into to the IVC.

On its medial surface, the caudate lobe is attached to the right liver by the caudate process. The proper hepatic ar- tery bifurcates earlier than the common bile duct and portal vein. The posterior sectoral branch initially runs horizontally through the hilar transverse fissure of Gunz normally present at the base of Segment V and adjacent to the caudate process. The left hepatic artery runs vertically towards the umbilical fissure where it gives off a small branch often called the middle hepatic artery to Segment IV, before continuing on to supply Segments II and III.

Additional small branches of the left hepatic artery supply the 8 Heptobiliary Surgery Fig. Normal celiac axis anatomy. The sectoral and segmental bile ducts and portal veins follow the course of the hepatic artery branches.

Intrahepatic branching of these structures will be discussed in more detail below.

The blood supply to the common bile duct is varied and multiple. Branches of the common hepatic, gastroduodenal, and pancreaticoduodenal arteries have all been shown to provide arterial supply at various levels.

Hepatic Arterial Anomalies Variations in the arterial blood supply to the liver are common. Although the hepatic artery typically arises from the celiac axis, complete replacement of the main hepatic artery or its branches occur with variable frequency. Similarly, duplication or accessory hepatic arterial branches, particularly an accessory left hepatic artery, may be more the norm than an anomaly. In this situation, the replaced right hepatic artery usually arises from the superior mesenteric artery and runs lateral and posterior to the portal vein within the hepatoduodenal liga- ment.

In rare instances, the entire common hepatic artery, or its indi- vidual branches may arise directly off the celiac trunk or aorta. Portal Venous Anatomy The portal vein is formed by a union of the superior mesenteric vein SMV and splenic vein behind the neck and body of the pancreas.

Hepatic arterial anomalies. Venous tribu- taries from the pancreas may also drain directly into the portal vein, and generally correspond to the arterial supply. More precisely, there are anterior, posterior, superior 10 Heptobiliary Surgery and inferior pancreatic vessels.

In addition, the left gastric vein and inferior mesen- teric vein typically drain into the splenic vein, but in rare instances these vessels may enter the portal vein directly. Surgical dogma states that there are no venous branches on the anterior surface of the portal vein and, for the most part this is true—most veins enter the portal vein tangentially from the side.

However, having paid homage 1 to surgical dogma, the reality is that small anterior venous branches may exist, and any manipulation posterior to the pancreatic neck and anterior to the portal vein should be performed with maximum operative exposure and care.

Access to the portal vein is typically obtained by identifying the superior mesen- teric vein on the inferior surface of the pancreas. In some circumstances it is neces- sary to first locate the middle colic vein within the transverse mesocolon and follow it inferiorly to the SMV.

Blumgart's Surgery of the Liver, Biliary Tract and Pancreas

The length of the SMV is highly variable, and may range from only a few millimeters up to 4 cm. In many circumstances the SMV is made up of two to four venous branches that coalesce shortly before joining the portal vein rather than a single dominant vein. The inferior pancreaticoduodenal vein, which can be quite prominent, is the only vein that normally enters the SMV di- rectly. Proper identification of this vein is necessary to avoid injury and often sub- stantial blood loss. All other pancreatic venous tributaries enter the portal vein rather than the SMV.

Once a determination has been made regarding the resectability of the pancreatic lesion, we favor early transection of the common bile duct.

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If the tumor later proves unresectable, a palliative end to side bilioenteric bypass can be performed. In addition to those variants described above, there are additional but rare congenital anomalies of the portal vein with which the surgeon should be aware. The importance of careful dissection around the portal vein cannot be overemphasized. Inadvertent injury or transection of the portal vein or a main tributary is difficult to correct and remains among the most lethal of surgical errors.

Intrahepatic Arterial and Portal Venous Anatomy Throughout the course of the liver, the sectoral and segmental bile ducts, hepatic arteries and portal venous branches run together. The Biliary Tract The extrahepatic biliary system consists of the extrahepatic portions of the right and left bile ducts that join to form a single biliary channel coursing through the posterior head of the pancreas to enter the medial wall of the second portion of the duodenum.

The gallbladder and cystic duct form an additional portion of this ex- trahepatic biliary system that typically joins with the terminal portion of the common Essential Hepatic and Biliary Anatomy for the Surgeon 11 hepatic duct to form the common bile duct. In most instances, the confluence of the right and left bile ducts lies to the right of the umbilical fissure and anterior to the right branch of the portal vein.

In contrast, the left hepatic duct has a relatively long extrahepatic course 1 cm along the base of the quadrate lobe Segment IV and enters the hepatic parenchyma at the umbilical fissure.

Lowering the hilar plate i. The common bile duct continues inferiorly positioned anterior to the por- tal vein and lateral to the common hepatic artery. This duct does not drain any specific area of the liver and never communicates with the gallbladder, but may be damaged during cholecystectomy and therefore contribute to postoperative biliary leak. Anomalies of the accessory biliary apparatus Gross described a number of anomalies of the accessory biliary apparatus in Furthermore, the gallbladder may be abnormally positioned, either lying deep within the liver parenchyma or lying under the left liver.

Surgical Management of hepatobiliary and pancreatic disorders 22 Figure 1. The union of the cystic duct with the common hepatic duct may be angular, parallel or spiral. Surgical anatomy of the liver and bile ducts 23 The arterial blood supply of the liver and bile ducts The hepatic artery The hepatic artery usually arises as one of the three named branches of the coeliac trunk along with the left gastric and splenic arteries Fig.

The first named branch of the hepatic artery is the gastroduodenal artery and either of these arteries may then give rise to the right gastric and retroduodenal arteries Fig. The hepatic artery then divides into right giving rise to the cystic artery and left hepatic arteries. In a small number of people other variations of these arrangements will occur Fig.

However, these variations will be readily apparent to an experienced surgeon at operation and the authors do not advocate preoperative visceral angiography to delineate these anomalies before routine hepatectomy. The blood supply of the extrahepatic biliary apparatus The extrahepatic biliary system receives a rich arterial blood supply, 46 which is divided into three sections.

The hilar section receive arterioles directly from their related hepatic arteries and these form a rich plexus with arterioles from the supraduodenal section. The Surgical anatomy of the liver and bile ducts 25 blood supply of the supraduodenal section is predominantly axial, most vessels to this section arising from the retroduodenal artery, the right hepatic artery, the cystic artery, the gastroduodenal artery and the retroportal artery.

Usually, eight small arteries, each 0. The most important of these vessels run along the lateral borders of the duct and are referred to as the 3 oclock and 9 oclock arteries. The retropancreatic section of the bile duct receives its blood supply from the retroduodenal artery.

The veins draining the bile duct mirror the arteries and also drain the gallbladder. This venous drainage does not enter the portal vein directly but seems to have its own portal venous pathway to the liver parenchyma. Although intraoperative ultrasound has made easier the location of dilated intrahepatic biliary radicals, surgical exposure of the extrahepatic biliary confluence and the segment III duct demands knowledge of precise anatomical landmarks.

Biliary-enteric anastomosis necessitates precise bile duct exposure to facilitate the construction of a mucosa to mucosa apposition. This manoeuvre will expose considerably more of the left hepatic duct than the right, which runs a shorter extrahepatic course. Contraindications to this approach include patients with a very deep hilum which is displaced upwards and rotated laterally, 36 and those patients who have undergone removal or atrophy of either the right or left livers resulting in hilar rotation.

In this situation the bile duct may come to lie behind the portal vein. Surgical Management of hepatobiliary and pancreatic disorders 26 Figure 1. The anatomy of biliary exposure When approaching the segment III duct segment III hepaticojejunostomy , follow the round ligament in which runs the remnant of the obliterated umbilical veins through the umbilical fissure to the point where it connects with the left branch of the portal vein within the recessus of Rex.

This junction may sometimes be deeply embedded within the parenchyma of the fissure. The bile ducts of the left liver are located above the left branch of the portal vein, whereas the corresponding arteries lie below the portal vein. Dissection of the round ligament on its left side allows exposure of either the pedicle or anterior branch of the duct from segment III.

This is achieved by mobilizing the round ligament and pulling it downwards, thereby freeing it from the depths of the umbilical fissure. This procedure usually requires the preliminary division of the bridge of liver tissue which runs between the inferior parts of segments III and IV. The umbilical fissure is then opened and with downward traction of the ligamentum teres an anterior branch of the segment III duct is exposed on its left side.

Sometimes it may be necessary to perform a superficial liver split to gain access to this duct. In the usual situation of chronic biliary obstruction with dilatation of the Surgical anatomy of the liver and bile ducts 27 intrahepatic bile ducts, the segment III duct is generally easily located above the left branch of the portal vein.

However, in the situation of left liver hypertrophy, it may be necessary to perform a more extensive liver split to the left of the umbilical fissure in order to widen the fissure to achieve adequate access to the biliary system.

Access to the right liver system is less readily achieved than to the left as the anatomy is more imprecise. However, intraoperative ultrasonography greatly enhances the ability of the surgeon to locate these ducts at surgery.

Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 6th Edition – Surgery Books

The ideal approach on the right side is to the segment V duct, 52 which runs on the left side of its corresponding portal vein. The segment V duct should lie relatively superficially on the left aspect of the portal vein to that segment. Key points A full understanding of the lobar, sectoral and segmental anatomy of the liver and biliary system is an essential prerequisite for successful liver surgery.

The surgeon must appreciate the wide variation in extrahepatic biliary anatomy. Glisson F. Anatomia hepatis.

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Beitrage zur Chirurgie der Leber. Arch Klin Chir Berlin ; Cattell RB. Successful removal of liver metastasis from carcinoma of the rectum. Lehey Clin Bull ; Wangensteen OH. The surgical resection of gastric cancer with special reference to: 1 the closed method of gastric resection; 2 coincidental hepatic resection; and 3 preoperative and postoperative management.

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Biliary tract. Edinburgh: Churchill Livingstone, Vol 5, Long term results of Roux-en-Y hepaticojejunostomy. A technique for construction of high biliary enteric anastomoses. Surg Gynecol Obstet p; Hepaticojejunostomy in benign and malignant bile duct stricture: approaches to the left hepatic ducts. Hepp J, Couinaud C, Labord et Lutilisation du canal hepatique gauche dans le reparations de la voie biliaire principale.

Smadja C, Blumgart LH. The biliary tract and the anatomy of biliary exposure. Surgery of the liver and biliary tract, 2nd edn. The glandular or acinar cells of the pancreas form the major part of the lining of the acini and are the most abundant cells within the exocrine lobule Fig. These cells are interspersed with epithelial cells which are cuboidal or flat and are termed centroacinar cells. The epithelial cell lined ductules drain the acini and coalesce to form intralobular and interlobular ducts.