 So this is going to be a clinical demonstration of the liver. I'm holding the e-viscerated liver in front of me to bring up to speed This is an anatomical right lobe, anatomical left lobe. This memorial structure that you see here This is the fancy-form ligament and attached to the free margin of the fancy-form ligament is this round ligament of liver Let's talk about the Petronium spaces around the liver. This is under the right dome of the diaphragm So between the right dome of the diaphragm and the liver we have this space where my hand is located This is referred to as the sub-phrenic recess. This sub-phrenic recess Convigates with the general peritoneal cavity and it is divided into two halves Right and a left half by this fancy-form ligament The next space that we have is on the visceral surface of the liver where my hand is located This is known as the sub-hypatic space and if I were to push my finger beyond the sub-hypatic space Where my hand is going right now then it goes into yet another deep recess and that is known as the Hepatorenal recess. This is a very special recess It is also called the Morrison pouch and this is located between the right anatomical lobe of the liver and The right kidney. This is one of the two most dependent parts of the peritoneal cavity When there is a peritoneal fluid the other dependent part being the pelvis So what is the clinical significance of these three spaces? Whenever there is excess fluid in the peritoneal cavity or pus collection They tend to collect here and then they tend to gravitate into the hepatorenal recess And from there they gravitated along the paracolic gutters and they collected to the pelvis Not only that after surgery if there's any collection of blood they tend to collect in these spaces Now let's come to some interventions on the liver itself. Most of the liver is located in the right hypochondrium So the extent of the liver is from the seventh to the eleventh ritz When do you have to do a liver puncture an ultrasound or a CT scan guided liver puncture? Of course pre-vetal that we have to do pro thrombin type an international normalized ratio and After that when it is normal only then we can do a liver puncture We should do it in the ninth intercostal space in the mid-axillary line And we must remember that the glistens capsule is painful We can use the same procedure for taking a liver biopsy earlier days They used to use a Wim silver man needle nowadays. They use Tiba needle which has been designed by the Chiba University of Japan Now let's come to some other aspects. This is the portahepatus The portahepatus is not covered by peritoneum So only the margins of the portahepatus are lined by the peritoneum So what are the three structures which are entering or leaving the portahepatus first we have this structure here This is the common bile duct Next structure we have is the hepatic artery and the third structure we have is the portal vein So these three structures together constitute extra hepatic portal triad So here we have several important clinical correlations I have held up the three structures of the extra hepatic portal triad in my instrument here These three structures are running in double fold of peritoneum referred to as the hepato-duodenal ligament It touches it to the first part of the duodenal When we are doing a liver surgery it is bleeding from the hepatic artery or from the cystic artery And we cannot control the blood and the whole area gets filled with blood We can do what is known as a Pringles maneuver and that is exactly what I have done with my finger I have put two of my fingers behind the extra hepatic portal triad into the epiploid foramen My thumb is in front and it is compressing the structures of the portal triad And by so doing I can compress the hepatic artery And then we can stop the bleeding and then we can look for the source of bleeding and then we can ligate it This is a very useful in a life-saving procedure for the surgeon as well as for the patient And that is known as Pringles maneuver Now let's quickly look at some of the other structures in the portal triad As I mentioned, this is the common bile duct In this particular cadaver she has only undergone cholecystectomy And if you look very closely you can see that the cystic duct there is a clip here So this is the remnant of the cystic duct And if we trace the common bile duct we notice that it is dividing into a right hepatic duct and a left hepatic duct We can get a special type of cholangiocarcinoma where the cholangiocarcinoma involves a bifurcation between the two hepatic ducts And that is referred to as claskin tumor Cholangiocarcinoma occurs when there is a asiatic cholangio hepatitis or long-standing inflammation or due to some parasitic inflammation Then there is a condition which is referred to as congenital biliary atresia Where the whole biliary system is atritic at newborn itself Only dilated portions are the intra-hepatic biliary radicals And those are used in the portahepatitis to anastomers with the gigenome And that is referred to as hepatic co-gigenostomy and that procedure is also referred to as Kasi operation Now let's come to portal vein here The portal vein as it goes inside the portahepatitis again we can see it is dividing into a right branch and a left branch This left branch of the portal vein communicates with paraumbilical veins To show you the paraumbilical veins let me just turn the liver again Come back to the phasemom ligament This is the phasemom ligament and as I said the phasemom ligament has got the round ligament in its free margin The round ligament is the fibrose remnant of the umbilical vein which carried oxygenary blood in the fetal life If you look closely we can see some small venous channels here These are referred to as the paraumbilical veins which are present in adults These paraumbilical veins run with the round ligament of liver and they open into the left branch of the portal vein Approximately they communicate with the veins around the umbilicus This is the umbilicus The veins around the umbilicus are tributaries of the superficial epigastric vein which drains into the femoral vein So therefore paraumbilical veins are a source of portah systemic communication In a patient with cirrhosis with portal hypertension These paraumbilical veins can become engorged with blood because of reversal of flow And the patient can present with dilated superficial epigastric veins around the umbilicus Which will radiate out around the umbilicus in a radial fashion And that is a clinical sign, syn cirrhosis And that is referred to as Gapot Medusa So that is the significance of the left branch of the portal vein Communicating with the paraumbilical veins Now let me show you the hepatic artery itself This is the hepatic artery And if you were to look closely, we notice that the hepatic artery is making a sharp right angle bend here This portion of the hepatic artery is coming from the celiac trunk So this is the celiac trunk which I have lifted up here We have completely removed all the celiac plexus around here And we can see three branches coming out from the celiac trunk The largest branch of course is the spleenic artery which is highly tortuous And the second largest branch, this is the common hepatic artery And this is the left gastric artery This common hepatic artery runs to the right This is the other end of the common hepatic artery that we see here And then it makes a right angle bend At the place where it makes a bend, it gives up this branch here This is the gastrodural artery This gastrodural artery runs behind the first part of the diurnal And this gastrodural artery can be a source of bleeding in a posterior diurnal ulcer After it makes a bend, then the rest of the hepatic artery which we see here Is referred to as hepatic artery proper From the hepatic artery proper, we have this another branch coming out here This is the right gastric artery The hepatic artery proper ideally is supposed to divide into a right hepatic artery And a left hepatic artery But here we can see one, two, three And from the right hepatic artery is supposed to arise the cystic artery Which runs in the cholecystoo hepatic triangle of callot And supplies the gallbladder But again, as I mentioned in this particular cadaver The gallbladder has been removed So therefore this is the stump of the cystic artery And we can see the clip is attached here So therefore we have seen two clips We have seen the clip of the cystic duct here And we can see the clip of the cystic artery here This is the fossil for the gallbladder So therefore when we do cholecystic to me We are operating in this region That is called the cholecystoo hepatic triangle of callot This triangle is bounded by the liver above And the common hepatic duct And the content of this triangle is cystic artery Which I showed you just now And the cystic lymph node So these are some of the clinical aspects of the liver That I wanted to mention to you Thank you very much for watching Dr. Sanjay Sanyath signing out Dr. Gomthi Chundilal is the camera person If you have any questions or comments Please put them in the comment section below Have a nice day