This document discusses the anatomy of the liver, pancreas, and portal system. It begins with the embryological development of these organs, then describes the anatomy and blood supply of the liver in detail. It also discusses the gallbladder, biliary tree, pancreas, and their related structures and variations. Key functions of the liver are outlined. The document provides a thorough overview of the anatomy relevant to upper gastrointestinal and hepatobiliary surgery.

1. Anatomy of the liver,
pancreas and portal system
Surgical case discussion
Antonio Manzelli MD MSc PhD
Upper GI and HPB Consultant

2. Embryology of the digestive glands
 Liver, gallbladder and pancreas develop from endodermal diverticulae that
bud from the duodenum in the 4th to 6th weeks
 Liver sprouts first and expands in ventral mesentery
 Cystic diverticulum also in ventral mesentery
 Pancreas arises from a dorsal and ventral bud.
 Ventral pancreatic bud migrates posteriorly to fuse with the dorsal bud.
 Main duct of ventral bud becomes the main pancreatic duct.

3. Liver
 Largest gland in the body
(1.5 Kg)
 Lies in right upper
quadrant.
 Underlies the thoracic
cage.
 Conforms to right dome
of diaphragm
 Connected to the
diaphragm by the
falciform and coronary
ligaments

4. Liver Functions
 Exocrine (digestive) functions:
1. Synthesizes and secrets bile salts
2. Secrets into the bile a bicarbonate-rich
solution
 Endocrine functions:
1. Secrets insulin-like growth factor I (IGF-I)
2. Contributes to the activation of vitamin D
3. Metabolizes hormones
4. Secretes cytokines involved in immune
defenses

5. Liver Functions
 Clotting functions:
-Produces many of the plasma clotting
factors
 Plasma protein
-Synthesizes and secretes plasma
albumin

6. Liver Functions
Organic metabolism
 Converts plasma glucose into glycogen
 Converts plasma amino acids to fatty
acids
 Synthesizes triacylglycerols and secrets
them as lipoproteins
 Produces glucose from glycogen
(glycogenolysis)
 Converts fatty acids to keones during
fasting
 Produces urea

7. Liver Functions
Cholesterol metabolism
1. Synthesizes cholesterol and releases it
into the blood
2. Secretes plasma cholesterol into the bile
3. Converts plasma cholesterol into bile
salts
 Excretory function:
1. Secrets bilirubin and other bile pigments
into the bile
2. Destroys old erythrocytes

8. At laparotomy the liver is divided by the umbilical fissure and falciform ligament into a
larger ‘right’ lobe and a smaller ‘left’ lobe

9. Liver - relations
 Surfaces separated by
inferior border of liver and
coronary ligament
posteriorly
 Bare area between the
reflections of coronary
ligaments in direct
contact with diaphragm
and not covered by
peritoneum
 Diaphragmatic surface
 Smooth and convex
 Separated from diaphragm
by subphrenic recess

14. Liver – relations (2)
 Visceral (posteroinferior) surface
 Lies in contact with oesophagus,
stomach and lesser omentum on
the left
 Duodenum in midline
 Right kidney, adrenal and hepatic
flexure of the colon on the right
 H-shaped arrangement of
structures
 Crossbar formed by porta hepatis
(portal vein, hepatic artery, hepatic
ducts, nerve plexus and lymph
vessels
 Left: ligamentum teres (remnant of
left umbilical v.) and ligamentum
venosum (remnant of ductus
venosum)

16. Liver - old lobar anatomy
 Right and left lobes divided by plane through the IVC and gallbladder fossa
 Caudate lobe
 Lies posteriorly between lig. venosum and IVC fossa
 Porta hepatis inferiorly
 Tail-like caudate process connects to right lobe and separates portal vein from IVC
 Quadrate lobe
 Anteroinferior between GB bed and lig. teres
 Porta hepatis superiorly
 Caudate and quadrate lobe considered to be part of left lobe
 Reidel’s lobe (not a true lobe)
 Lower border of the right lobe lateral to the GB may project downwards for a considerable distance as a broad or bulbous process
 Occurs in 5-10% of females and rarely in males

17. Liver - segmental anatomy
(Couinaud system)
 Knowledge of segments
important in the assessment of
location and extent of hepatic
pathology as surgery is
performed in segmental
fashion and distribution of
disease determines whether
lesions are resectable.
 The hepatic veins divide the
liver into 4 divisions
 A horizontal plane through the
portal vein divides the 4
divisions into superior and
inferior segments
 Segments numbered in
clockwise direction starting at
caudate lobe (segment 1)

18. R ant / R Post Left medial / Left lateral

19. Liver - vascular anatomy
 Double blood supply from hepatic artery (30%) and portal vein (70%)
 Arterial supply by common hepatic artery branch of coeliac artery.
 Gives off right gastric and gastroduodenal arteries before reaching the liver
in the free edge of the lesser omentum.
 Divides into left and right hepatic arteries before entering the liver at the
porta.
 Variants of right hepatic artery below
 Portal vein formed posterior to neck of pancreas by union of SMV and
splenic vein

21. In approximately 25% of individuals, the
right hepatic artery arises partially or
completely from the superior mesenteric
artery (A, C, E), and in a similar proportion
of patients, the left hepatic artery may be
partially or completely replaced by a branch
arising from the left gastric artery and
coursing through the gastrohepatic
omentum to enter the liver at the base of
the umbilical fissure (D, F). Rarely, the right
or left hepatic arteries originate
independently from the celiac trunk or
branch after a very short common hepatic
artery origin from the celiac (B, C). The
gastroduodenal artery may originate from
the right hepatic artery (B, C).

25. The portal vein is formed behind the neck of the pancreas by
confluence of the superior mesenteric and splenic veins

29. Biliary and vascular
anatomy of the left liver.
Note the position of
segment III duct above
the corresponding vein
and its relationship to
the recessus of Rex.
Biliary and vascular
anatomy of the right
liver. Note the horizontal
course of the posterior
sectoral duct and the
vertical course of the
anterior sectoral duct.

32. Liver - vascular anatomy (2)
 Right and left lobes functionally independent and defined by arterial
distribution
 Each supplied by left and right portal v., left or right hepatic arteries
and drained by left or right hepatic duct (portal triad)
 Quadrate lobe supplied by left hepatic artery
 Caudate lobe supplied by both

33. Liver - hepatic veins
 Hepatic veins are intersegmental and do not run with the
structures of the portal triad
 Right, middle and left hepatic veins drain corresponding
thirds of the liver
 Middle hepatic vein lies in the principal plane between right and
left lobes
 Left hepatic vein lies between medial and lateral segments of the
left lobe
 Right hepatic vein lies between anterior and posterior segments
of the right lobe
 All drain into the IVC without an extrahepatic course
 Inferior group of small veins from right lobe also drains
into IVC

38. Liver – Lymph drainage and
innervation
 Lymph drainage
 Superficial and most deep lymph vessels converge at
the porta and end in the hepatic lymph nodes (eg.
Cystic LN near GB neck or LN of omental foramen)
 Hepatic LN’s drain into coeliac LN’s around the
coeliac trunk, then thoracic duct
 Some deep lymph vessels follow hepatic veins to IVC
foramen in diaphragm and end in middle phrenic LN’s
 Innervation
 Sympathetic and parasympathetic supply from the
hepatic plexus, a derivative of coeliac plexus (formed
from fibres of left and right vagus and right phrenic
nerves)

39. Terminology of Liver Anatomy and Resections:
The Brisbane 2000 Terminology
In 1998 at its meeting in Berne, Switzerland, the Scientific Committee of the International
Hepato-Pancreato-Biliary Association (IHPBA) established a Terminology
Committee to deal with the confusion in terminology of hepatic anatomy and liver
Resections. The terminology was published in the official journal of the IHPBA in 2000.
The terminology shown below is based on the hepatic artery and bile duct.
A terminology based on the division of the portal vein was added as an addendum.

43. Primary and secondary, benign and malignant liver Tumors / Liver cysts / Liver abcess
and pyogenic disease / Hydatic disease
Liver resections
Laparoscopic Liver Resection
Cryosurgery
Radiofrequency Ablation of Liver Tumors
Selective Hepatic Intra-arterial Chemotherapy
Unroofing and Resection for Benign Non-Parasitic Liver Cysts
Pericystectomy for Infectious Liver Cyst
Orthotopic Liver Transplantation
Partial Cadaveric Liver Transplantation: Donor Procedure and Implantation, Right Living Donor Hemihepatectomy
Living Donor Liver Transplantation: Left Hemiliver Donor Procedure and Implantation

44. Portal Hypertension
Distal Splenorenal Shunt
Low-Diameter Mesocaval Shunt
Interposition Portacaval Shunt Portacaval Shunts:
Side-To-Side and End-To-Side Gastroesophageal
Devascularization: Sugiura Type Procedures

45. Gallbladder and cystic duct
 Pear shaped sac lies to the right of
the quadrate lobe in GB fossa on
the visceral surface of liver
 Concentrates and stores bile
secreted by the liver
 Cholecystokinin produced by
intestinal mucosa during digestion,
passes to GB and causes it to
contract and release bile
 Fundus, body and neck
 Mucosal membrane arranged into
spiral folds (valves of Heister) at GB
neck and cystic duct

46. Gallbladder - relations
 Anterosuperiorly
 GB fossa of liver
 Fundus projects from inferior border of liver, located
at tip of 9th costal cartilage in MCL where lateral edge
of rectus abdominis meets costal margin
 Posteroinferiorly
 Neck: lesser omentum. Omental (epiploic) foramen
lies immediately to the left.
 Body: D1
 Fundus: transverse colon

47. Gallbladder – blood supply
 Arterial supply
 cystic artery
 Venous drainage
 directly into liver or via a cystic vein

48. Biliary Tree
 Bile is secreted by hepatocytes into bile
canuliculi which drain into interlobular bile
ducts. Progressively larger ducts formed.
 Left and right hepatic ducts emerge from
porta and merge to form common hepatic
duct (4cm)
 Joined on the right by the cystic duct from
the GB to form the common bile duct (8-
10cm long, 5-6mm diameter)
 Runs in free edge of lesser omentum,
passes posterior to D1 and head of
pancreas
 Comes in contact with pancreatic duct on
the left side of D2
 Usually unite in the duodenal wall to form
hepatopancreatic ampulla (of Vater)
 Ampulla opens into descending part of
duodenum at summit of major duodenal
papilla, 8-10cam from pylorus

49. Biliary Duct – blood supply
 Arterial supply
 Proximally: cystic artery
 Middle: right hepatic artery
 Distally: posterior superior pancreaticduodenal a.
 Venous drainage
 Proximally: drainage directly into liver
 Distally: posterior superior pancreaticduodenal v.
 Lymph drainage
 Cystic LN, node of omental foramen, hepatic LN’s

50. Biliary Tree - variants
 Accessory hepatic ducts may arise
in the liver and join the right
hepatic duct, common hepatic
duct, common bile duct, cystic
duct or GB
 Right and left hepatic ducts may
fail to unite giving a double duct
 Cystic duct
 Absent
 Joins common hepatic duct on the
left rather than the right
 Joins the right hepatic duct or an
accessory duct
 Joins the common hepatic duct
anywhere between the porta and
the duodenum (low and high
union)

51. Variants in union of CBD and
pancreatic duct

52. Biliary Tract and Gallbladder
Laparoscopic Cholecystectomy, Open Cholecystectomy
and Cholecystostomy
Resection of Gallbladder Cancer, Including Surgical Staging
Exploration of the Common Bile Duct:
The Laparoscopic Approach
Bile Duct Resection
Resection of the Mid Common Bile Duct Intrahepatic Biliodigestive
Anastomosis Without Indwelling Stent
The Ligamentum Teres Approach and Other Approaches
to the Intrahepatic Ducts for Palliative Bypass Choledochojejunostomy and
Cholecystojejunostomy Choledochoduodenostomy Reconstruction of Bile
Duct Injuries Operative Treatment of Choledochal Cysts

54. Pancreas
 Retroperitoneal organ lies transversely
and slightly obliquely at L1-L2 level
 Transverse mesocolon attached to
anterior margin
 Exocrine (pancreatic enzymes) and
endocrine functions (glucagon and insulin)
 Head, neck, body and tail

55. Pancreas - Relations
 Head
 Lies in curvature of duodenum
 Anterior to IVC, aorta, right renal vessels and left renal vein
 Uncinate process projects posteriorly and to the left and lies posterior to
superior mesenteric vessels
 CBD passes posteriorly in a groove or embedded within
 Neck
 Anterior to the union of splenic vein and SMV to form the portal vein
 Body
 Curves over vertebrae and great vessels
 Anterior to the aorta and lies between the coeliac trunk and the SMA
 Splenic vein passes posterior
 Tail
 lies in the splenorenal ligament
 Usually contacts the hilum of the spleen

57. A, The head of the pancreas is globular with an extension, the uncinate process, which curves behind the superior
mesenteric vessels. The uncinate process may finish even before it embraces the superior mesenteric vein (a), or it may
pass completely behind between the aorta and the left of the patient's superior mesenteric artery (b, c). All variations are
commonly seen. Posteriorly, the head of the pancreas lies in juxtaposition to the IVC at the level of the entry of the left and
right renal veins. The head of the pancreas forms a narrow neck in front of the superior mesenteric and splenic vein
confluence. The neck joins to the body of the gland, which forms a narrow tail. B, The common bile duct (CBD) passes
through the pancreas either directly in the substance of the gland or initially with a posterior groove. C, The duct of
Wirsung courses from left to right within the pancreas, curves downward approaching the CBD, and runs parallel with but
separated from it by the transampullary septum to enter the duodenum 7 to 10 cm distal to the pylorus at the papilla of
Vater after traversing the sphincter of Oddi. An accessory duct (duct of Santorini) runs more proximally in the head of the
pancreas and usually terminates in the duodenum at an accessory papilla. Multiple variations of the ductal system occur
depending on the extent of development of the accessory duct of Santorini, such that rarely the accessory duct can enter
the duodenum inferior to the main duct. It can be in communication with the main duct directly (i), or it can occur in
duplicate version known as pancreas divisum (ii). The duct of Santorini drains the body and tail of the organ, and the duct
of Wirsung drains the head and the uncinate process.

60. Pancreatic Duct
Schematic representation of the
sphincter of Oddi: notch (a);
biliary sphincter (b);
transampullary septum (c);
pancreatic sphincter (d);
membranous septum of Boyden
(e); common sphincter (f);
smooth muscle of duodenal wall
(g).

62. NERVE SUPPLY TO THE LIVER AND PANCREAS
Note the distribution of
sympathetic and
parasympathetic nerves
to the liver and pancreas
from the celiac ganglion
mainly in association
with major arteries.

63. Stylized representation of the major nerves serving the pancreas.

64. Nerve supply to the extrahepatic bile tree.

65. Pancreas - Embryology
 Arises from the junction of the primitive foregut
and midgut as a larger dorsal division and a
smaller ventral bud
 Ventral bud swings posteriorly to unite with the
inferior aspect of the dorsal bud trapping the
superior mesenteric between divisions
 Ventral bud forms the uncinate process
 Duct of the ventral bud forms the proximal end
of the main pancreatic duct; the distal end of the
dorsal pancreatic duct forms the remainder.

66. Pancreas – blood supply
 Arterial supply
 Head: superior pancreaticoduodenal a. (from
gastroduodenal artery) and inferior
pancreaticoduodenal a. (from SMA)
 Body and tail: branches from splenic artery
 Venous drainage
 Mostly splenic v., but also portal v. and SMV

67. Pancreatic operation – Primary and secondary, benign and malignant pancreatic tumors / cystic lesions / pancreatic
psedeudocyst / acute and chronic pancreatitis
Drainage of Pancreatic Pseudocysts
Denervation: Pain Management
Enteric Ductal Drainage for Chronic Pancreatitis
Resection for Neoplasms of the Pancreas
Enteric Drainage of Pancreatic Fistulas with Onlay Roux-en-Y
Sphincteroplasty for Pancreas Divisum
Sphincterotomy/Sphincteroplasty for Papillary Dysfunction:
Stenosing Papillitis
Pancreatic Enucleation
Transduodenal Resection of Periampullary Villous Neoplasms
Pancreas Transplantation
Chronic Pancreatitis
Exploration of the Gastrinoma Triangle
Laparoscopic Staging of Periampullary
Distal Pancreatectomy