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Chapter 29: Liver and Biliary Tract

Brandon R. Bruns; Rosemary A. Kozar

INTRODUCTION

Liver injury occurs in approximately 5% of all trauma admissions.¹ The sheer size of the organ, along with its position under the right costal margin, make the liver exceedingly susceptible to traumatic injury. The management of liver injuries continues to evolve with improved modes of diagnosis and management, both operatively and nonoperatively. However, the most severe liver parenchymal and retrohepatic venous injuries as well as those involving the portal triad continue remain a challenge and despite technological advances, still often lead to death. Therefore, despite our progress in liver injury management, many avenues for improvement remain to be explored.

ANATOMY

Comprehensive knowledge of hepatic anatomy is essential to the proper management of traumatic liver injuries. The understanding of the ligamentous attachments, parenchyma, and intraparenchymal and extraparenchymal vascularity of the liver is key to the effective application of methods for control and repair in liver injuries (Fig. 29-1).

FIGURE 29-1

Surgical anatomy of the liver: (1) inferior vena cava; (2) right hepatic vein; (3) middle hepatic vein; (4) left hepatic vein; (5) portal vein; (6) right branch portal vein; (7) left branch portal vein; (8) right triangular ligament; (9) coronary ligament; (10) left triangular ligament; (11) falciform ligament; (12) ligamentum teres.

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Lobes

Cantlie first described the lobar anatomy in 1898. The liver is divided into two lobes by a 75° angle traversing from the gallbladder fossa posteriorly to the left side of the inferior vena cava. This is the so-called line of Cantlie. Therefore, the left lobe includes the hepatic tissue to the left of the falciform ligament along with the quadrate and caudate lobes. Whereas, the right lobe consists of the remaining parenchyma.

Functional Anatomy

The functional anatomy of the liver separates the liver into segments pertinent to resection. In 1953, Couinaud provided the basis of modern resection planes by dividing the liver based on the distribution of the hepatic veins and glissonian pedicles.² The right hepatic vein traverses between the right posterolateral (VI and VII) and right anteromedial (V and VIII) segments. On the left, the left hepatic vein delineates the anterior (III and IV) and posterior (II) segments. The caudate lobe (I) drains directly into the inferior vena cava (Fig. 29-2).

FIGURE 29-2

Functional division of the liver, according to Couinaud’s nomenclature. (Reproduced with permission from Blumgart LH, ed. Surgery of the Liver and Biliary Tract. New York, NY: Churchill Livingstone; 1988. Copyright © Elsevier.)