1.

Raihan
2. Sharon
3. Vino
Anatomy
• Site : Upper part of abdominal cavity
- right hypochondrium , epigastrium, left hypochondrium.
- Extends from 5th intercostal space to right costal margin.
• Size : Largest abdominal organ ( 1500 g )
• Shape : Wedge shape
• Anatomical lobes : Divided by falciform ligament into right
and left lobes.
• Surgical lobes : On the basis of intrahepatic distribution of
hepatic artery, portal vein and biliary duct, the liver is divided
into 2 nearly equal lobes (right & left) by an antero-posterior
plane passing through the gallbladder fossa and grove for IVC.
Divided into 8 segments
based on hepatic and portal
venous segments
(Couinaud System):
 Caudate lobe : segment I
 Left lobe : segment II - IV
 Right lobe : segment V -
VIII
 Blood supply
• 70% from portal vein
• 30% from hepatic artery

 Blood of both vessels is

mixed in the liver
sinusoids
 Blood is collected from
each hepatic lobule by a
central vein
 The central vein unite to
form 2-3 hepatic veins
which open into IVC.
Nerve supply
Liver receives nerve supply from the hepatic plexus
containing:
• Sympathetic fibres: derived from coeliac plexus
• Parasympathetic fibres: from the anterior and
posterior vagal trunks

Lymphatic Drainage
• Mainly into hepatic lymph nodes in porta hepatis.
• Efferent vessels pass to celiac lymph nodes
 Gall Bladder
• Pear- shaped sac, lying
undersurface liver.
• Has capacity 30 -50 ml stores
bile.
• Divided into fundus, body,
neck.
• Blood supply : cystic artery
and cystic vein.
• Lymph drainage : Cystic
lymph node.
1) HEMANGIOMA

• These are the most common liver lesions, and the

reported incidence has increased with the widespread
availability of diagnostic ultrasound.
• Consist of an abnormal plexus of vessels, and their
nature is usually apparent on ultrasound.

• They are often multiple and usually found incidentally.

• Mostly asymptomatic but if it is symptomatic, it is
usually due to the rupture of the hemangioma.
• There is usually no association with underlying liver
diseases.
Clinical Features Investigation
• Right upper • Ultrasound: Well defined,
quadrant pain hyperechoic lesions
• Contrast CT maybe
• Jaundice (if the
obtained
hemangioma is
large and • Biopsy is avoided as it may
lead to perfuse peritoneal
compressess the
bleeding
bile duct) Ultrasound scan

CT scan
 Treatment
• If the lesions are large, resection of the
large lesions may be considered (higher
chances of rupture)
• No indication for surgery otherwise
• Since its asymptomatic, rarely treatments
are required unless as stated above.
2) Hepatic Adenoma

• Benign
• Rare
• Female
• Child bearing age
• A/w enzyme sex hormones (including OCPs) 
withdraw hormonal stimulation leads to regression
of symptomatic adenomas
• May bleed (d/t spontaneous rupture) / potentially
malignant (HCC)
Investigations: Ultrasound
• U/S: solitary well-demarcated
heterogeneous mass w variable
echogenicity
• CT/MRI: well-circumscribed &
vascular solid tumor
• No characteristic radiological features
to differentiate from HCC
• Arterial phase CT: well-developed
peripheral arterialisation of tumor
• Biopsy: confirmation &
characterisation of nature of the CT arterial phase CT venous phase
lesions

Treatment:
• Treatment of choice: resection
 to eliminate risk of
spontaneous rupture & to
conclusively confirm diagnosis
• If inoperable  hepatic arterial
embolisation
 3) FOCAL NODULAR
HYPERPLASIA
• Focal overgrowth of
functioning liver tissue
supported by fibrous
stroma
• Etiology is unknown
• Unusual
• Usually middle-aged
• Female
• No association with
underlying liver disease
INVESTIGATION:
• Contrast CT or/and MRI
-Central scarring and evidence of well-
vascularised lesion.
- MRI using liver specific-agents(eg:
gadoxetic acid) maybe useful in
determining the hepatocellular origin
and allow differentiation of FNH from
metastatic cancer.
• Sulphur colloid liver scan ( Tc-99m)
-Kupffer cells take up the colloid

TREATMENT:
• FNH do no have any malignant potential
• Once diagnosis is confirmed, they do not require
any treatment.
 Benign biliary disorders

• Cholelithiasis
• Cholecystitis
• Choledocholithiasis
• Ascending
cholangitis
 CHOLELITHIASIS
• 3 main types : cholesterol
: pigment
: mixed
• Causes : obesity
: high calorie diet (cholesterol)
: abnormal emptying of gall bladder
: foreign bodies
: excessive hemolysis
• PATHOGENESIS
- lithogenic bile
- Stasis (TPN)

CLINICAL FEATURES
- Asymptomatic
- RUQ pain that radiate to back
- Nausea / vomiting
- food intolerance
- Jaundice if stone migrate to CBD
• Investigations
- Blood (FBC/LFT/BLOOD c+s/serum amylase)
- Imaging ( TAS / CT)

• Treatment
- Cholecystectomy
(laparoscopic/ open)
 CHOLECYSTITIS
• Inflammation of gallbladder that occur most common dt
obstruction of cystic duct

• Etiology : calculous vs acalculous

• CLINICAL FEATURES
- RUQ pain that radiate to right shoulder and tip of scapula (boas
sign)
- Fever/nausea/vomiting
- Jaundice present if a/w CBD stone
- +ve murphy sign
INVESTIGATIONS
- Baseline investigations
- TAS
- AXR
- Serum amylase
- CT

• Management
- Conservative tx followed by delayed
cholecystemy
• Conservative tx
• (6 weeks untill inflammation subsides)

- NBM
- Analgesics
- Antibiotics
(cefuroxime/ciprofloxacillin/cefazolin)
 CHOLEDOCHOLITHIASIS
• Stone obstructing CBD
• 2 types : primary (stasis) and secondary (cholelithiasis)

• S&S :
- RUQ pain
- Jaundice
- Dark urine (tea colour)
- Pale stool
- Itchiness
- Nausea vomiting
INVESTIGATIONS • IMP BASELINE IX

• IMAGING - FBC
- LFT
- TAS
- ERCP - RFT
- MRCP - Coagulation Profile
- PTC - Serum amylase
 MANAGEMENT
• Supportive treatment • Definitive treatment
- Rehydration - ERCP
- Monitor vital signs - Stenting
- Anagesics - Endoscopic basketting and
stone removal
- biopsy
Cx of ERCP
1. Pancreatitis
2. Cholangitis
3. Duodenal perforation /
stricture
4. Bleeding
 ASCENDING CHOLANGITIS
• Ascending bacterial • IX : FBC/LFT/C+S/TAS
infection of biliary tract in
a/w partial and complete • Management
obstruction of bile ducts
- Broad spectrum IV Ab
• Causes - Fluids
- Gallstone - Find the cause of
infection
- Stents
• Cx
• clinical features - Pyogenic liver abscess
(CHARCOT TRIAD) : FPJ
- Fever
- Intermittent RUQ pain
- jaundice
THANK YOU

REFERENCE
- Bailey & love
- Doctrina
- Mc Graw Hill Lange Surgery
- Clinical surgery 2nd edition (bwp)