Blumgart Anatomy

CHAPTER 2
Surgical and radiologic anatomy of the liver, biliary

tract, and pancreas
Leslie H. Blumgart, Lawrence H. Schwartz, and Ronald P. DeMatteo*
ANATOMY OVERVIEW the pancreas as a retroperitoneal structure passing upward

behind the foramen of Winslow posterior to the right hilar struc-
Precise knowledge of the architecture of the liver, biliary tract, tures of the liver. The renal veins lie in front of the arteries and
and pancreas and the related blood vessels and lymphatic drain- join the IVC at almost a right angle on the left and obliquely on
age is essential for the successful performance of hepatopancre- the right. The IVC is embraced in a groove on the posterior
aticobiliary surgical operations. surface of the liver. The IVC comes to lie on the right crus of
the diaphragm, behind the bare area of the liver; it extends to
LIVER the central tendon of the diaphragm, which it pierces on a level
with the body of T8, behind and higher than the beginning of
The liver lies protected under the lower ribs, closely applied to the abdominal aorta. While the IVC courses upward, it is sepa-
the undersurface of the diaphragm and on top of the inferior rated from the right crus of the diaphragm by the right celiac
vena cava (IVC) posteriorly (Fig. 2.1). Most of the liver bulk ganglion and, higher up, by the right phrenic artery. The right
lies to the right of the midline, where the lower border lies near adrenal vein is a short vessel that enters the IVC behind the bare
the right costal margin. The liver extends as a wedge to the left area. There may be a small accessory right adrenal vein on the
of the midline, between the anterior surface of the stomach and right that enters into the confluence of the right renal vein and
the left dome of the diaphragm. The upper surface is boldly the IVC. Also, occasionally, a right adrenal vein drains directly
convex and molded to the diaphragm, and the surface projec- into the posterior liver. The lumbar veins drain posterolaterally
tion on the anterior body wall extends up to the fourth inter- into the IVC below the level of the renal veins, but above this
costal space on the right and to the fifth intercostal space on level, there are usually no vena caval tributaries posteriorly.
the left. The convexity of the upper surface slopes down to a
posterior surface that is triangular in outline. The liver is Hepatic Veins
invested with peritoneum except on the posterior surface, The hepatic veins (Figs. 2.2 to 2.4) drain directly from the
where the peritoneum reflects onto the diaphragm, forming the upper part of the posterior surface of the liver at an oblique
right and left triangular ligaments. The undersurface of the liver angle directly into the vena cava. The right hepatic vein, which
is concave and extends down to a sharp anterior border. The is larger than the left and middle hepatic veins, has a short
posterior surface of the liver is triangular in outline with its base extrahepatic course of approximately 1 to 2cm. The left and
to the right, and here the liver lying between the upper and middle hepatic veins may drain separately into the IVC but are
lower leaves of the triangular ligaments is bare and devoid of usually joined, after a short extrahepatic course, to form a
peritoneum. The peritoneum reflects onto the right posterior common venous channel approximately 2cm in length that
liver from the medial aspect of Gerotas fascia, which is associ- traverses to the left part of the anterior surface of the IVC below
ated with the right kidney. The right adrenal gland lies beneath the diaphragm. In addition to the three major hepatic veins,
this reflection. The anterior border lies under cover of the right there is the umbilical vein, which is single in most cases and
costal margin, lateral to the right rectus abdominis muscle, but runs beneath the falciform ligament between the middle and
it slopes upward to the left across the epigastrium. Anteriorly, left hepatic veins; it empties into the terminal portion of the left
the convex surface of the liver lies against the concavity of the hepatic vein, although, rarely, it drains into the middle hepatic
diaphragm and is attached to it by the falciform ligament, left vein or directly into the confluence of the middle and left
triangular ligament, and upper layer of the right triangular hepatic veins. In approximately 15% of patients, an accessory
ligament. right hepatic vein is present inferiorly (see Fig. 2.3). Hepatic
venous drainage of the caudate lobe is directly into the IVC, as
Retrohepatic Inferior Vena Cava described later.
The IVC runs to the right of the aorta on the bodies of the This classic description of the anatomy of the liver is suffi-
lumbar vertebrae, diverging from the aorta as it passes upward. cient for gross appreciation and for mobilization of the liver to
Below the liver, the IVC lies behind the duodenum and head of allow access for repair of injuries, liver transplantation, or the
placement of probes onto or into the liver substance. Hidden
beneath this external gross appearance is a detailed internal
anatomy, an understanding of which is essential to the perfor-
*The authors acknowledge Dr. Lucy E. Hann who coauthored this chapter in mance of precise hepatectomy. This internal anatomy has been
the fifth edition of this book. Much of her initial contribution is included here. called the functional anatomy of the liver.
32
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Chapter 2 Surgical and radiologic anatomy of the liver, biliary tract, and pancreas 33
Gallbladder
Quadrate lobe
Umbilical
fissure
Left lobe
Right lobe
Gallbladder Caudate lobe

A B
IVC
Lumen of MHV Lumen of RHV
and LHV
Left triangular LHV
ligament Right lobe
Left lobe
Right adrenal
vein
Ligamentum Right triangular
venosum ligament
Ligamentum
teres
LEFT LOBE RIGHT LOBE

C
FIGURE 2.1. A, The liver as seen in situ has two main lobes, a large right and a smaller left, and conventional description places their line of fusion
on the upper surface of the liver along the attachment of the falciform ligament at the inferior extent of which the ligamentum teres enters the umbili-
cal fissure. B, With the liver flipped upward, the inferior surface of the right lobe is seen as the transverse hilar fissure, which constitutes the posterior
limit of this lobe. The portion of the right lobe located anterior to the fissure is called the quadrate lobe, which is limited on the left by the umbilical
fissure and on the right by the gallbladder fossa. Posterior to the hilar transverse fissure is a fourth lobe, the caudate lobe, which hugs the inferior
vena cava (IVC) and extends upward on its left side. Thus the liver comprises two main lobes and two smaller lobes, separated by visible, well-defined
fissures on the liver surface. C, The posterior aspect of the liver is shown. The IVC lies snugly in a deep groove within the bare area; the hepatic
veins open directly into it. Within this bare area, the right suprarenal gland lies adjacent to the IVC, and the adrenal vein drains into the right of the
IVC. The remainder of the bare area of liver is directly in contact with the diaphragm. To the left of the IVC, the caudate lobe slopes upward from
the inferior to the posterior surface of the liver and is demarcated on the left by a fissure, within which lies the ligamentum venosum. The gastrohe-
patic omentum is attached to the ligamentum venosum, placing the caudate lobe within the lesser sac of the peritoneum. The left lobe of the liver
is situated anteriorly in the supracolic compartment of the peritoneal cavity. The posterior surface of the left lobe is narrow; there is a very fine bare
area on this side. While the vena cava traverses upward in the groove on the posterior surface of the liver, it is shielded on the right side by a layer
of fibrous tissue that passes from the posterior edge of the liver backward toward the lumbar vertebrae and fans out posteriorly, especially in the
upper part. Behind the IVC, a prolongation of this fibrous layer joins a less marked fibrous extension from the lateral edge of the caudate lobe. This
layer of fibrous tissue, sometimes called the ligament of the vena cava, must be divided on the right, to allow surgical exposure of the IVC and the
right hepatic vein, and on the left, to allow mobilization of the caudate lobe. Occasionally, the liver tissue embraces the vena cava completely, so
that it runs within a tunnel of parenchyma. LHV, Left hepatic vein; MHV, middle hepatic vein; RHV, right hepatic vein.

34 PART 1 LIVER, BILIARY, AND PANCREATIC ANATOMY AND PHYSIOLOGY
M
L
R
IVC
FIGURE 2.4. The anterior surfaces of the major extrahepatic veins and
the inferior vena cava are retroperitoneal and masked behind the layers
of the falciform ligament, while it splits and passes to the right and left
triangular ligaments. The left and middle hepatic veins usually join within
the liver, and not outside the liver as depicted here for visual simplicity.
FIGURE 2.2. Transverse ultrasound image of the hepatic vein conflu-
ence shows the left (L), middle (M), and right (R) hepatic veins as they
join the inferior vena cava (IVC).
M
M
IVC
IVC
R
R
A B
R
PV IVC
IVC A
C D
FIGURE 2.3. Two inferior accessory right hepatic veins. A, Contrast-enhanced computed tomographic (CT) image of the hepatic vein confluence.
IVC, inferior vena cava; M, middle hepatic vein;R, Right hepatic vein. B, A small right inferior accessory vein (arrow) enters the IVC below the hepatic
venous confluence. C, The second, larger right inferior accessory right hepatic vein (arrow) is seen more inferiorly. PV, Portal vein. D, CT coronal
reconstruction image shows the right hepatic vein (R) and one right inferior accessory vein (arrow). A, Aorta.

subdivisions are referred to as segments in the description of

Functional Surgical Anatomy Goldsmith and Woodburne (1957), but in Couinauds nomen-
The internal architecture of the liver is composed of a series of clature (1957), they are termed sectors.
segments that combine to form sectors separated by scissurae The right portal scissura separates the right liver into two
that contain the hepatic veins (Fig. 2.5), as described by Couin- sectors: anteromedial (anterior) and posterolateral (posterior).
aud (1957). Together or separately, these constitute the visible With the body supine, this scissura is almost in the frontal
lobes described previously. The internal structure has been plane. The right hepatic vein runs within the right scissura. The
clarified by the publications of McIndoe and Counseller (1927), left portal scissura divides the left liver into two sectors, but the
Ton That Tung (1939, 1979), Hjrtsj (1931), Healey and left portal scissura is not within the umbilical fissure because
Schroy (1953), Goldsmith and Woodburne (1957), Couinaud this fissure is not a portal scissura, and instead it contains a
(1957), and Bismuth and colleagues (1982). Essentially, the portal pedicle. The left portal scissura is located posterior to
three main hepatic veins within the scissurae divide the liver the ligamentum teres and within the left liver, along the course
into four sectors, each of which receives a portal pedicle. The of the left hepatic vein.
main portal scissura contains the middle hepatic vein and pro- Although the description by Couinaud has been used widely,
gresses from the middle of the gallbladder bed anteriorly to the it is being replaced by an alternative terminology suggested by a
left of the vena cava posteriorly. The right and left parts of the committee of the International Hepato-Pancreatico-Biliary
liver, demarcated by the main portal scissura, are independent Association in 2000 (Strasberg, 2005). The main difference is
in terms of portal and arterial vascularization and biliary drain- that in the alternative terminology, Couinauds sectors are
age (Fig. 2.6). These right and left livers are themselves divided
into two by the remaining portal scissurae. These four
VII
RIGHT MAIN LEFT
VIII
SCISSURA SCISSURA SCISSURA
II
V I
III
IV
VI
Umbilical
fissure
Right portal pedicle Left portal pedicle II
VIII
RIGHT LIVER LEFT VII
FIGURE 2.5. The portal vein, hepatic artery, and draining bile ducts
are distributed within the liver in a beautifully symmetric pedicular pattern, III
which belies the asymmetric external appearance. Each segment (I to
VIII) is supplied by a portal triad composed of a branch of the portal vein
and hepatic artery and drained by a tributary of the right or left main
hepatic ducts. The four sectors demarcated by the three main hepatic IV
veins are called the portal sectors (now referred to as sections in the V
Brisbane terminology); these portions of parenchyma are supplied by
independent portal pedicles. The hepatic veins run between the sectors
in the portal scissurae; the scissurae containing portal pedicles are called VI
the hepatic scissurae. The umbilical fissure corresponds to a hepatic
scissura. The internal architecture of the liver consists of two hemilivers,
the right and the left liver separated by the main portal scissura, also
known as Cantlies line. It is preferable to call them the right and left liver, B
rather than the right and left lobes because the latter nomenclature is FIGURE 2.6. The functional division of the liver and its segments
erroneous; there is no visible mark that permits identification of a true according to Couinauds nomenclature. A, As seen in the patient. B, In
hemiliver. the ex vivo position.

referred to as sections (Table 2.1) (see Chapter 103B for differ- This prolongation of the left portal pedicle turns anteriorly and
ences in the terminology of the various hepatic resections). Also, caudally within the umbilical fissure, giving branches of supply
note that the left medial section, in the terminology of Strasberg to segment II first and then segment III and recurrent branches
(2005), is composed of one segment (i.e., segment IV). (feedback vessels) to segment IV (Fig. 2.8; see Fig. 2.6).
At the hilus of the liver, the right portal triad pursues a short Beneath segment IV, the pedicle is composed of the left branch
course of approximately 1 to 1.5cm before entering the sub- of the portal vein and the left hepatic duct, but it is joined at
stance of the right liver (Fig. 2.7). In some cases, the right the base of the umbilical fissure by the left branch of the hepatic
anterior and posterior pedicles arise independently, and their artery.
origins may be separated by 2cm. In some cases, it appears as The branching of the portal pedicle at the hilus (Fig. 2.9),
if the left portal vein arises from the right anterior branch (see the distribution of the branches to the caudate lobe (segment
Fig. 2.40). On the left side, however, the portal triad crosses I) on the right and left sides, and the distribution to the seg-
over approximately 3 to 4cm beneath segment IV (formerly ments of the right (segments V through VIII) and left (segments
called the quadrate lobe), embraced in a peritoneal sheath at the II through IV) hemiliver follow a remarkably symmetric pattern
upper end of the gastrohepatic ligament and separated from the and, as described by Scheele (1994), allow separation of
undersurface of segment IV by connective tissue (hilar plate). segment IV into segment IVa superiorly and segment IVb
TABLE 2.1 Brisbane Terminology of Liver Anatomy

and Resections
Couinaud
Anatomic Term Segments Surgical Resection
Right hemiliver/ 5-8 Right hepatectomy

right liver
RAPV Left hemiliver/left 2-4 Left hepatectomy
liver
LPV
Right anterior 5, 8 Right anterior sectionectomy
section
RPPV Right posterior 6, 7 Right posterior sectionectomy
MPV section
Left medial section 4 Left medial sectionectomy or
Resection of segment 4
IVC
Left lateral section 2, 3 Left lateral sectionectomy or
Bisectionectomy 2, 3
A 4, 5, 6, 7, 8 Right trisectionectomy or
Extended right hepatectomy
2, 3, 4, 5, 8 Left trisectionectomy or
Extended left hepatectomy
4 3
U
2
p
B
FIGURE 2.7. A, Transverse sonogram at the level of the portal vein
bifurcation. The main portal vein (MPV) bifurcates into the left and right
portal veins (LPV and RPV). The RPV bifurcates shortly into the right IVC
anterior (RAPV) and right posterior (RPPV) branches, but the LPV has a
longer horizontal course within the hilar plate. The inferior vena cava
(IVC) is seen posteriorly. B, Coronal view of computed tomographic FIGURE 2.8. Transverse sonogram shows the branching pattern of
angioportography. Reconstruction shows the right hepatic vein (open the left portal vein (P), which courses horizontally and into the umbilical
arrow) and the portal vein (large arrow); anterior and posterior sectional fissure. The umbilical portion of the left portal vein (U) gives branches to
branches of the RPV (small arrows) are seen to arise directly and sepa- the left hepatic segments (II to IV). The left hepatic vein (arrow) and
rately from the main portal trunk. inferior vena cava (IVC) also are shown.

MHV Ligamentum venosum
II/III
IV
LPV
Lesser
omentum
VII
L
I
IVC
RA R
FIGURE 2.11. The main bulk of the caudate lobe (segment I; dark
area) lies to the left of the inferior vena cava (IVC); the left and inferior
margins are free in the lesser omental bursa. The gastrohepatic (lesser)
omentum separates the left portion of the caudate from segments II and
RP
III of the liver, while it passes between them to be attached to the liga-
mentum venosum. The left portion of the caudate lobe inferiorly tra-
verses to the right between the left portal vein (LPV) and IVC as the
caudate process, where it fuses with the right lobe of the liver. Note the
position of the middle hepatic vein (MHV).
2.10 to 2.11). The caudate is intimately related to major vas-

FIGURE 2.9. Contrast-enhanced computed tomographic image of the
cular structures. On the left, the caudate lies between the IVC
portal vein bifurcation. L, Left portal vein; R, right portal vein; RA, right
anterior portal vein; RP, right posterior portal vein.
posteriorly and the left portal triad inferiorly and the IVC and
the middle and left hepatic veins superiorly (Fig. 2.12). The
portion of the caudate on the right varies but is usually quite
small. The anterior surface within the parenchyma is covered
by the posterior surface of segment IV, the limit an oblique
plane slanting from the left portal vein to the left hepatic vein.
Thus there is a caudate lobe with a constantly present left
portion and a right portion of variable size. This portion of
the caudate on the right is adjacent to the recently described
segment IX, which lies between it and segment XIII. The
authors find segment IX of little practical clinical
p
significance.
The caudate is supplied by blood vessels and drained by
IVC
a biliary tributaries from the right and left portal triad. Small
vessels from the portal vein and tributaries joining the biliary
ducts also are found. The right portion of the caudate, includ-
ing the caudate process, predominantly receives portal venous
blood from the right portal vein or from the bifurcation of the
main portal vein, whereas on the left side, the portal supply
arises from the left branch of the portal vein almost exclusively.
FIGURE 2.10. Contrast-enhanced computed tomographic scan of the
Similarly, the arterial supply and biliary drainage of the right
liver shows the intimate relationship of the caudate lobe (arrow), inferior
vena cava (IVC), portal vein (p), and aorta (a). portion is most commonly associated with the right posterior
sectional vessels and the left portion with the left main vessels.
The hepatic venous drainage of the caudate is unique in that it
is the only hepatic segment that drains directly into the IVC.
inferiorly (see Fig. 2.6). This arrangement of subsegments These veins can sometimes drain into the posterior aspect of
mimics the distribution to segments V and VIII on the right the vena cava, if a significant retrocaval caudate component is
side. The umbilical vein provides drainage of at least parts of present.
segment IVb after ligation of the middle hepatic vein, and it is In the usual and common circumstance, the posterior edge
important in the performance of segmental resection. of the caudate lobe on the left has a fibrous component, which
The caudate or segment I is the dorsal portion of the liver fans out and attaches lightly to the crural area of the dia-
lying posteriorly and embraces the retrohepatic IVC (Figs. phragm; but it extends posteriorly, behind the vena cava, to

IVC
MHV
LHV
II/III
Ligamentum
venosum
*
RPV IVC
v
a
PV
LPV
FIGURE 2.12. The caudate lobe (shaded) and segments II and III,
rotated to the patients right. Superiorly, the left portion of the caudate
lobe is linked by a deep anterior portion, embedded in the parenchyma
immediately under the middle hepatic vein (MHV), reaching inferiorly to
the posterior margin of the hilus of the liver and fusing anterolaterally to
the inferior vena cava (IVC) on the right side to segments VI and VII of
the right liver. The major blood supply arises from the left branch of the A
left portal vein (LPV) and the left hepatic artery close to the base of the
umbilical fissure of the liver. The hepatic veins (MHV, LHV) are short in
course and drain from the caudate directly into the anterior and left
aspect of the vena cava. LHV, Left hepatic vein; RPV, right portal vein;
PV, main trunk of portal vein.
link with a similar component of fibrous tissue (called the

venal caval ligament) that protrudes from the posterior surface
of segment VII and embraces the vena cava (see Figs. 2.1C
and 2.11). In 50% of patients, this ligament is replaced by
hepatic tissue, in whole or in part, and the caudate may com- p
pletely encircle the IVC and may contact segment VII on the
right side; a significant retrocaval component may prevent a *
left-sided approach to the caudate veins. The caudal margin
v
of the caudate lobe can have a papillary projection that occa-
sionally may attach to the rest of the lobe via a narrow con- a
nection. It is bulky in 27% of cases and can be mistaken for
an enlarged lymph node on computed tomography (CT) scan
(Fig. 2.13).
To summarize:
1. The liver is divided into two hemilivers by the main hepatic
scissura, where the middle hepatic vein runs.
2. The left liver is divided into two sections. The
B
Brisbane 2000 nomenclature describes the left lateral
section (segments 2 and 3) and the left medial section FIGURE 2.13. Computed tomographic image of the caudate lobe with
(segment 4). papillary process. A, Caudate lobe (asterisk) positioned between the left
3. The right liver is divided into an anterior section (segments portal vein (arrow) and inferior vena cava (v). a, Aorta. B, Papillary
5 and 8) and posterior section (segments 6 and 7). process of the caudate (p) represents the lower medial extension of the
4. Segment 1, the caudate lobe, lies posteriorly and embraces caudate (asterisk) and may mimic a periportal lymph node (Arrow) indi-
the IVC, its intraparenchymal anterior surface abutting the cates left portal vein.
posterior surface of segment 4 and merging with segments
6 and 7 on the right (Fig. 2.14; see Fig. 2.11).
Further details of segmental anatomy important in sectional
or segmental resection are described in Chapters 103B and
108B.

Surgical Implications and Exposure

All methods for precise partial hepatectomy depend on control
of the inflow vasculature and draining bile ducts and the outflow
hepatic veins of the portion of liver to be excised, which may
IVa be a segment, a subsegment, or an entire lobe. The remnant
II remaining after partial hepatectomy must be provided with an
excellent portal venous inflow, hepatic arterial supply, and
I
VIII biliary drainage and unimpeded hepatic venous outflow. The
classification of the various partial hepatic resection procedures,
incisions and exposure, necessary mobilization of the liver, and
VII the methods of control of the structures within the portal triads
and of the hepatic veins are described in detail in Chapters 103
and 108B.
BILIARY TRACT
A Biliary exposure and precise dissection are the most important
steps in any biliary operative procedure. A thorough under-
standing of biliary anatomy is necessary.
Intrahepatic Bile Duct Anatomy

The right and left livers are drained by the right and the left
hepatic ducts, whereas the caudate lobe is drained by several
IVb III ducts that join both the right and left hepatic ducts. The intra-
hepatic ducts are tributaries of the corresponding hepatic ducts,
which form part of the major portal triads that penetrate the
V I liver, invaginating Glissons capsule at the hilus. Bile ducts
usually are located above the corresponding portal branches,
whereas hepatic arterial branches are situated inferiorly to the
VI veins. Each branch of the intrahepatic portal veins corresponds
to bile duct tributaries that join to form the right and left
hepatic ductal systems, converging at the liver hilus to consti-
tute the common hepatic duct. The umbilical fissure divides
the left liver, passing between segments III and IV, which may
B be bridged by a tongue of liver tissue. The ligamentum teres
passes through the umbilical fissure to join the left branch of
the portal vein.
The left hepatic duct drains the three segmentsII, III,
and IVthat constitute the left liver (Fig. 2.15). The duct
that drains segment III is located slightly behind the left horn
of the umbilical recess. It is joined by the tributary from
IVb III segment IVb to form the left duct, which is similarly joined
by the duct of segment II and the duct of segment IVa, where
the left branch of the portal vein turns forward and caudally.
V
I The left hepatic duct traverses beneath the left liver at the
base of segment IV, just above and behind the left branch of
the portal vein; it crosses the anterior edge of that vein and
VI joins the right hepatic duct to constitute the hepatic ductal
confluence. In its transverse portion, it receives a few small
branches from segment IV.
The right hepatic duct drains segments V, VI, VII, and VIII
and arises from the junction of two main sectional duct tribu-
taries. The posterior or lateral duct and the anterior or medial
duct are each accompanied by a corresponding vein and artery.
C The right posterior sectional duct has an almost horizontal
FIGURE 2.14. Hepatic segmental anatomy as shown by computed course and constitutes the confluence of the ducts of segments
tomography at A, the level of the hepatic veins, B, at the portal vein VI and VII (Fig. 2.16). The duct then runs to join the right
bifurcation, and C, below the hepatic hilus. anterior sectional duct, as it descends in a vertical manner. The
right anterior sectional duct is formed by the confluence of the
ducts draining segments V and VIII. Its main trunk is located
to the left of the right anterior sectional branch of the portal

II
VIII V IV
VI
III
III
IV
V
V
VII II
Right Left
A B
Left hepatic duct
II
VIII
VII
IV
III
V
Common hepatic
duct
VI
C Right hepatic duct Common bile

duct
FIGURE 2.15. A, Biliary drainage of the two functional hemilivers. Note the position of the right anterior and right posterior sections. The caudate
lobe drains into the right and left ductal system. B, Inferior aspect of the liver. The biliary tract is represented in black, and the portal branches are
represented in white. Note the biliary drainage of segment IV (segment VIII is not represented because of its cephalad location). C, T-tube cholan-
giogram shows the most common arrangement of hepatic ducts.
vein, which pursues an ascending course. The junction of these system only. In about 7%, the drainage is into the right hepatic
two main right biliary channels usually occurs above the right system.
branch of the portal vein. The right hepatic duct is short and
joins the left hepatic duct to constitute the confluence lying in Extrahepatic Biliary Anatomy and Vascular Anatomy of
front of the right portal vein and forming the common hepatic the Liver and Pancreas
duct.
The caudate lobe (segment I) has its own biliary drainage The extrahepatic bile ducts are represented by the extrahepatic
(Healey & Schroy, 1953). The caudate lobe is divided into right segments of the right and left hepatic ducts, joining to form the
and left portions and a caudate process. In 44% of individuals, biliary confluence and the main biliary channel draining to the
three separate ducts drain these three parts of the lobe, whereas duodenum. (Figs. 2.17 and 2.18). The confluence of the right
in another 26%, a common duct lies between the right portion and left hepatic ducts occurs at the right of the hilar fissure of
of the caudate lobe proper and the caudate process and an the liver, anterior to the portal venous bifurcation and overlying
independent duct that drains the left part of the caudate lobe. the origin of the right branch of the portal vein. The extrahe-
The site of drainage of these ducts varies. In 78% of patic segment of the right duct is short, but the left duct has a
cases, drainage of the caudate lobe is into the right and left much longer extrahepatic course. The biliary confluence is
hepatic ducts, but in 15%, drainage is by the left hepatic ductal separated from the posterior aspect of segment IVB of the liver

Right posterior
VIII sectoral duct
A VII
Left hepatic duct
VI
Right anterior
sectoral duct
B
FIGURE 2.16. A, Biliary and vascular anatomy of the right liver. Note the horizontal course of the posterior sectional duct and the vertical course
of the anterior sectional duct. B, Transtubal cholangiogram shows a common normal variant: the right posterior sectional duct drains into the left
hepatic duct. In this case, the posterior duct is anterior to the posterior sectional duct. Frequently in this variant, the posterior duct passes posteriorly
to the anterior sectional pedicle.
by the hilar plate, which is the fusion of connective tissue et al, 1981). The commonly accepted working definition of
enclosing the biliary and vascular elements with the Glisson the triangle of Calot recognizes, however, the inferior surface
capsule (Fig. 2.19). Because of the absence of any major vas- of the right lobe of the liver as the upper border and the cystic
cular interposition, it is possible to open the connective tissue duct as the lower border (Wood, 1979). Dissection of the
constituting the hilar plate at the inferior border of segment IV triangle of Calot is of key significance during cholecystectomy,
and, by elevating it, to display the biliary confluence and left because in this triangle runs the cystic artery, often the right
hepatic duct (Fig. 2.20). branch of the hepatic artery, and occasionally a bile duct,
which should be displayed before cholecystectomy (see
Main Bile Duct and Sphincter of Oddi Chapter 35). If there is a replaced or accessory common or
The main bile duct, the mean diameter of which is approxi- right hepatic artery, it usually runs behind the cystic duct to
mately 6 mm, is divided into two portions: the upper is called enter the triangle of Calot (Fig. 2.21).
the common hepatic duct and is situated above the cystic duct, The common variations in the relationship of the hepatic
which joins it to form the lower portion, the common bile artery and origin and course of the cystic artery to the biliary
duct (CBD). The common duct courses downward anterior apparatus are shown in Figure 2.22. Ignorance of these varia-
to the portal vein, in the free edge of the lesser omentum; it tions may provoke unexpected hemorrhage or biliary injury
is closely applied to the hepatic artery, which runs upward on (Champetier etal, 1982) during cholecystectomy and may
its left, giving rise to the right branch of the hepatic artery, result in bile duct injury during efforts to secure hemostasis
which crosses the main bile duct usually posteriorly, although (see Chapter 42). The union between the cystic duct and the
in approximately 20% of cases, it crosses anteriorly. The cystic common hepatic duct may be located at various levels. At its
artery, arising from the right branch of the hepatic artery, may lower extrahepatic portion, the CBD traverses the posterior
cross the common hepatic duct posteriorly or anteriorly. The aspect of the pancreas, running in a groove or tunnel. The
common hepatic duct constitutes the left border of the triangle retropancreatic portion of the CBD approaches the second
of Calot, the other corners of which were originally described portion of the duodenum obliquely, accompanied by the ter-
as the cystic duct below and the cystic artery above (Rocko minal part of the pancreatic duct of Wirsung.

a b
c
i
d
j e
f
g
h
k
FIGURE 2.18. Endoscopic retrograde choledochopancreatogram

showing the pancreatic duct (arrow), gallbladder, and biliary tree.
V VIII
VII
C
FIGURE 2.17. Anterior aspect of the biliary anatomy and of the head
of the pancreas: right hepatic duct (a), left hepatic duct (b), common II
hepatic duct (c), hepatic artery (d), gastroduodenal artery (e, cystic duct VI
(f), retroduodenal artery (g), common bile duct (h), neck of the gallbladder B
(i), body of the gallbladder (j), fundus of the gallbladder (k). Note particu-
larly the position of the hepatic bile duct confluence anterior to the right III
branch of the portal vein, the posterior course of the cystic artery behind IV
the common hepatic duct, and the relationship of the neck of the gall-
bladder to the right branch of the hepatic artery. Note also the relation- A
ship of the major vessels (portal vein, superior mesenteric vein, and
superior mesenteric artery) to the head of the pancreas.
FIGURE 2.19. Anatomy of the plate system. A, Cystic plate, above the
Gallbladder and Cystic Duct gallbladder. B, Hilar plate, above the biliary confluence and at the base
The gallbladder is a reservoir located on the undersurface of of segment IV. C, Umbilical plate, above the umbilical portion of the portal
vein. Large, curving arrows indicate the plane of dissection of the cystic
the right lobe of the liver, within the cystic fossa; it is separated
plate during cholecystectomy and of the hilar plate during approaches
from the hepatic parenchyma by the cystic plate, which is com-
to the left hepatic duct.
posed of connective tissue that extends to the left as the hilar
plate (see Fig. 2.19). Sometimes the gallbladder is deeply
embedded in the liver, but occasionally it occurs on a mesen-
teric attachment and may be susceptible to volvulus. The gall- The cystic duct arises from the neck or infundibulum of the
bladder varies in size and consists of a fundus, a body, and a gallbladder and extends to join the common hepatic duct. Its
neck (Fig. 2.23). The fundus usually, but not always, reaches lumen usually measures approximately 1 to 3mm, and its
the free edge of the liver and is closely applied to the cystic length varies, depending on the type of union with the common
plate. The cystic fossa is a precise anterior landmark to the main hepatic duct. The mucosa of the cystic duct is arranged in spiral
liver incisura. The neck of the gallbladder makes an angle with folds known as the valves of Heister (Wood, 1979). Although the
the fundus and creates Hartmanns pouch, which may obscure cystic duct joins the common hepatic duct in its supraduodenal
the common hepatic duct and constitute a real danger point segment in 80% of cases, it may extend downward to the ret-
during cholecystectomy. roduodenal or retropancreatic area. Occasionally, the cystic

A B
Umbilical
fissure
Ligamentum
teres
Gallbladder
fossa
C
FIGURE 2.20. A, Relationship between the posterior aspect of segment IV and the biliary confluence. The hilar plate (arrow) is formed by the fusion
of the connective tissue enclosing the biliary and vascular elements with the Glisson capsule. B, Biliary confluence and left hepatic duct exposed by
lifting segment IV upward after incision of the Glisson capsule at its base. This technique, lowering of the hilar plate, generally is used to display a
dilated bile duct above an iatrogenic stricture or hilar cholangiocarcinoma. C, Line of incision (left) to allow extensive mobilization of segment IV. This
maneuver is of particular value for high bile duct strictures and in the presence of liver atrophy or hypertrophy. The procedure consists of lifting
segment IV upward (A and B), then not only opening the umbilical fissure but also incising the deepest portion of the gallbladder fossa. Right, Inci-
sion of the Glisson capsule to gain access to the biliary system (arrow). (B, From Hepp J, Couinaud C: Labord et lutilisation du canal hpatique
gauche dans les reparations de la voie biliare principale. Presse Med 64:947-948, 1956.)
duct may join the right hepatic duct or a right hepatic sectional 16% the right anterior sectional duct, and in 4% the right
duct (Fig. 2.24). posterior sectional duct, may approach the main bile duct in
this fashion. In 6%, a right sectional duct may join the left
BILIARY DUCTAL ANOMALIES hepatic duct (the posterior duct in 5% and the anterior duct in
1%. In 3%, there is an absence of the hepatic duct confluence,
Full knowledge of the frequent variations from the described and the right posterior sectional duct may join the neck of the
normal biliary anatomy is required when any hepatobiliary gallbladder, or it may be entered by the cystic duct in 2%
procedure is performed (Fig. 2.25). The constitution of a (Couinaud, 1957). In any event, these multiple biliary ductal
normal biliary confluence by union of the right and left hepatic variations at the hilus are important to recognize in resection
ducts, as described previously, is reported in only 72% of and reconstructive surgery of the biliary tree at the hilus and
patients (Healey & Schroy, 1953). There is a triple confluence during partial hepatectomy and cholecystectomy.
of the right anterior and posterior sectional ducts and the left Intrahepatic bile duct variations also are common (Fig.
hepatic duct in 12% of individuals (Couinaud, 1957), and a 2.26) (Healey & Schroy, 1953). The main right intrahepatic
right sectional duct joins the main bile duct directly in 20%. In duct variations are represented by an ectopic drainage of

A B
CBD HA
CD
Replaced or
accessory
RHA
C
FIGURE 2.21. Hepatic artery variations shown by angiography. A, Replaced common hepatic artery arises from the superior mesenteric trunk. B,
Left, The hepatic artery (large arrowhead) arises from the celiac axis. The small arrowheads indicate a drainage catheter in the bile duct. Right, An
accessory right hepatic artery (large arrowhead) is arising from the superior mesenteric artery and lies lateral to the catheter (small arrowheads) in
the common bile duct (CBD). C, The accessory right hepatic artery usually courses upward in the groove posterolateral to the CBD, appearing on
the medial side of the triangle of Calot, usually running just behind the cystic duct (CD). This common variation occurs in about 25% of individuals.
HA, Hepatic artery; RHA, right hepatic artery.
segment V in 9%, of segment VI in 14%, and of segment VIII In 67% of patients (Healey & Schroy, 1953) a classic distri-
in 20%. In addition, a subvesical duct has been described in bution of the main left intrahepatic biliary ductal system exists.
20% to 50% of cases. This duct, sometimes deeply embedded The main variation in this region is represented by a common
in the cystic plate, joins either the common hepatic duct or the union between the ducts of segments III and IV in 25%, and
right hepatic duct. It does not drain any specific liver territory, in only 2% does the duct of segment IV join the common
never communicates with the gallbladder, and is not a satellite hepatic duct independently. Several anomalies of drainage of
of an intrahepatic branch of the portal vein or hepatic artery. the intrahepatic ducts into the neck of the gallbladder or cystic
Although not of major anatomic significance, injury may occur duct have been reported (Fig. 2.27) (Albaret etal, 1981;
during cholecystectomy if the cystic plate is not preserved. This Couinaud, 1957), and these must be kept in mind during cho-
may lead to a postoperative biliary leak. lecystectomy (see Chapter 33).

a b c
d e f
g h
A
FIGURE 2.22. The main variations of the cystic artery: typical course
(a), double cystic artery (b), cystic artery crossing anterior to main bile
duct (c), cystic artery originating from the right branch of the hepatic
artery and crossing the common hepatic duct anteriorly (d), cystic artery
originating from the left branch of the hepatic artery (e), cystic artery
originating from the gastroduodenal artery (f), cystic artery arising from
the celiac axis (g), cystic artery originating from a replaced right hepatic
artery (h).
GB
PV
IVC
B
FIGURE 2.23. Longitudinal sonogram shows the relationship of the
FIGURE 2.24. A, T-tube cholangiogram shows a very low insertion of
liver, gallbladder (GB), portal vein (PV), inferior vena cava (IVC), hepatic
a right sectional duct into the common hepatic duct (arrow). B, Endo-
artery (curved arrow) and common bile duct (straight arrow).
scopic retrograde choledochopancreatogram shows a low right sec-
tional duct (large arrow), into which is draining the cystic duct (small
arrow), an uncommon but important normal variant.

ra ra duct but two fundi (Hobby, 1970), and duplication of the

rp lh rp lh gallbladder with two cystic ducts all have been described. A
double cystic duct may drain a unilocular gallbladder (Perel-
man, 1961), and congenital diverticulum of the gallbladder
A 57% B 12% with a muscular wall may also be found (Eelkema etal, 1958).
More frequently reported are anomalies of position of the gall-
bladder, which may be in an intrahepatic position, completely
ra ra
lh surrounded by normal liver tissue, or it may be found on the
rp lh left of the liver (Newcombe & Henley, 1964).
The mode of union of the cystic duct with the common
rp hepatic duct may be angular, parallel, or spiral. An angular
union is the most frequent and is found in 75% of patients
16% 4%
C 20% (Kune, 1970). The cystic duct may run a parallel course to the
C1 16% C2 common hepatic duct in 20%, with connective tissue ensheath-
ra
ing both ducts. Finally, the cystic duct may approach the CBD
ra in a spiral fashion. The absence of a cystic duct is probably an
rp acquired anomaly, representing a cholecystocholedochal fistula.
rp lh lh
D 6% BILE DUCT BLOOD SUPPLY

5% 1%
The bile duct may be divided into three segments: hilar, supra-
D1 D2 duodenal, and retropancreatic. The blood supply of the supra-
IV III duodenal duct is essentially axial (Fig. 2.29) (Northover &
ra IV III
Terblanche, 1979). Most vessels to the supraduodenal duct
rp ra
arise from the superior pancreaticoduodenal artery, right branch
II II of the hepatic artery, cystic artery, gastroduodenal artery, and
rp
E 3% I I retroduodenal artery. On average, eight small arteries, each
measuring approximately 0.3mm in diameter, supply the
2% 1%
supraduodenal duct. The most important of these vessels run
E1 E2 along the lateral borders of the duct and have been called the
3 oclock and 9 oclock arteries. Of the blood vessels vascularizing
ra the supraduodenal duct, 60% run upward from the major infe-
rp rior vessels, and only 38% of arteries run downward, originating
lh from the right branch of the hepatic artery and other vessels.
Only 2% of the arterial supply is nonaxial, arising directly from
the main trunk of the hepatic artery, as it courses up parallel
F 2% to the main biliary channel. The hilar ducts receive a copious
supply of arterial blood from surrounding vessels, forming a
rich network on the surface of the ducts in continuity with the
FIGURE 2.25. Main variations of the hepatic duct confluence. plexus around the supraduodenal duct. The source of blood
A, Typical anatomy of the confluence. B, Triple confluence. C, Ectopic supply to the retropancreatic CBD is from the retroduodenal
drainage of a right sectional duct into the common hepatic duct. C1, artery, which provides multiple small vessels running around
Right anterior (ra) duct draining into the common hepatic duct; C2, right the duct to form a mural plexus.
posterior (rp) duct draining into the common hepatic duct. D, Ectopic The veins draining the bile ducts are satellites to the cor-
drainage of a right sectional duct into the left hepatic ductal system. D1, responding described arteries, draining into 3 oclock and 9
Right posterior sectional duct draining into the left hepatic (lh) ductal
oclock veins along the borders of the common biliary channel.
system; D2, right anterior sectional duct draining into the left hepatic
Veins draining the gallbladder empty into this venous system,
ductal system. E, Absence of the hepatic duct confluence. F, Absence
of right hepatic duct and ectopic drainage of the right posterior duct into not directly into the portal vein, and the biliary tree seems to
the cystic duct. (From Couinaud C: Le Foi: tudes Anatomogiques et have its own portal venous pathway to the liver.
Chirurgicales. Paris, 1957, Masson.)
ANATOMY OF BILIARY EXPOSURE

Biliary-Vascular Sheaths and Exposure of the Hepatic
Bile Duct Confluence
ANOMALIES OF THE GALLBLADDER AND Fusion of the Glisson capsule with the connective tissue sheaths
CYSTIC DUCT surrounding the biliary and vascular elements at the inferior
aspect of the liver constitute the plate system (see Figs. 2.19
Many anomalies of the accessory biliary apparatus have been and 2.20), which includes the hilar plate above the biliary con-
described (Fig. 2.28) (Gross, 1936). Although rare, agenesis of fluence, the cystic plate related to the gallbladder, and the
the gallbladder (Boyden, 1926; Rachad-Mohassel etal, 1973; umbilical plate situated above the umbilical portion of the left
Rogers etal, 1975), bilobar gallbladders with a single cystic portal vein (Couinaud, 1957). Hepp and Couinaud (1956)

VIII D seg IV
VII
A seg V
VI a 67% b 1%
II II
91%
VIII VII VIII III

VII III
VI VI c 1%
II
5% 4%
III
VII
d 25% e 1% II
B seg VI II
VIII 86%
V
VII VII III III
VII
VIII VIII
VIII f 1%
II
V 10% V 2% V 2%
III
VII VII
VI g 4%
VI II
V
80% V 20%
C seg VIII
III
FIGURE 2.26. The main variations of the intrahepatic ductal system. A, Variations of segment V. B, Variations of segment VI. C, Variations of
segment VIII. D, Variations of segment IV. There is no variation of drainage of segments II, III, and VII. seg, Segment.
described a technique whereby lifting the segment IV upward Frequently, by a simultaneous opening of the deepest portion
and incising the Glisson capsule at its base offers a good expo- of the gallbladder fossa and the umbilical fissure (see Fig.
sure of the hepatic hilar structures (see Fig. 2.20). This tech- 2.20C), good exposure of the biliary duct confluence, and
nique is referred to as lowering of the hilar plate. It can be carried especially the right hepatic duct, can be obtained without the
out safely because only exceptionally (in 1% of cases) is there necessity for full hepatotomy.
any major vascular interposition between the hilar plate and the
inferior aspect of the liver, although tiny venules are common. Umbilical Fissure and Segment III (Ligamentum
This maneuver is of particular value in exposing the extrahe- Teres) Approach
patic segment of the left hepatic duct because it has a long
course beneath the segment IV. It is not as effective in exposing The round ligament, which is the remnant of the obliterated
the extrahepatic right duct or its secondary branches, which are umbilical vein, runs through the umbilical fissure to connect
short. The technique is of major importance for the identifica- with the left branch of the portal vein. The round ligament is
tion of proximal biliary mucosa during bile duct repair after sometimes deeply embedded in the umbilical fissure. At the
injury. Basically, an incision is required at the posterior edge of junction of the round ligament and the termination of the left
segment IV, where the Glisson capsule is attached to the hilar portal vein, elongations containing channels that are elements
plate. The upper surface of the hilar plate can be separated from of the left portal system course into the liver. The bile ducts of
the hepatic parenchyma and, by lifting segment IV upward, the left lobe of the liver (Figs. 2.30 and 2.31A) are located above
display of the hepatic duct convergence, which is always extra- the left branch of the portal vein and lie behind these elonga-
hepatic, is effected. Bile duct incision allows performance of a tions, whereas the corresponding artery is situated below the
mucosa-to-mucosa anastomosis. Rarely, it may be hazardous to vein. Dissection of the round ligament on its left side and divi-
approach the biliary confluence in this manner, especially when sion of one or two vascular elongations of segment III allow
anatomic deformity has been created by atrophy or hypertrophy display of the pedicle or anterior branch of the duct of segment
of liver lobes and in patients in whom there appears to be a III (Fig. 2.32). In the event of biliary obstruction with intrahe-
very deep hilus that is displaced upward and rotated laterally. patic biliary ductal dilation, a dilated segment III duct is

VI
A B C d
RP a
D
b f
RP
g
c
h
E F
FIGURE 2.27. The main variations of ectopic drainage of the intrahe-
patic ducts into the gallbladder and cystic duct. A, Drainage of the cystic
duct into the biliary confluence. B, Drainage of cystic duct into the left
hepatic duct, associated with no biliary confluence. C, Drainage of
segment VI duct into the cystic duct. D, Drainage of the right posterior
(RP) sectional duct into the cystic duct. E, Drainage of the distal part of
the right posterior sectional duct into the neck of the gallbladder. F,
Drainage of the proximal part of the right posterior sectional duct into FIGURE 2.29. The bile duct blood supply. Note the axial arrangement
the body of the gallbladder. of the vasculature of the supraduodenal portion of the main bile duct
and the rich network enclosing the right and left hepatic ducts: right
branch of the hepatic artery (a), 9 oclock artery (b), retroduodenal artery
(c), left branch of the hepatic artery (d), hepatic artery (e), 3 oclock artery
A (f), common hepatic artery (g), gastroduodenal artery (h).
1 2 3
C
IV
B
II
1
1 2
1 2
III
E
FIGURE 2.30. Biliary and vascular anatomy of the left liver. Note the
location of the segment III duct above the corresponding vein. The
75% 20% 5% anterior branch of the segment IV duct is not represented.
a b c
FIGURE 2.28. Main variations in gallbladder and cystic duct anatomy.
A, Duplicated gallbladder. B, Septum of the gallbladder. C, Diverticulum
of the gallbladder. D, Variations in cystic ductal anatomy. E, Different
types of union of the cystic duct and common hepatic duct: angular
union (a), parallel union (b), spiral union (c).
II
b
a
III
b
IV
c
c
d
A B
FIGURE 2.31. A, The biliary and vascular anatomy of the left liver. Note the relationship of the left horn of the umbilical recess with the segment
III ductal system: left portal vein (a), left hepatic duct (b), segment III systemnote that the duct (black) lies adjacent to the portal venous branch
indicated (c), ligamentum teres (d). B, Segment III ductal approach: exposure of the left horn of the umbilical recess (a), division of the left horn of
the umbilical recess including segment III portal vein branches (b), exposure and opening of segment III duct: hepaticojejunostomy to the segment
III ductal system (c; see also Chapters 31 and 42).
A B
FIGURE 2.32. A, The liver is split to the left of the ligamentum teres in the umbilical fissure. It may be necessary to remove a small wedge of liver
tissue (c). B, Segment III duct is exposed at the base of the liver split, above and behind its accompanying vein, and is ready for anastomosis (see
also Chapters 31 and 42).

A B
FIGURE 2.33. A, Anterior sectional approach. If necessary, the liver substance is opened through a short distance in the line of the right anterior
sectional pedicle. B, The duct is displayed anterior and to the left side of the corresponding vein. This can be facilitated by using a posterior pedicular
approach as described by Launois (see Chapter 103B).
generally easily located above the left branch of the portal vein. of the mobilization of segment IV after opening of the principal
It is often preferable to split the normal liver tissue just to the scissura and the umbilical fissure as described previously.
left of the umbilical fissure to widen the fissure further, which
allows access to the ductal system with no need to divide any EXTRAHEPATIC VASCULATURE
elements of the portal blood supply to segment III (see Fig.
2.32). Celiac Axis and Blood Supply of Liver, Biliary Tract,
and Pancreas
Surgical Approaches to the Right Hepatic Biliary
Ductal System The usual classic description of the arterial blood supply of the
Because of the lack of precise anatomic landmarks, exposure liver, biliary system, and pancreas is found in only approxi-
of the right intrahepatic ductal system is much more hazardous mately 60% of patients (Figs. 2.34 to 2.36). The right and the
and imprecise than that of the left. In some cases of hilar left hepatic arteries, the former in the right of the hilus of the
cholangiocarcinoma, the planned surgical procedurepartial liver and the latter in the left at the base of the umbilical fissure,
hepatectomy (see Chapters 51B and 103B) or segment III become enclosed in the sheath of peritoneum, forming the right
duct bypass (see Chapters 31 and 42)seems impossible at and left portal triads. In this sheath, further branching to the
operation. In such a critical operative situation, intrahepatic right anterior and posterior sections of the liver and on the left
right ductal system drainage is an option. Anatomically, the to segments II, III, and IV occurs within the respective pedicles,
anterior sectional duct and its branches run on the left side which also come to enclose the portal vein branches and the
of the corresponding portal vein. In essence, the end of the tributary bile ducts from these sections and segments. The arte-
liver scissura, within which lies the right branch of the portal rial supply of the CBD was described earlier; it arises from
vein, is opened through a short distance. The anterior sectional branches of the hepatic artery, the gastroduodenal artery, and
duct is displayed on the left aspect of the vein, and the dilated the pancreaticoduodenal arcades.
duct is opened longitudinally and sewn to a Roux-en-Y loop For practical surgical issues, the most important relation-
of jejunum (Fig. 2.33). Although this technique is rarely used, ships in the anatomy of the pancreas concern the arterial blood
it may be valuable in selected cases. Preferably, the right-sided supply and the venous drainage. The dorsal pancreatic artery
pedicles can be encircled and exposed by the technique used is a major branch, usually arising from the splenic artery, but
for pedicle exposure and control described for right-sided liver it can arise directly from the hepatic artery. When splenectomy
resection. is performed, it is important to establish the site of origin of the
dorsal pancreatic artery to avoid distal pancreatic ischemia. The
Exposure of the Bile Ducts by Liver Resection superior mesenteric artery (SMA) arises from the aorta poste-
This chapter does not detail exposure of the bile ducts by resec- riorly behind the pancreas and runs forward and upward to run
tion of liver substance. In essence, a segment of the left lobe first behind and then to the left of the superior mesenteric vein
may be amputated to expose the segment II or III ducts, or a (SMV) (see Fig. 2.35).
similar procedure may be carried out after removal of the infe-
rior tip of the right lobe. Finally, in some instances, removal of Variations in the Hepatic Artery
segment IV may be carried out to effect exposure of the biliary As a result of the complex embryologic development of the
confluence. This procedure really represents a simple extension celiac axis and SMA, wide variations in the arterial supply of

MH LH Left gastric
Aorta LGA SA
PV
RH HA
Celiac trunk RGA DP
GDA
Cystic Splenic SPDA
Proper hepatic
Pancreas
Supraduodenal Post PDA
MCA
Gastroduodenal MCV
Right Common hepatic GEA
gastric
FIGURE 2.34. The celiac trunk is a short, thick artery originating from Ant PDA
the aorta just below the aortic hiatus of the diaphragm and extending
horizontally and forward above the pancreas, where it divides into the IPDA
left gastric, common hepatic, and splenic arteries. An inferior phrenic SMA
artery, usually arising from the aorta or the splenic artery, occasionally SMV
arises from the celiac trunk. The left gastric artery curves toward the FIGURE 2.35. The primary arteries that supply the pancreas are the
stomach and extends along its lesser curve, forming anastomoses with gastroduodenal artery (GDA), which arises usually from the common
the right gastric artery. The splenic artery, the largest of the three celiac hepatic artery (HA) while it crosses the portal vein (PV) above the pan-
branches, takes a tortuous course to the left, behind and along the creas proper, and the dorsal pancreatic artery (DP), arising from the
upper border of the pancreas and at the hilus of the spleen, where it splenic artery (SA). The superior pancreaticoduodenal arteries (SPDAs)
splits into numerous terminal branches. The splenic artery usually arise from the GDA and join the inferior pancreaticoduodenal arteries
approaches and runs superiorly to the splenic vein. An uncommon but (IPDAs) from the superior mesenteric artery (SMA), forming two arcades
dangerous abnormality can occur when the splenic artery runs inferiorly along the anterior and posterior aspects of the head of the pancreas.
and behind the splenic vein, close to the splenic veinmesenteric vein The GDA, after giving rise to the pancreaticoduodenal artery (PDA),
confluence. The left gastroepiploic artery and the short gastric arteries passes forward and to the left as the right gastroepiploic artery (GEA).
originate from one of these terminal branches. The common hepatic The GDA is a good landmark for the identification of the portal vein above
artery passes forward into the retroperitoneum then curves to the right the pancreas, and surgical division of the GDA just at its origin from the
to enter the right margin of the lesser omentum, just above the pancreas, common HA gives much greater access to the anterior surface of
and ascends; it approaches the common bile duct (CBD) on its left side the portal vein at this site. The right gastric artery (RGA) also usually
and runs usually anterior to the portal vein. While it turns upward just arises from the common HA just distal to the GDA, but it can arise from
above the pancreas, it gives rise to the gastroduodenal artery, which various sites. The GDA commonly divides into a larger right GEA and
also may originate from the right hepatic artery. This descends to supply smaller SPDA. The right GEA runs forward between the first part of the
the anterior, superior, and posterior surfaces of the first inch of the duodenum and pancreas; the SPDA divides into anterior and posterior
duodenum. The gastroduodenal artery can be duplicated and often has branches. The anterior superior PDA continues downward on the ante-
a small branch running with it toward the pylorus. The right gastric artery rior surface of the head of the pancreas to anastomose with the IPDA,
passes to the left along the lesser curve of the stomach, and anasto- which arises from the SMA. The posterior superior PDA behaves simi-
mosis is to the left gastric artery. The continuation of the common larly. Ant, Anterior; LGA, left gastric artery; MCA, middle colic artery;
hepatic artery, beyond the origin of the gastroduodenal artery and right MCV, middle colic vein; Post, posterior; SMV, superior mesenteric vein.
gastric artery, is known as the proper hepatic artery and usually soon
divides into a right and a left branch. The left branch extends vertically,
directly toward the base of the umbilical fissure, and usually gives off a
branch known as the middle hepatic artery (MH), which is directed
toward the right of the umbilical fissure and is destined to supply
segment IV of the liver. A further branch of the left hepatic artery (LH)
courses to the left to supply the caudate lobe, and further smaller
caudate branches arise from the left and right hepatic artery. The right
hepatic artery (RH) usually passes behind the common hepatic duct and
enters the cystic triangle of Calot; in some cases, it passes in front of
the bile duct, which is important in surgical exposure of the CBD. The p
cystic artery usually arises from the right hepatic artery but has many c
variations. IVC a s
FIGURE 2.36. Computed tomographic image of the main portal vein

shows the hepatic artery (solid arrows) coursing anterior to the portal
vein (p). The interlobar fissure (open arrow), splenic vein (s), celiac axis
(c), aorta (a), and inferior vena cava (IVC) are also shown.

the liver are found (Fig. 2.37). These variations are important posteriorly to the right renal vein and the anterior surface of
to recognize. Failure to show all arteries feeding the liver at the IVC. The neck and body of the pancreas lie atop the SMA
angiography may not only result in errors of diagnosis but may and the splenic vessels and their branches, the left renal vein,
also seriously mislead the surgeon or the interventional radiolo- and, more laterally, the left kidney. The right gastroepiploic vein
gist. In most cases, the hepatic artery arises from the celiac axis commonly drains into the anterior surface of the SMV just at
as described earlier, but it may be entirely replaced by a common the inferior border of the pancreas; this can often be involved
hepatic artery that originates from the SMA. In this instance, by tumor, as can the anterior branch of the inferior pancreati-
the hepatic artery passes posterior and then lateral to the portal coduodenal vein; the middle colic vein may also join at this
vein while it ascends and lies posterolateral to the CBD in the point. In mobilizing the SMV, these vessels are ligated so as to
hepatoduodenal ligament, where it is susceptible to operative avoid bothersome hemorrhage. Abnormalities of the IVC are
injury if not recognized. This applies to a right replaced or an uncommon, with duplication of the vena cava and a left-sided
accessory hepatic artery. Other variations in the origin of the vena cava seen rarely.
common hepatic artery include its origin directly from the aorta Several variations in anatomy and rare congenital anomalies
and the persistence of a primitive embryologic link between the of the portal vein are of surgical significance (Figs. 2.40 to
celiac and superior mesenteric systems. These variations are of 2.43). For example, performance of right hepatic resection,
considerable importance in controlling the arterial blood supply with division of what appears to be the right portal vein in a
to the liver during hepatic resection, liver transplantation, devas- patient with absence of the left portal vein (see Figs. 2.42 and
cularization of the liver, placement of intraarterial hepatic infu- 2.43) can be fatal. Agenesis of the right branch of the portal
sion devices, and in the resection of the head of the pancreas. vein is associated with agenesis of the right hemiliver and left
liver hypertrophy. This may be associated with biliary and
Portal Vein hepatic venous anatomic anomalies, which can compromise
The portal vein (Fig. 2.38) is formed behind the neck of the surgical approaches to the liver and to biliary repair (Fields
pancreas by confluence of the superior mesenteric and splenic etal, 2008).
veins (Fig. 2.39). The venous drainage of the pancreas usually Portal venous blood is derived from the venous drainage of
runs parallel to the arterial supply. There are anterior and the stomach, small bowel, spleen, and pancreas, and this drain-
posterior and superior and inferior pancreaticoduodenal veins age is important when considering surgery of the pancreas and
that drain to the portal vein and the SMV. The left gastric vein in patients with portal hypertension; it is described in detail
and the inferior mesenteric vein (IMV) usually drain into the along with the description of the anatomy of the pancreas.
splenic vein, but they can drain directly into the portal vein,
whereas the various small splenic tributaries drain directly to PANCREAS
the splenic vein.
The anatomic relationship of the pancreas to the SMV, the The pancreas is a posteriorly situated retroperitoneal organ that
splenic vein, and the portal vein (see Fig. 2.38) is important in lies transversely (Fig. 2.44). The organ is composed of a head,
pancreatic resection (see Chapter 66). The uncinate process can neck, body, and tail. The head is encompassed by the duode-
extend behind the SMV to well behind the SMA (see Fig. 2.35). num, whereas the tail rests in the splenic hilum (Figs. 2.45 and
Access to the portal vein behind the pancreas usually is obtained 2.46). A portion of the head inferiorly is termed the uncinate
from below by elevating the pancreas from the surface of the process and is intimately related to the SMV and SMA. Poste-
SMV just before it joins the splenic vein. With the exception of riorly, the pancreas is related to the IVC, aorta, left renal vein
the inferior pancreaticoduodenal veins, which enter the SMV and kidney, and spleen. The portion lateral to the portal vein
at the inferior border of the pancreas, it is uncommon to see averages 56.4% of the total weight. The pancreatic capsule is
branches from the pancreas run directly posteriorly into the loosely attached to the surface of the pancreas and is contiguous
SMV. Fixation here is usually by some inflammatory or neo- with the anterior layer of the mesocolon such that it can be
plastic process. Superiorly, the portal vein runs behind the dissected in continuity if necessary. The mesenteric attach-
pancreas and is identified first in the gap between the curvature ments to the pancreas tend to be contiguous (see Fig. 2.46).
of the splenic vein, splenic artery, common hepatic artery, and The arterial blood supply and venous drainage and the relation-
gastroduodenal artery. Division of the gastroduodenal artery ships to the CBD are described and illustrated earlier (see Figs.
provides much greater access to the superior surface of the 2.17, 2.29, 2.34, 2.35, and 2.38).
portal vein. If difficulty is encountered in this area, division of
the CBD, usually above the cystic duct, can provide excellent Pancreatic Duct
access to the right lateral aspect and anterior surface of the The duct of Wirsung, beginning in the distal tail as a confluence
portal vein. The SMA can be approached behind the pancreas of small ductules, runs through the body to the head, where it
above the point at which it is embraced by the uncinate process usually passes downward and backward in close juxtaposition
at the origin from the aorta. This allows dissection of the most to the CBD (see Fig. 2.45). The sphincter of Oddi (Fig. 2.47)
proximal part of the SMA. has been thoroughly studied (Boyden, 1957; Delmont, 1979)
Occasionally, the middle colic artery and other vessels of and consists of a unique cluster of smooth muscle fibers distin-
supply to the colon can arise from the more proximal SMA, guishable from the adjacent smooth muscle of the duodenal
such that they pass through the pancreas; this abnormality wall. The papilla of Vater at the termination of the CBD is a
should be searched for carefully. Division of the middle colic small, nipple-like structure that protrudes into the duodenal
artery is usually not a problem, however, because the colon is lumen and is marked by a longitudinal fold of duodenal mucosa.
well supplied with blood, and ischemia typically does not occur. The duct of Wirsung runs downward and parallel to the CBD
Of special importance to the surgeon is the direct relation- for approximately 2cm and joins it within the sphincter
ship of the head of the pancreas to the duodenum and Text continued on p. 58

FIGURE 2.37. In approximately 25% of individuals, the right hepatic artery arises
partially or completely from the superior mesenteric artery (A, C, E); in a similar propor-
tion of patients, the left hepatic artery may be partially or completely replaced by a
branch arising from the left gastric artery, 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, and the gastroduodenal artery
may originate from the right hepatic artery (B, C). Multidetector computed tomography
(CT) angiogram demonstrating an accessory right hepatic artery (arrow) arising from
the superior mesenteric artery (G). Multidetector CT angiogram demonstrating a A B
replaced left hepatic artery arising from the left gastric artery (H). Another common
arterial variant is the hepatic trifurcation (I).
C D
E F
G I

RAS LPV
Ligamentum teres
IVb
RAS III
RPS IVa
II
LPV
RPS
PV
RPV
CV
B
RAS LPV
SV
SMV
IMV PV
RPS
A C
FIGURE 2.38. A, The superior mesenteric vein (SMV) at the root of the lesser omentum is usually a single trunk; two, or sometimes even three,
branches may unite as the vessel enters the tunnel beneath the neck of the pancreas (shaded) to form a superior mesenteric trunk. This trunk
ascends behind the neck of the pancreas and is joined by the splenic vein (SV), which enters it from the left to form the portal vein (PV), which
emerges from the retroperitoneal upper border of the neck of the pancreas and ascends toward the liver within the free edge of the lesser omentum,
lying behind the bile duct and the hepatic artery and surrounded by the lymphatics and nodes of the lesser omentum. During this course, it receives
blood through the coronary vein (CV), which communicates with esophageal venous collaterals, which connect with the gastric vein and the esopha-
geal plexus. Sometimes a separate right gastric vein enters the PV in this area. A superior pancreaticoduodenal vein often enters the PV just above
the level of the pancreas, and several smaller veins enter the SMV and PV from the right side beneath the neck of the pancreas. As the PV ascends
behind the common bile duct and common hepatic duct, it approaches the hilus of the liver and bifurcates into two branches, a larger right (RPV)
and a smaller left portal vein (LPV). The branch on the left courses below the left hepatic duct to enter the umbilical fissure, in company with the left
hepatic artery, and subsequently branches to supply the left liver segments (II-IV). Just before its entry into the umbilical fissure, it gives off a major
caudate vein, segment I, which runs posteriorly and laterally to the left. Sometimes this vein consists of two or more branches; the right portal branch,
which is much shorter in length before its entry into the liver, divides at the extremity of the hilus into the right anterior (RAS) and posterior (RPS)
sectional branches and is accompanied by the respective arterial branches and biliary tributaries. B, The division of the portal vein may arise more
proximally, however, and C, the right anterior and posterior sectional portal veins may arise independently from the portal venous trunk. IMV, Inferior
mesenteric vein.
L
RA
M
p s
RP
sm
FIGURE 2.39. Magnetic resonance imaging of the splenoportal con-

fluence: postcontrast, T1-weighted, three-dimensional gradient-echo
coronal maximum intensity projection. Shown are the splenic vein (s),
portal vein (p), and superior mesenteric vein (sm).
FIGURE 2.40. Contrast-enhanced computed tomographic scan of

variant portal vein branching with trifurcation pattern. L, Left portal vein;
M, main portal vein; RA, right anterior portal vein; RP, right posterior portal
vein. (From Covey AM, etal: Incidence, patterns, and clinical relevance of
variant portal vein anatomy. Am J Roentgenol 183:1055-1064, 2004.)

A C
FIGURE 2.41. A, The portal vein anterior to the head of the pancreas and the duodenum may be in an abnormal position. B, Another rare but
interesting anomaly is the entrance of the portal vein into the inferior vena cava. C, Very rare, the entrance of a pulmonary vein into the portal vein.
FIGURE 2.42. In a congenital absence of the left branch of the portal

vein as described by Couinaud, the right branch courses through the right
lobe of the liver supplying it and curves within the liver substance to supply FIGURE 2.43. Computed tomographic scan in a patient with Carolis
the left lobe, which in such instances is usually smaller than normal. disease shows a large right portal trunk. The left branch of the portal
vein is absent, with findings confirmed at operation for left hepatic
lobectomy.

D
S
v
v
a
i a
r IVC
A
A B
FIGURE 2.44. A, Magnetic resonance imaging of the pancreas, oblique axial reconstruction, T1-weighted three-dimensional gradient-echo tech-
nique. Aorta (a), inferior vena cava (i), common bile duct (CBD) (arrow), inferior mesenteric vein at the splenoportal confluence (v), superior mesenteric
artery (arrowhead), and left renal vein (r) are shown. B, Normal pancreatic anatomy. Postcontrast computed tomographic scan at the level of the
pancreas. A, Aorta; a, superior mesenteric artery; D, duodenum; IVC, inferior vena cava; S, stomach; v, superior mesenteric vein;. Long arrow, CBD;
short arrow, inferior pancreaticoduodenal artery; open arrow, gastroduodenal artery.
Aorta
NECK BODY
HEAD POSITION OF THE COMMON BILE DUCT
Superior mesenteric
vein and artery
Uncinate
process
B
UNCINATE PROCESS
a b c
(i) (ii)
A C
FIGURE 2.45. A, The head of the pancreas is globular with an extension, the uncinate process, which curves behind the superior mesenteric
vessels and may end even before it embraces the superior mesenteric vein (a), or it may pass completely behind between the aorta and the left of
the patients superior mesenteric artery (b, c). All variations are commonly seen. Posteriorly, the head of the pancreas lies in juxtaposition to the
inferior vena cava 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 10cm distal to the pylorus, at the papilla of Vater after traversing the sphincter of Oddi. An accessory duct, the 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 duct of Santorini, such that rarely the accessory duct can enter the duo-
denum 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.

Aorta
Portal vein
Vena cava Aorta
Peritoneum
Neck of Superior mesenteric

Middle
pancreas artery
colic
vessels Left renal vein
Uncinate process
of pancreas
Middle
Superior mesenteric artery colic
artery Third part of
Superior mesenteric vein duodenum
Superior
mesenteric
artery
A B
Pancreas posterior view
Portal Common
vein bile duct
Splenic Splenic Hepatic Pancreatic

artery vein artery duct
Superior
mesenteric
artery
Uncinate
FIGURE 2.46. A, The anterior surface of the pancreas, covered by the posterior process Superior
layer of the omental bursa or lesser peritoneal sac, can often be obliterated by adhe- mesenteric vein
sions. The transverse mesocolon arises from the lower border of the pancreas and Left Right
envelops the middle colic vessels as they arise from the superior mesenteric vessels Related Related to left kidney, Related to
just beneath the pancreatic neck. B, The relationship of the pancreatic neck and unci- to spleen left renal vein and inferior
nate process to the aorta and superior mesenteric artery. Note the position of the left adrenal gland vena cava
and aorta
renal vein and duodenum. C, The posterior relationships of the duodenal loop and
pancreas. Note the relationship to the inferior vena cava, aorta, and hilum of the spleen. C
b
c
d
e
f
FIGURE 2.47. 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).

MRCP: PANCREAS DIVISUM
B
Posterior Anterior
FIGURE 2.48. A, Magnetic resonance imaging cholangiography (MRCP), T2-weighted coronal image at the level of the ampulla, shows the duo-
denum (D) and the pancreatic head with common bile duct (curved arrow) and pancreatic duct (straight arrow). B, MRCP of pancreas divisum.
Anterior projection shows variant anatomy with the duct of Santorini (vertical arrow) between the duodenum above the duct of Wirsung (angled
arrow). The two ducts are separate; the duct of Santorini drains mainly the neck and body of the pancreas, and the duct of Wirsung drains mainly
the uncinate process portion of the head of the pancreas.
segment in 70% to 85% of patients; it enters the duodenum Annular Pancreas

independently in 10% to 13% of patients and is replaced by Annular pancreas is the development of a ring of pancreatic
the duct of Santorini in 2% of patients (Fig. 2.48; see Fig. tissue that surrounds and often embraces the duodenum
2.45). Rarely, the duct of Santorini and the duct of Wirsung (see Chapter 1). This ring may contain a large duct and
are separate, which is known as pancreas divisum (see Figs. can be firmly affixed to the duodenal musculature. The
2.45Cii and 2.48B). The islets of Langerhans, which provide duodenum beneath this annulus is often stenosed such that
the endocrine component of the gland, are scattered through- dividing this ring does not always relieve chronic duodenal
out the pancreas. obstruction. This accounts for the common process of

Splanchnic nerves
Vagal nerves
Celiac ganglion
FIGURE 2.50. Note the distribution of sympathetic and parasympa-

thetic nerves to the liver and pancreas from the celiac ganglion, mainly
A in association with major arteries.
applying duodenojejunostomy to relieve strictures caused by

such an annulus.
LYMPHATIC DRAINAGE
Liver and Pancreas
The lymphatic drainage of the liver and gallbladder is mainly
to nodes in the hepatoduodenal ligament and along the hepatic
artery; this is shown in Figure 2.49. The lymphatic drainage of
i PV the pancreas is predominantly to the nodes that lie in juxtaposi-
tion to the arteries and veins (Fig. 2.50B).
HA BD
SA
NERVE SUPPLY TO THE LIVER AND PANCREAS
The nerve supply to the liver and pancreas (see Fig. 2.50) is
from branches of the celiac ganglion. It is composed of sympa-
thetic and parasympathetic elements.
SV
IMV
References are available at expertconsult.com.
SMA SMV
B ii
FIGURE 2.49. A, The liver drains principally to hepatoduodenal nodes
at the hilus and along the hepatic artery and portal vein. The gallbladder
drains partly to the liver, but it also drains via the cystic node to nodes
of the hepatoduodenal ligament and to suprapancreatic nodes.
B, Numerous nodes (i) lie along the superior mesenteric vein along the
borders of the pancreas, draining back into the splenic hilar nodes; along
the superior border of the pancreas to the superior pancreatic nodes;
and to the celiac trunk and nodes at the base of the common hepatic
artery. A large node commonly lodges in intimate association with the
surface of the superior border of the pancreas and the right side of the
common hepatic artery. This node often needs to be dissected and
elevated to gain access to the anterior surface of the portal vein. Removal
of this node often improves access, as does division of the gastroduo-
denal artery. Posterior pancreaticoduodenal nodes (ii) lie along the pos-
terior pancreatic duodenal arterial arcade. BD, Bile duct; HA, hepatic
artery; IMV, interior mesenteric vein; PV, portal vein; SA, splenic artery;
SMA, superior mesenteric artery; SMV, superior mesenteric vein; SV,
splenic vein.

Chapter 2 Surgical and radiologic anatomy of the liver, biliary tract, and pancreas 59.e1
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Anat (Basel) 11:599615, 1931.
Albaret P, etal: propos des caneaux hpatiques directement abou- Hobby JAE: Bilobed gallbladder, Br J Surg 57:870872, 1970.
chs dans la voie biliaire accessorie, Ann Chir 35:8892, 1981. Kune GA: The influence of structure and function in the surgery of
Bismuth H, etal: Major and minor segmentectomiesrglesin the biliary tract, Ann R Coll Surg Engl 47:7891, 1970.
liver surgery, World J Surg 6:1024, 1982. McIndoe AH, Counseller VX: A report on the bilaterality of the liver,
Boyden EA: The accessory gallbladder: an embryological and compara- Arch Surg 15:589, 1927.
tive study of aberrant biliary vesicles occurring in man and the Newcombe JF, Henley FA: Left-sided gallbladder: a review of the lit-
domestic mammals, Am J Anat 38:177231, 1926. erature and a report of a case associated with hepatic duct carci-
Boyden EA: The anatomy of the choledochoduodenal junction in man, noma, Arch Surg 88:494497, 1964.
Surg Gynecol Obstet 104:641652, 1957. Northover JMA, Terblanche J: A new look at the arterial blood supply
Champetier J, etal: Aberrant biliary ducts (vasa aberrantia): surgical of the bile duct in man and its surgical implications, Br J Surg
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Couinaud C: Le foi: tudes anatomogiques et chirurgicales, Paris, 1957, Perelman H: Cystic duct reduplication, JAMA 175:710711, 1961.
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Healey JE, Schroy PC: Anatomy of the biliary ducts within the human Ton That Tung: La vascularisation veineuse du foie et ses applications aux
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CHAPTER 2

Surgical and radiologic anatomy of the liver, biliary

ANATOMY OVERVIEW the pancreas as a retroperitoneal structure passing upward

Gallbladder Caudate lobe

LEFT LOBE RIGHT LOBE

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subdivisions are referred to as segments in the description of

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TABLE 2.1 Brisbane Terminology of Liver Anatomy

Right hemiliver/ 5-8 Right hepatectomy

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MHV Ligamentum venosum

2.10 to 2.11). The caudate is intimately related to major vas-

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link with a similar component of fibrous tissue (called the

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Surgical Implications and Exposure

Intrahepatic Bile Duct Anatomy

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Left hepatic duct

C Right hepatic duct Common bile

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FIGURE 2.18. Endoscopic retrograde choledochopancreatogram

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ra ra duct but two fundi (Hobby, 1970), and duplication of the

D 6% BILE DUCT BLOOD SUPPLY

ANATOMY OF BILIARY EXPOSURE

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VIII VII VIII III

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FIGURE 2.36. Computed tomographic image of the main portal vein

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FIGURE 2.39. Magnetic resonance imaging of the splenoportal con-

FIGURE 2.40. Contrast-enhanced computed tomographic scan of

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FIGURE 2.42. In a congenital absence of the left branch of the portal

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Neck of Superior mesenteric

Splenic Splenic Hepatic Pancreatic

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MRCP: PANCREAS DIVISUM

segment in 70% to 85% of patients; it enters the duodenum Annular Pancreas

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FIGURE 2.50. Note the distribution of sympathetic and parasympa-

applying duodenojejunostomy to relieve strictures caused by

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