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TheInferiorVenaCa va &thehepatobiliary system Victoria Brown vbrown14@qub.ac.ukLearningoutcomes IDENTIFY THE INFERIOR VENA DESCRIBE THE COURSE AND CAVA AND THE TRIBUTARIES RELATIONS OF THE INFERIOR OF THIS VESSEL VENA CAVA IDENTIFY AND DESCRIBE THE ANATOMY AND RELATIONS OF THE LIVER AND GALLBLADDER DESCRIBE THE PORTO- SYSTEMIC ANASTOMOSES DESCRIBE THE HEPATIC BETWEEN THE PORTAL AND PORTAL SYSTEM OF VEINS SYSTEMIC VENOUS SYSTEMS InferiorV enaCa va oCommon point of venous drainage of structures below the. diaphragm oBrings deoxygenated blood to the right atrium of the heart oCourse Inferior vena cava • Formed by union of the common iliac veins • Vertebral level L5 • Ascends superiorly • Leaves abdomen via the caval hiatus (T8 level) Common iliac vein • Located on posterior abdominal wall • Anterior to the vertebral column • To the right of the abdominal aorta 16/02/2023 IVC & hepatobiliary system 3RelationsoftheIVC • Aorta & cisterna chyli • IVC is on the right of these structures • R. sympathetic trunk and R ureter • IVC is on the left of these structures • Liver, duodenum and pancreas • IVC passes posteriorly • Portal triad (lesser omentum ) • IVC passes anteriorly • R. gonadal artery & R. common iliac artery • IVC passes anteriorly • R. renal artery and azygous vein • IVC passes anteriorly 16/02/2023 IVC & hepatobiliary system 4 •No tributaries from spleen, pancreas, gallbladder or the abdominal part of the TributariesoftheIVC GI tract • Common iliac veins •Drain to portal-venous system • Formed by external & internal iliac v. •Drain to IVC via the hepatic veins • Lumbar veins • R. suprarenal vein • Drains posterior abdominal wall • Drains R. adrenal gland • Renal veins • Inferior phrenic veins • Drains the kidney, • Drains the diaphragm • L. suprarenal v. & L. gonadal v. • R. gonadal vein • Hepatic veins • Drains R. testes/ R. ovary • Drains the liver 16/02/2023 IVC & hepatobiliary system 5 presentation title 6 16/02/2023 IVC & hepatobiliary system16/02/2023 7 presentation title 8 16/02/2023 IVC & hepatobiliary system20XX presentation title 9Liver oPeritoneal organ oFound in the • Right hypochondrium • Epigastrium • Left hypochondrium (partially) oLargest visceral organ oLargest gland in body • Accessory digestion gland oFunction • Synthesis of bile • Glycogen storage • Clotting factor production 16/02/2023 IVC & hepatobiliary system 10Grossanatomyoftheliver • Fibrous layer Glisson’s capsule • Lobes • Accessory lobes • Left • Caudate • Right • quadrate • Caudate lobe • Upper aspect of visceral surface • Between IVC & fossa for ligamentum venosum • Quadrate lobe • Lower aspect of visceral surface • Between gallbladder and fossa produced by ligamentum teres • Accessory lobes separated by porta hepatis • Transmits all vessels, nerves & ducts entering/leaving liver hepatic veins 16/02/2023 IVC & hepatobiliary system 11Microanatom yoftheliver • Hepatocytes arranged in lobules • Each lobule is hexagonal shaped • Drain into central vein • Peripheral has each portal triad • Portal triad • Arteriole • Branch of hepatic a. entering liver • Venule • Branch of hepatic portal v. entering liver • Bile duct • Branch of bile duct leaving the liver • Also contains • Lymphatic vessels • Vagus n. 16/02/2023 IVC & hepatobiliary system 12 Liversurfaces • Diaphragmatic surface • Anterosuperior surface • Smooth & convex • Fits snugly beneath R crus of diaphragm • Posterior aspect not covered in visceral peritoneum • In direct contact with diaphragm • Visceral surface • Posteroinferior surface • Covered in peritoneum • Except fossa of gallbladder & porta hepatis • Molded for surrounding organs • R kidney • Oesophagus • 1st part of • R adrenal gland • Transverse colon duodenum • R colic flexure • Gallbladder • stomach 16/02/2023 IVC & hepatobiliary system 13 Ligamentsoftheliver • Lesser omentum • Falciform ligament • Liver to lesser curvature of the stomach & first part of duodenum • Sickle shaped ligament • Consists of • Ant. surface of liver to ant. abdomen wall • Hepatoduodenal ligament • Free edge contains ligamentum teres • Hepatogastric ligaments • Remnants of the umbilical v. • Posterior surface of liver is also secured to • Coronary ligament (anterior & posterior folds) the IVC • Sup. surface of the liver to inf. surface of the diaphragm • Demarcates bare area of the liver • Unit to form the triangular ligaments • Triangular ligament (left & right) • Fcoronary ligament ant. & post. Layers of the • Left - Left lobe of liver to the diaphragm • Right-Right lobe of liver to the diaphragm 16/02/2023 IVC & hepatobiliary system 14 Hepaticrecesses • Anatomical spaces between liver & surrounding structures • Clinical importance as infection can collect here • Subphrenic space • Between diaphragm & ant. & sup aspects of liver • Divided into R. & L. by falciform ligament • Subhepatic space • Subdivision of supracolic compartment • Above transverse mesocolon • Between inf. surface of liver & transverse colon • Hepatorenal recess (Morison’s pouch) • Between visceral surface of liver & R. kidney • Deepest part of peritoneal cavity when supine • Pathological abdominal fluid e.g. blood/ascites collect in a bed ridden patient 16/02/2023 IVC & hepatobiliary system 15Neovasculature • Artery • Nerves • Hepatic artery proper (25%) • Hepatic plexus • From Coeliac trunk • Sympathetic- coeliac plexus • Hepatic portal vein (75%) • Parasympathetic- vagus nerve • Partially deoxygenated blood • Enter via porta hepatits • Carries nutrients absorbs from small • Follow course of branches of hepatic a. & HPV intestine • Glisson’s capsule • functioniver to perform gut related • Innervated lower intercostal nerves • E.g. detoxification • Sharp localised pain • Veins • Lymphatic drainage • Hepatic veins • Central veins of hepatic lobules form • Anterior - hepatic lymph nodes collecting veins • Empty into colic lymph nodes -> cisterna chyli • Combine forming multiple hepatic v. • Posterior phrenic & post. mediastinal nodes • Open into inferior vena cava • Join R. lymphatic & thoracic ducts 16/02/2023 IVC & hepatobiliary system 16Gallbladder o Gastrointestinal organ in right hypochondrium o Intraperitoneal, pear shaped sac o Fossa formed between inferior aspects of the: • right lobe of liver • quadrate lobe of liver o Function- to store and concentrate bile - Released in response to cholecystokinin Anatomical relation • Anterior and superiorly • Inferior border of the liver • Anterior abdominal wall • Posterior • Proximal duodenum • Inferior • Biliary tree • Remaining parts of duodenum 16/02/2023 IVC & hepatobiliary system 17AnatomicalstructureoftheGallbladder Storage capacity 30-50ml • Fundus • Rounded distal portion • Project into inf. Surface of the liver (MCL) • Body • Largest part of gallbladder • Lies adjacent to • Posteroinf. Aspect of liver • Transverse colon • Sup part of duodenum • Neck • Tapers & continues as cystic duct • Contains mucosal fold (Hartmann’s pouch) common site for gallstones to lodge 16/02/2023 IVC & hepatobiliary system 18Cholelithiasis o Small lumps of cholesterol, bile salts or mix of two o Relatively common often asymptomatic o Symptoms o Pain o Jaundice o Systemic upset o Cholelithiasis o Uncomplicated gallstones o Biliary colic o RUQ pain following fatty meals o Obstruct cystic duct during contraction of gallbladder o No systemic upset 16/02/2023 IVC & hepatobiliary system 19Cholelithiasis o Cholecystitis • Inflammation of the gallbladder • Pain is associated with • Nausea • Vomiting • Fever o Choledocholithiasis • Gallstones in the common bile duct • Often causes deranged LFTs o Cholangitis • Infection of the CBB • Secondary to choledocholithiasis • Presents with Charcot’s triad • Pain • Fever • Jaundice 16/02/2023 IVC & hepatobiliary system 20Biliarytree • Series of gastrointestinal ducts • Bile drains from liver • Via L. & R. hepatic duct • L. & R. hepatic duct join • Form common hepatic duct • Runs along hepatic vein • Common hepatic duct is joined by cystic duct • Join forming common bile duct • Course • Descends and passes post. to first part of duodenum & head of pancreas • Joined by main pancreatic duct forms hepatopancreatic ampulla (ampulla of Vater) • Empties into duodenum via the major duodenum papilla • Regulated by sphincter of Oddi 16/02/2023 IVC & hepatobiliary system 21Neovasculaturebiliarysystem • Arterial • Innervation • Cystic artery • Coeliac plexus • (branch of R. hepatic a.) • Sympathetic • Sensory fibres • Venous • Cystic veins • Vagus n. • (drain to portal v.) • Parasympathetic fibres • Fundus & body drain directly into • Contract the gallbladder • Relax the sphincter of Oddi hepatic sinusoids • Lymphatics • Cystic lymph nodes • (at gallbladder neck) • Empty into hepatic nodes--> coeliac nodes 16/02/2023 IVC & hepatobiliary system 22Portalvenoussystem Carries nutrient rich venous blood from GI tract to liver Major vessel is the hepatic portal vein • Point of convergence for venous drain of the • Gallbladder • Spleen • abdominal part of the Gl tract • Pancreas Hepatic portal vein formed by union of • Splenic vein & SMV • Posterior to the neck of pancreas (L2) • Divides into right and left branches Tributaries • Spleinc v. • SMV • R. & L gastric v.-drain stomach • Cystic veins- drain gallbladder • Para-umbilical veins- drains the skin of the umbilical region 16/02/2023 IVC & hepatobiliary system 23Splenicvein • Formed by variety of small vessels as they leave the hilum of the spleen • In close contact with body of pancreas • Crosses post. Abdo wall • Forms portal vein • Tributaries • Short gastric veins – drain the fundus of the stomach. • Left gastro-omental vein – drains the greater curvature of the stomach. • Pancreatic veins – drain the pancreas. • Inferior mesenteric vein – drains the colon. • The inferior mesenteric • Rectum- superior rectal vein • sigmoid colon- sigmoid veins • descending colon - left colic veins • splenic flexure. 16/02/2023 IVC & hepatobiliary system 24Superiormesentericvein • Drains blood from: • small intestine, • ascending colon • cecum • transverse colon • Begins in R. iliac fossa • Ascends in mesentery of the small intestine • Tributaries • Right gastro-omental v. – drains the greater curvature of the stomach. • Ant. & post. Inf. pancreaticoduodenal v.– drain the pancreas & duodenum • Jejunal v. – drain the jejunum • Ileal v. – drain the ileum • Ileocolic v. – drains the ileum, colon and cecum. • R. colic v.– drains the ascending colon. • Middle colic v. – drains the transverse colon . 16/02/2023 IVC & hepatobiliary system 25Porto-Systemic Anastomoses Connection between the portal venous system & systemic venous system • Gastroesophageal anastomoses • Oesophageal branch of the left gastric vein • Oesophageal tributaries to the azygous system . • Anorectal anastomoses • Superior rectal vein • Middle & Inferior rectal veins. • Retroperitoneal • Veins of the retroperitoneal organs & liver • .Renal, lumbar & phrenic veins • Paraumbilical • Portal veins of the liver • Superficial veins of the anterior abdominal wall. 16/02/2023 IVC & hepatobiliary system 2620XX presentation title 2716/02/2023 IVC & hepatobiliary system 2816/02/2023 IVC & hepatobiliary system 29Portalh ypertension • Enlarges portal-systemic connections • Accompanied by congestive enlargement of the spleen • Portocaval shunts used to treat • Presentations • varices (distal oesophagus)s-Oesophageal • Paraumbilical anastomosis- caput medusae 16/02/2023 IVC & hepatobiliary system 30MCQs Question1 Which of the following is the function of the human liver? (a) Production of bile (b) Metabolization of fats (c) Metabolization of carbohydrates (d) All of the above. 16/02/2023 IVC & hepatobiliary system 32 Solution1 •Which of the following is the function of the human liver? •(a) Production of bile •(b) Metabolization of fats •(c) Metabolization of carbohydrates •(d) All of the above. 16/02/2023 IVC & hepatobiliary system 33 Question2 Which of the following statements is true about the human liver? (a) Liver is triangular in shape (b) Liver is the only visceral organ that can regenerate (c) Liver is the largest and the internal organ of the human body (d) All of the above. 16/02/2023 IVC & hepatobiliary system 34 Solution2 Which of the following statements is true about the human liver? (a) Liver is triangular in shape (b) Liver is the only visceral organ that can regenerate (c) Liver is the largest and the internal organ of the human body (d) All of the above. 16/02/2023 IVC & hepatobiliary system 35 Question3 The division between the true right and left lobes (internal lobes) of the liver may be visualized on the outside of the liver as a plane passing through the: gallbladder fossa and round ligament of liver falciform ligament and ligamentum venosum gallbladder fossa and inferior vena cava falciform ligament and right hepatic vein gallbladder fossa and right triangular ligament 16/02/2023 IVC & hepatobiliary system 36 Solution3 The division between the true right and left lobes (internal lobes) of the liver may be visualized on the outside of the liver as a plane passing through the: gallbladder fossa and round ligament of liver falciform ligament and ligamentum venosum gallbladder fossa and inferior vena cava falciform ligament and right hepatic vein gallbladder fossa and right triangular ligament 16/02/2023 IVC & hepatobiliary system 37This question is asking you to identify the structures that make the line that separates the true/functional lobes of the liver. The concept of functional lobes contrasts with traditional anatomical terminology, which separated the liver into the left, right, quadrate and caudate lobes. These traditional lobes were based on anatomical appearance, while the functional lobes are based on the distribution of the portal vein, hepatic arteries, and hepatic bile ducts. The functional lobes of the liver are separated into a right and left lobe by the gallbladder fossa and the inferior vena cava. So, the old "right lobe" corresponds to the functional right lobe, while the caudate, quadrate, and left lobes under anatomical terminology are lumped together as one big left lobe. 16/02/2023 IVC & hepatobiliary system 38 Question4 You are observing a laparoscopic cholecystectomy. The surgeon states that he is next going to expose the cystic artery in order to staple across it. He asks you where he should look for it. You reply, "In the triangle of Calot." What structures form this triangle and are the keys to finding the artery? Common hepatic duct, liver and cystic duct Cystic duct, right hepatic artery and right hepatic duct Gall bladder, liver and common bile duct Left hepatic duct, liver and cystic duct Right branch of portal vein, liver and common bile duct 16/02/2023 IVC & hepatobiliary system 39 Solution4 You are observing a laparoscopic cholecystectomy. The surgeon states that he is next going to expose the cystic artery in order to staple across it. He asks you where he should look for it. You reply, "In the triangle of Calot." What structures form this triangle and are the keys to finding the artery? Common hepatic duct, liver and cystic duct Cystic duct, right hepatic artery and right hepatic duct Gall bladder, liver and common bile duct Left hepatic duct, liver and cystic duct Right branch of portal vein, liver and common bile duct 16/02/2023 IVC & hepatobiliary system 40 • The triangle of Calot is formed by the cystic duct laterally, the liver superiorly, and the common hepatic duct medially. It is an important landmark in this region, because the cystic artery can be found in the triangle of Calot. During a cholecystectomy, the cystic artery needs to be ligated. Although the cystic artery usually branches from the right hepatic artery, there is some variation. However, if you locate the triangle of Calot, you can find the cystic artery in that triangle, trace it back to its origin, and then ligate it there. 16/02/2023 IVC & hepatobiliary system 41 Question5 1.A radiological examination of a patient revealed a large tumor in the quadrate lobe of the liver. During the surgical removal of the tumor, one of the vessels that needs to be clamped to effectively control bleeding is the: Left hepatic artery Right hepatic artery 16/02/2023 IVC & hepatobiliary system 42 Solution5 1.A radiological examination of a patient revealed a large tumor in the quadrate lobe of the liver. During the surgical removal of the tumor, one of the vessels that needs to be clamped to effectively control bleeding is the: Left hepatic artery Right hepatic artery 16/02/2023 IVC & hepatobiliary system 43 • The left and right hepatic arteries help support the parenchyma and stroma of the liver. The left hepatic artery supplies the left & quadrate lobes of liver, and part of the caudate lobe. The right hepatic artery supplies the right lobe and part of the caudate lobe. So, the left hepatic artery must be clamped to perform surgery on the quadrate lobe. 16/02/2023 IVC & hepatobiliary system 44 Question6 • Caput medusae is a clinical sign seen in portal hypertension in which portosystemic anastomosis? • A paraumbilical • B gastroesophageal • C anorectal • D retroperitoneal • E anterior 16/02/2023 IVC & hepatobiliary system 45 Solution6 • Caput medusae is a clinical sign seen in portal hypertension in which portosystemic anastomosis? • A paraumbilical • B gastroesophageal • C anorectal • D retroperitoneal • E anterior 16/02/2023 IVC & hepatobiliary system 46 Thankyou vbrown14@qub.ac.uk 47 16/02/2023 IVC & hepatobiliary system