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  • Print publication year: 2020
  • Online publication date: October 2019

Chapter 27 - Liver and Biliary Tract Injuries

from Section 6 - Abdomen

Summary

  • The liver is tethered by the following ligaments:
    • The falciform ligament attaches the liver anteriorly to the diaphragm and the anterior abdominal wall above the umbilicus.
    • The coronary ligaments extend laterally to attach the liver to the diaphragm. Beginning at the suprahepatic inferior vena cava (IVC), the lateral extensions of the coronary ligaments form the triangular ligaments (right and left), which are also attached to the diaphragm.
  • The anatomical division of the liver into the eight classic Couinaud segments has no practical application in traumatic liver resection, where the resection planes are nonanatomical and are dictated by the extent of injury. However, the external anatomical landmarks may be useful in planning operative maneuvers.
    • The plane between the center of the gallbladder and IVC runs along the middle hepatic vein, and serves as the line of division between the right and left lobes.
    • The left lobe is divided by the falciform ligament into the medial and lateral segments.
    • Dissection along the falciform ligament should be performed carefully, so as to avoid injury to the portal venous supply to the medial segment of the left lobe inferiorly and the hepatic veins superiorly.
  • The retrohepatic IVC is approximately 8–10 cm long and is partially embedded into the liver parenchyma. In some cases, the IVC is completely encircled by the liver, further complicating exposure and repair.
  • There are three major hepatic veins (right, middle, and left), as well as multiple accessory veins. The first 1–2 cm of the major hepatic veins are extra-hepatic, with the remaining 8–10 cm intra-hepatic. In approximately 70% of patients, the middle hepatic vein joins the left hepatic vein before entering the IVC.
  • The common hepatic artery originates from the celiac artery. It is responsible for approximately 30% of the hepatic blood flow, but supplies 50% of the hepatic oxygenation. It branches into the left and right hepatic arteries at the liver hilum in the majority of patients. In a common anatomical variant, the right hepatic artery may arise from the superior mesenteric artery. Less frequently, the entire arterial supply may arise from the superior mesenteric artery. Alternatively, the left hepatic artery may arise from the left gastric artery in 15–20% of patients.
  • The portal vein provides approximately 70% of hepatic blood flow, and 50% of the hepatic oxygenation. It is formed by the confluence of the superior mesenteric vein and the splenic vein behind the head of the pancreas. The portal vein divides into right and left extrahepatic branches at the level of the liver parenchyma.
  • The porta hepatis contains the hepatic artery (medial), common bile duct (lateral), and portal vein (posterior, between the common bile duct and the hepatic artery).
  • The right hepatic duct is easier to expose after removal of the gallbladder.
  • The left hepatic duct, the left hepatic artery, and the left portal vein branch enter the undersurface of the liver near the falciform ligament.