Liver, GB, Pancreas and Spleen

Liver (~1.5kg)

  • left and right anatomic lobes separated by fissure for ligamentum venosum, ligamentum teres, falciform ligament (R includes I,IV)
  • visceral/posteroinferior surface
    • groove/impression for oesophagus, stomach, IVC
    • fissure for ligamentum venosum (obliterated ductus venousum > L hepatic v or IVC; posterior to porta)
    • porta hepatis = hepatic hilum
    • ligamentum teres = round ligament (obliterated umbilical v; anterior to porta)
    • gallbladder fossa
    • bare area of the liver (IVC, superior and inferior coronary lig)
  • diaphragmatic/anterosuperior surface
    • falciform ligament
  • superior and inferior coronary ligaments
  • left and right triangular ligaments
  • accessory liver fissures (V)


  • A= diaphragm, anterior abdo wall
  • P = R adrenal, kidney, hepatic flexure, pancreas, duodenum, oesophagus, stomach, leser omentum


  • lobule (portal triad [outer] > liver cell plates with sinusoids > central veins > sublobular veins > hepatic veins)

Segmental Anatomy (Couinaud System)

  • principal plane (GB, IVC) dividing surgical/functional parts = true halves (supplied by right/left vessels)
  • separated by portal vein (horizontally), hepatic veins (vertically), planes of hepatic veins and falciform ligament (betw III and IV)
  • I = caudate lobe = posterior segment (betw IVC and fissure for ligamentum venosum, posterior to porta)
    • caudate process (towards GB, V)
    • papillary process (>L of portal v)
  • II = LLS, III = LLI, IV = quadrate lobe (IVa LMS, IVb LMI), V = RAI, VI = RPI, VII = RPS, VIII = RPS


  • Riedel’s lobe (5-10%, inferiorly enlarged right lobe)
  • tunnel for IVC instead of groove

Hepatic Arteries (suppy 15%)

  • see section on vascular supply to the GI tract
  • accompany portal veins
  • hepatic a proper > right and left (>middle > IV) hepatic aa
  • segment I from < left and right hepatic aa
  • hepatic artery posterior to portal v (V10%)

Hepatic Veins

  • veins are intersegmental, with middle lying in the principal plane; no valves
  • right, middle and left hepatic veins >IVC at T9
  • small accessory hepatic veins (right and I lobes) >IVC
  • middle > left hepatic (V)
  • anterior or posterior segmental v > left hepatic v (V)


  • deep lymph > portal vessels > porta hepatis nodes > hepatic nodes > lesser omentum > retropyloric nodes > coeliac nodes
  • anterior superficial > deep lymphatics
  • post superficial > bare area > phrenic nodes or posterior mediastinal nodes

Nerve Supply

  • sympathetics from coeliac ganglion
  • parasympathetic from left vagal trunk

Biliary Tree

  • bile canaliculi/capillaries (in hepatic lobules)
  • portal canals
  • segmental bile ducts ( <2mm, <40% of adjacent portal v, usually anterior to portal vv)
    • RPD passes posterior to RAD to join on left side of RHD
  • left to right major/main sectoral biliary ducts (RHD, LHD; 3mm). LHD anterior to RHD, hence contrast preferentially opacify R ducts.
  • common hepatic duct (CHD; P = portal vein, L = hepatic a; 7mm)
  • cystic duct (>common hepatic after 3.5cm; 3.5cm long)
  • common bile duct (CBD, ~8cm, 5mm + 1mm/decade)
    • upper/supraduodenal third (>D1; L = hep a; P = port v)
    • middle/retroduodenal third (A = D1, GDA; L = port v)
    • lower/pancreatic third (A = panc head; R renal vein)
  • main pancreatic duct
  • ampulla of Vater (postero-medial D2) @ duodenal papilla
  • sphincter of Oddi

Gallbladder (3 x 10 cm)

  • wall <3mm thick
  • fundus (ant-inf), body (indenting anterior D1) and neck
  • Hartmann’s pouch (dilated proximal to neck in disease)
  • cystic duct (spiral valve of Hiester and smooth parts)
  • cystic artery < R hepatic artery; and branches directly from liver
  • small vv > GB bed; cystic vein > portal v


  • A/S = GB bed of liver, anterior abdo wall
  • P/I = lesser omentum, D1, transverse colon



  • mesentery of GB (to hang free from liver)
  • Phrygian cap (2-6%, fundus folded back onto body)
  • bilobed GB with septum
  • gall bladder diverticula (most common at fundus)
  • intrahepatic, retrohepatic or suprahepatic location
  • left-sided location (under L lobe, herniated through epiploic foramen or part of transposition of viscera)
  • agenesis (0.05%)
  • double gallbladder (0.025%, sharing a duct)

intrahepatic ducts (normal in 60%)

  • RPD >LHD (15%)
  • RPD > right side of RAD (12%)
  • triple confluence of RAD, RPD and LHD (11%)
  • RPD > R or left side CHD (5%; =aberrant hepatic duct)
  • accessory duct > R hepatic, main hepatic, CBD, cystic or GB
  • RPD or RHD > cystic duct
  • segments 2 and 3 drain separately > R or common hepatic duct
  • double hepatic duct (R&L fail to unite)

extrahepatic ducts

  • low cystic duct insertion (9%)
  • cystic duct > medial side of CBD (15%; crossing anterior or post)
  • parallel course of cystic and CHD (closely adhered for >2cm)
  • high union of cystic duct
  • cystic duct > R or L hepatic duct
  • cystic duct absent/very short
  • ducts of Luschka (ducts from hepatic bed > GB)
  • duplication of cystic duct/CBD
  • anomalous pancreaticobiliary junction (outside duodenal wall with >15mm common channel)
  • separate openings of CBD and pancreatic ducts close together (40%) or far apart (4%)

Pancreas ~15cm, L1-2

  • lobulated with interdigitating retroperitoneal fat
  • head (20mm x up to 8cm), neck (5-10mm), body (10-20mm) and tail (10-20mm; into lienorenal lig, more superior than head)
  • uncinate process (post with SMA/SMV, GDA between head)
  • pancreatic duct (head 3mm dia, neck 2, tail 1)
  • (ventral) duct of Wirsung = main/inferior pancreatic duct
  • ampulla of Vater (common dilated termination of pancreatic and CBD)
  • (dorsal) duct of Santorini = accessory/superior pancreatic duct (persists in 60%; inferior head > sup-ant > minor papilla; as minor [91%] or major [9%] drainage)
  • <superior and inferior pancreaticoduodenal aa, dorsal pancreatic, transverse pancreatic, pancreatica magna arteries
  • neck, body and tail > splenic v; head > superior mesenteric and portal vv


  • A = D1, lesser sac, transverse mesocolon, GDA, stomach
  • P = CBD, IVC, right renal vein, portal vein, splenic v, aorta, L suprarenal, L kidney, lienorenal lig
  • S/P = splenic a
  • R = D2
  • L = splenic hilum



  • pancreas divsism (5-10%, failure of fusion between dorsal and vetral pancreatic buds with Santorini draining head and tail > minor papilla; Wirsung uncinate process > major papilla)
    • santrorinicele (dilated distal Santorini in divism)
  • annular pancreas (ring around 2nd or 1st/3rd parts of duodenum when part of ventral pancreatic bud fails to atrophy)
  • hypoplasia = partial agenesis (agenesis of ventral or dorsal pancreatic moiety)
  • left-sided pancreas (from laxity of suspensory fascia)
  • ectopic pancreas = accessory nodules = pancreatic rests (in wall stomach, duodenum, small intestine, Meckels; rarely colon, oesophagus, GB)


  • atrophy (30%) or dominant duct of Santorini (1%) with (10%) or without (10%) communication with main duct
  • ansa pancreatica (1%; Santorini forms sigmoid curve to Wirsung)
  • short, no or long common channel between CBD and pancreatic ducts
  • pancreatic duct > CBD
  • double accessory or main pancreatic ducts
  • anastomosis between accessory and main ducts
  • crossing or double crossing of acc and main ducts


  • 1 (3-4cm) x 3 (7cm) x 5 (12-14cm) in, 7oz, ribs 9-11
  • diaphragmatic and visceral (ant-inf)-R hilar surfaces
  • inferior notch
  • phrenicosplenic, gastrosplenic and splenorenal ligaments


  • A = splenic flexure
  • P = L kidney, suprarenal gland
  • R = stomach, pancreatic tail


  • unfused and accessory splenules/splenunculi (10-15%, 10-30,,, in hilum, lienorenal lig, small bowel mesentery or greater omentum)
  • anatomical asplenia (Ivemark syndrome) – associated with bilateral right-sidedness, major cardiac anomaliesin 50%, poor prognosis.
  • functional asplenia (interruption to blood supply of diffused disease causing no functioning splenic tissue)
  • polysplenia – rare, several small rudimentary splenic bodies usually in R abdo, associated with situs ambiguous
  • wandering spleen – position other than LUQ due to lax suspensory ligaments
  • bare area of spleen (portion of spleen adherent to anterior L kidney)