15. liver

• Liver


  • Lies mainly in the RUQ of the abdomen
  • Occupies most of the R hypochondrium, the upper epigastrium & extends into the L hypochondrium
  • Largest visceral organ and largest gland
  • Normal weight – 1,500 gms
• Relations of the liver

  • Anterior: diaphragm, right and left costal margins, right and left pleura, lower margins of both lungs, xiphoid process, anterior abdominal wall in the subcostal angle
  • Posterior: diaphragm, right kidney, hepatic flexure of the colon, duodenum, GB, IVC, esophagus, fundus of stomach
• Diaphragmatic surface of the liver


  • Dome shaped; anterior, superior and posterior parts
  • Covered with visceral peritoneum except posteriorly in the bare area
  • Surrounded by peritoneum and is attached to the diaphragm by the CORONARY and FALCIFORM ligaments and R/L TRIANGULAR ligaments
  • Has a BARE AREA (devoid of peritoneum)
• Ligaments of the liver

  • falciform ligament
  • Coronary ligament
  • R / L triangular ligaments
  • Ligamentum teres / round ligament
  • Ligamentum venosum – remnant of ductus venosus; between left lobe & caudate lobe
• Fissure for the ROUND LIGAMENT / LIGAMENTUM TERES


  Between the Quadrate and Left lobes
• Fissure for LIGAMENTUM VENOSUM

  Between Caudate and Left lobes
• Fossa for the Gall Bladder


  Between Right and Quadrate lobes
• Fissure for the IVC

  Between the Caudate and Right lobes
• Ligamentum teres / round ligament

  Remnant of umbilical vein; between left lobe & quadrate lobe
• Umbilical vein


  Ligamentum teres
• Umbilical artery


  Medial umbilical ligament
• Ductus venosus


  Ligamentum venosum
• Urachus


  Median umbilical ligament
• Functional segments of the liver

  • Caudate lobe = I
  • Lateral superior = II
  • Lateral inferior = III
  • Medial superior = IV A
  • Medial inferior = IV B - Quadrate lobe
  • Anterior inferior = V
  • Posterior inferior = VI
  • Posterior superior= VII
  • Anterior superior= VII
• Foramen ovale


  Fossa ovalis
• Ductus arteriosus


  Ligamentum arteriosum
• Liver lobes


  • Divided into RIGHT and LEFT lobes by the attachment of the peritoneum of the Falciform ligament
  • RIGHT lobe is further subdivided into a QUADRATE and CAUDATE lobes by the presence of the gall bladder, inferior vena cava and fissures of the ligamentum venosum and ligamentum teres
• Each part of the liver has its own blood supply, venous drainage and biliary drainage
• Diaphragmatic


  • Dome shaped
  • Anterior, superior and posterior parts
  • Covered with visceral peritoneum except posteriorly in the bare area
• Bare area


  Devoid of peritoneum on the diaphragmatic surface
• Surrounded by peritoneum


  Attached to the diaphragm by the CORONARY and FALCIFORM ligaments and R/L TRIANGULAR ligaments
• Umbilical vein


  Ligamentum teres
• Umbilical artery


  Medial umbilical ligament
• Ductus venosus


  Ligamentum venosum
• Urachus


  Median umbilical ligament
• Liver lobes


  • Divided into RIGHT and LEFT lobes by the attachment of the peritoneum of the Falciform ligament
  • RIGHT lobe is further subdivided into a QUADRATE and CAUDATE lobes by the presence of the gall bladder, inferior vena cava and fissures of the ligamentum venosum and ligamentum teres
• Each part of the liver has its own blood supply, venous drainage and biliary drainage
• Liver acinus


  "Acinus of Rappaport"
• Liver acinus


  • Based on blood flow
  • Diamond-shaped area of the liver whose long axis is the straight line between neighboring central veins and whose short axis is the intersecting line between neighboring portal areas
• Zones of the liver acinus

  • Zone 1 - closest to the portal tract and receives the most O2
  • Zone 2
  • Zone 3 - farthest and receives the least O2, most susceptible to ischemic injury
• Portal Triad


  • Portal vein
  • Hepatic artery
  • Bile duct
• Porta Hepatis or Hilum of the liver


  Found on the posteroinferior surface and lies between the Caudate and Quadrate lobes
• Structures found in the Porta Hepatis

  • Right and Left Hepatic ducts
  • Right and Left branches of the Hepatic artery
  • Portal vein
  • Sympathetic and Parasympathetic nerve fibers
  • Lymph nodes
• Portal vein


  Formed by union of superior mesenteric & splenic veins; 70%
• Hepatic artery


  Branch of celiac artery; 30%
• Paracentesis


  1. Midline, 2 cm below umbilicus

  2. Lateral to rectus abdominis muscle, 2 – 4 cm* superomedial to anterior superior iliac spine on either side
• Controlling hemorrhage from the liver

  1. Clamping the hepatoduodenal ligament - Pringle maneuver

  2. Hepatic artery and portal vein contained in the ligament
• Liver biopsy


  Usually done at right 10th intercostal space in midaxillary line
• Performing liver biopsy


  1. Patient holds breath in full expiration

  2. Needle inserted through right 8th or 9th intercostal space in midaxillary line
• Jejunum Ileum


  • Plicae circulares or valves of Kerckring