hepatobiliary pdf - د. سمير الصفار

Forth stage

Surgery

Lec-2

Dr.Samer

16/12/2015

Liver

Anatomy of Liver



Largest organ



Right upper quadrant



Having large right lobe and smaller left lobe



Functional anatomy: “Couinaud” : Divided into 2 lobes along the line passing between
gall bladder fossa and middle hepatic vein. “Cantil’s line”



8 segements

I – IV -------functional left lobe V – VII -----Functional right lobe

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Ligaments that fix the liver in its place:

Left triangular ligament

Right triangular ligament

Falciform ligament

Lesser omentum (hepatoduodenal ligament)

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Hilum of liver:

Bile duct

Hepatic artery

Portal vein



Foramen of Winslow:

Anterior: CBD, HA, PV

Posterior: IVC

Upper: Liver

Lower: duodenum



Liver Blood supply:

Portal vein 80%
Hepatic artery 20%



Internal anatomy of the liver

Liver Lobule: s the functional Unit within liver segments



Embryology

Foregut
Hepatocytes
Biliary passages
Septum transversum
Kupffer cells

Liver Functions



Metabolism of bilirubin



Formation of bile;



Water, electrolytes, bile pigments, bile salts, phospholipids (lecithin), and cholesterol.

Metabolism of bilirubin

Investigations of liver

Liver Function tests:
USED TO



Detect presence of liver disease



Distinguish among different types of liver diseases



Gauge the extent of known liver damage



Follow the response of treatment

Tests for excretory function



Serum bilirubin



Urine bilirubin



Blood ammonia

Tests that indicate liver cell injury
Serum enzymes :



AST



ALT



Gamma-glutamyl transpeptidase

Serum Enzymes – that reflect cholestasis



Serum Alkaline phosphatase



5’Nucleotidase

Tests that measure Biosynthetic function of liver



Serum Albumin



PT ,INR

Imaging of liver

Ultrasound: First line test
Useful for :



Liver SOL



State of biliary passages



As a guide for needle liver biopsy or catheterization.

Doppler Ultrasound:



Blood flow



Vascularity of liver tumors

Computerized tomography (CT scan) :



Triple-phase spiral CT is the gold standard imaging modality of liver.



Liver lesions down to 1cm



Its density can be measured



Vascularity of lesion---contrast

Magnetic resonance imaging



More or less similar to CT scan



Its advantages:

o No radiation
o No contrast of value in allergy to iodine

Magnetic resonance cholangiopancreatography MRCP:



Provide excellent quality imaging of billiary tracts noninvasively

Magnetic resonance angiography ”MRA “ :



Provide high quality images of portal veins and hepatic arteries without the need for
cannulation.

Endoscopic retrograde cholangiopancreatography (ERCP)



Diagnosis



Therapeutic



Indications:

o Obstructive jaundice ? Aetiology
o An imaging suggested abnormality in biliary tracts



Preparation:

o Checking coagulation state; PT , INR



Informed consent:

o  Pancreatitis
o  Cholangitis
o  Bleeding
o  Perforation of duodenum



Prophylactic antibiotics



Therapeutic ERCP

o  Sphincterotomy and Stone retrieval from CBD
o  Balloon dilatation of strictures
o  Stenting (Endoprosthesis) of strictures of CBD.

Percutaneous transhepatic cholangiography



Indications:

o When Endoscopic cholangiography failed
o When ERCP impossible <<polya gastrectomy

Selective Visceral angiography:



Diagnosis - Clear anatomy of hepatic artery prior to liver resections 6

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

Therapy:

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o  Embolization
o  arteriovenous malformation
o  Stop bleeding from liver
o  Chemoembolization for liver tumors

Nuclear medicine scanning



Technetium 99m labeled radionuclide:



Handled like bile and so its uptake and excretion can be monitored in real time.



Useful in:

o Bile leak

o Bile obstruction

Laparoscopy and laparoscopic ultrasound:



Staging of liver tumors



Detection of small lesions not detected by other imaging modalities

o Peritoneal sedlings
o Small superficial lesions



Help in detection of other additional lesions not detected by CT or MRI

Flurodeoxyglucose-postron emission tomography



Helpful for determing the nature of a mass lesion detected by other imaging modalities

Liver trauma

1-Blunt injuries:

Contusion, laceration, avulsion

2-Penetrating injuries:

Stab, Gunshot

Diagnosis of liver injury:

Clinical suspicion of liver injury

All lower chest and upper abdominal stab wounds should be suspect, especially if
considerable blood volume replacement has been required.

Similarly, severe crushing injuries to the lower chest or upper abdomen often combine rib
fractures, haemothorax and damage to the spleen and/or liver

Tools may be of help in the diagnosis of liver injury:

-FAST

-Peritoneal aspirate

-Laparoscopy

Management of liver injury

o  General consideration:
o  Not usual
o  Serious
o  Think of associated injuries

General plan:

General resuscitation: ATLS

-Penetrating injury :

emergency , laparotomy

-Blunt injury : stable circulation after initial resuscitation sent the patient for CT scan with
oral and iv contrast

In Blunt injury to liver There is a place for conservative treatment

When to stop conservative treatment ?

1-Ongoing blood loss

2-Generalized peritonitis

Surgical approach to liver trauma

1.  Good and wide access (rooftop) incision
2.  Stop blood inflow “Pringle manueuvre”
3.  Suturing of tears
4.  Excision of avulsed devitalized tissue
5.  Repair of major vessel injury
6.  Packing

Complications

1.  Massive blood loss
2.  Abscess ….. Subcapsular hematoma
3.  Bile collection “Biloma:, Biliary fistula
4.  Arteriovenous fistula
5.  Arteriobiliary fistula
6.  Hepatic artery aneurysm
7.  Liver failure

Pyogenic liver abscess

Aetiology: in the majority unknown

Possible causes:

1.  Impaired biliary drainage
2.  Hematogenous, drug abuse, teeth cleaning
3.  Local  spread : diverticulitis

4. Immune compromised : apportunistic
5. Infecting mo : Enteric organisms; Streptococcus faecalis, Klebseilla, Proteus vulgaris ,

E coli, Streptococus melleri

6. Opportunistic staph

Clinical features

Nonspecific , Fever, malaise, anorexia , Right upper quadrant discomfort

Jaundice occurs in up to one third of affected patients

Diagnosis:

Lab investigations:



Leucocytosis,



an elevated erythrocyte sedimentation rate



an elevated alkaline phosphatase (AP) level



Blood cultures reveal the causative organism in approximately 50% of cases

Ultrasound examination

reveals pyogenic abscesses as round or oval hypoechoic lesions with well-defined borders
and a variable number of internal echoes

CT scan

highly sensitive in the localization of pyogenic liver abscesses

Treatment:



Antibiotics



Percutaneous drainage under ultrasound guide

Look for the source !

Amoebic Liver Abscess

Causative: Entamoeba histolytica

Clinical Features



History of dysentery



Travel to endemic area



Symptoms : non specific

Diagnosis:



CT scan



Confirmation is by isolation of the causative organism.

Treatment

Metronidazol 750mg t.i.d for 5 – 10 days

Portal Hypertension

Portal circulation: Portal vein formed from confluence of SMV and splenic vein. Also a
tributary from coronary (left gastric) vein.

Portasystemic communications:



gastroesophagus junction



Anal canal

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Retroperitoneum



Falciform ligament

Normal portal venous pressure
is about 10 -15 mmHg.

Aetiology:

1.  Liver cirrhosis
2.  Extrahepatic portal vein occlusion
3.  Intrahepatic veno-occlusive disease
4.  Occlusion of main hepatic veins ( Budd- Chairi syndrome)

Clinical presentaion:



Variceal bleeding



decompensated chronic liver disease : Encephalopathy



Ascitis

Diagnosis

High portal venous pressure ( > 20mmHg ) :

-Hepatic venography

-Direct cannulation of portal vein

Oesophagoscopy; oesophagial varices

Doppler ultrasound and CT for patency of portal vein

Management of bleeding varices



General resuscitation: Blood replacement



Coagulopathy:
Vit K iv
Fresh frozen plasma



Thrombocytopenia

< 50*10^9/l



Urgent endoscopy:
Confirm dx
therapy

Measures to stop bleeding:



Drugs:
Vasopressin
Octreotide



Endoscopic:
Sclerotherapy ethanolamine oleate
Banding



Sengenstakin – Blackmore tube : Temporary control



Transjugular intrahepatic portosystemic stent shunt ( TIPS )

Complication :

-perforation of liver capsule and fatal haemorrhage

-Occlusion

-Post shunt encephalopathy

Surgical shunts for variceal haemorrhage

Child’s grade A cirrhosis in whom the initial bleed has been controlled by sclerotherapy

Types of shunts

Selective; splenorenal

Non-selective : porto-caval

Hydatid Liver Disease

The causative tapeworm: Echinococcus granulosis

Liver is affected in 80% of cases, Lung 15%. And 5% rest organs.

Clinical presentation:

Incidental finding on Ultrasound examination

Chronic right upper quadrant discomfort

Complications of cyst:



Rupture into peritoneum; features of

1.  acute peritoneal irritation
2.  Urticaria
3.  Anaphylaxis



Rupture into biliary passages: Jaundice and cholangitis



Rupture into pleura: Empyema



Infection-----Liver abscess

Diagnosis



Ultrasound exam :
Multilocular cyst



CT scan :
Floating membrane within the cyst



Serological :
ELISA for Antibody against hydatid
antigen

Treatment:



Mainly surgical
Open
laparoscopic



Other methods
Drugs Albendazol
Percutaneous injection of hypertonic saline or Alcohol

Surgical options:

-Deroofing and evacuation of contents

-liver resection

Liver tumors



Benign tumors:

Haemangiomas

Adenoma

Focal nodular hyperplasia



Malignant:

1) Primary

Hepatocellular carcinoma

Cholangiocarcinoma

2) Secondary metastesis

Metastatic colorectal cancer

Metastatic neuroendocrine cancer (carcinoid)

Other metastatic cancers

Hepatocellular carcinoma

Aetiology:

Association with chronic liver disease cirrhosis

- HBV, HCV

Presentation
-Middle aged
-Features of chronic liver disease
- Anorexia and Weight loss

Diagnosis:

-Ultrasound
-CT scan
-Alpha fetoprotein
-For staging:
-Chest scan
-Bone scan
-Laparoscopy

Assessment of patient:

of patient:

• General assessment
• Severity of underlying liver disease “Child score”

Treatment

•Surgical resection
• Liver transplantation
Depend on:
• Staging of liver tumor
• Size and site of tumor
• Availability of organ transplantation
Palliative procedures:
Local Ablation techniques:

Radiofrequency ablation

Ethanol ablation

Cryoablation

Microwave ablation

Regional liver therapies:

Chemoembolization/embolization

Hepatic artery pump chemoperfusion

Follow up:

Chemotherapy ??

Alpha fetoprotein as tumor marker

Imaging

Cholangiocarcinoma:

-Elderly
-Primary sclerosing cholangitis
-Site: confluence of right and left
-hepatic ducts fibrous(Klatskin tumors)
Presentation:
Elderly patient with progressive painless jaundice
Diagnosis:

Ultrasound: dilated intrahepatic biliary passages but notextrahepatic bile ducts.

Spiral CT scan little evidence of mass

Regional lymphadenopathy

Cholangiography: hilar stricture

Brush cytology + ve in 2/3rds

Treatment:
• Surgical resection
• Radical resection of liver parenchyma and the affected bile ducts ---potentially curative
• Local resection --- palliative

Impaired liver function:

Depends on:

-Severity of dysfunction
-Rapidity; acute or chronic