 So, this is the demonstration of the liver the first point is about the location of the liver. So, you can see that the liver is located under the right dome of the diaphragm and it extends partly into the epigastrium and it spins over into the left hypochondrium. So, the main location is right hypochondrium little bit in the epigastrium and little bit in the left hypochondrium. You know to understand the parts of the liver we have to look at this ligament that we are holding up here. This is the falciform ligament and we can see that the falciform ligament is attached to one area of the liver here and this is what divides the liver into its component anatomical parts. The portion to the right is called the right anatomical lobe and this is the left anatomical lobe. This portion which is in contact with the under surface of the diaphragm where my finger is gone in this is known as the diaphragmatic surface it is also referred to as the anterior superior surface. And this surface where my finger is gone in this is the visceral surface because it is in related to the viscer of the abdomen and this is also referred to as the posterior inferior surface because my hand is going posterior inferior. So, these are the essential parts of the liver right anatomical lobe left anatomical lobe anterior superior surface and posterior inferior surface and separating them is this sharp margin that we see here. This is the inferior border or the inferior margin of the liver in a normal person in whom the liver is not this is not a normal case this is a patient with no micro nodular cirrhosis, but in a normal patient the inferior margin of the liver is just above the costal margin. So, we should not be able to feel the inferior margin of the liver in a normal person. However, if the liver is enlarged which is called hepatomegaly then we can feel it when we palpate the liver from below up. In children the liver inferior margin may be palpable one centimeter below the right costal margin which is not considered abnormal. There is one portion of the liver on the right side of the right anatomical lobe which is referred to as the right surface of the liver in some anatomical textbooks and this is the surface which is used to perform what is known as a liver biopsy through the ninth intercostal space in the mid axillary line. So, these are the parts of the liver come to the visceral relationships of the liver in order to understand the visceral relationships we will reflect the liver up. So, this is the visceral surface of the liver or the posterior inferior surface this is the cut portion of the stomach and this is the location of the esophagus. So, let us put the structures in the normal anatomical position on the left side going from above down we have the esophagus then we have the stomach and then we have the pyloric atrium and then further to the right we have the diodenum this is the diodenum then we have the kidney the right kidney and then we have the right supravenum. So, esophagus stomach pylorus diodenum kidney right supravenum. So, these are the six structures which are located to the visceral surface this was the location of the transverse colon. So, the transverse colon is located in relation to the inferior margin of the liver. So, these are the visceral relationships of the liver. Let us take a look at the ligament switcher attached to the liver this ligament which is being held up by my assistant here this is the falciform ligament the falciform ligament as the term implies is a sickle shaped triangular ligament. So, therefore, it has got two attached margins and one free margin this margin that you see here this is the margin which is attached to the inner surface of the abdominal wall when it goes to the liver it gets attached to the fisher between the anatomical right room and the left room this portion is a part of the falciform ligament which then splits to form the coronary ligament this is the other attached margin and finally, we see this margin here this is the free margin of the liver and this contains this structure here this structure is a combination of two things one of them is called the round ligament of liver which is a remnant of the umbilical vein and other structure which is present is the para umbilical vein and we can see the para umbilical vein here the round ligament of the liver carries oxygenated blood in fetal life from the umbilicus to the fetus and the para umbilical veins in adult life communicate the left branch of the portal vein with us weights on the umbilicus and they get engorged in a patient with cirrhosis with portal hypertension so these are the structures which have seen on this surface let's come back to where we saw the under surface of the diaphragm again to come back this is part of the falciform ligament and we can see that the falciform ligament is getting attached to the under surface of the diaphragm so therefore, this is an important structure which holds up the liver and going further posteriorly the falciform ligament splits into this layer here and this layer here this is the anterior leaf of the coronary ligament similarly we have something called the posterior leaf of the coronary ligament which we cannot see which also holds up the liver against the diaphragm now let's come to the fissures of the liver for that again we will turn the liver up we are looking at the visceral surface but here we are now not focusing on the visceral organs but we are focusing on the fissures straight away we can see one fissure here and another fissure here this is the cystic fissure or the fossa for the gallbladder and we can see that the gallbladder is attached to the in this region this is the region where the liver does not have visceral peytonium because it is covered by the gallbladder so this is the gallbladder fossa or the cystic fissure to the left of that we see yet another fissure this is the fissure for the round ligament of liver and we already mentioned the round ligament liver is a remnant of the umbilical vein further posteriorly if you trace the fissure for the round ligament we see yet another fissure here this is the fissure for the ligamentum venosum which contain the ductus venosis which connects the umbilical vein directly to the inferior venaecaeva posterior to the gallbladder fossa we have this structure here where my finger is located though it has not been dissected out that is the fissure for the inferior venaecaeva so therefore if we were to look at the whole thing in totality we see one continuous fissure here this is the fissure for the gallbladder and the fissure for the inferior venaecaeva which is on the right side then we have the fissure for the round ligament and the ductus venosis which is on the left side so this is the left sagittal fissure also known as the umbilical fissure this is the right sagittal fissure which will later form portal fissures in the surgical segments and finally connecting the two limbs of the fissure we have this segment here this is referred to as the porta hepatus so these are the fissures that we can see forming a rough edge structure on the visceral surface of the liver now let's come to the extra hepatic portal triad my finger has picked up some structures here this three structures are the extra hepatic portal triad so now let's take a look at them we have consistently separated them out to show the extra hepatic portal triad this one this is the common by duct the right anterior another anterior hepatic artery the hepatic artery starts as a common hepatic artery and after it gives the gastrodeodontal artery it becomes known as the hepatic artery proper so hepatic artery proper and posteriorly we have this structure here portal way so these three structures constitute the extra hepatic portal triad they are located within the two folds of petronium which is collectively referred to as the hepato-deodontal ligament and the hepato-deodontal ligament stretches from the first part of the deodontum which is here and gets attached to the margins of the portal triad these extra hepatic portal triad structures enter the liver or leave the liver the common by duct continues up and it gives off a cystic duct here and then it becomes known as the common hepatic duct and which enters the portal triad the hepatic artery also divides into a right and left right and the portal way also divides in the hepatic as the right and left portal veins my finger is in this space here behind the extra hepatic portal triad this is the epiploid for oven or the omen for oven or the which slows for oven so the anterior boundary is formed by the structures in the extra hepatic portal triad the posterior boundary is formed by the inferior vena cava and the right supra renal gland the superior boundary is formed by the liver and the inferior boundary is formed by the first part of the deodontum so this is a triangular shaped window which is called the epiploid for oven and which leads into this space here which is actually the space behind the stomach and that space is referred to as the lesser sac or the mental person so this is the epiploid for oven now let's take a look at the spatial around the liver there are three principal spaces around the liver the first space is where my finger hand is gone in this is the known as the sub phrenic recess because it is under the diaphragm sub phrenic means under the diaphragm and you could see the sub phrenic recess is divided into two parts a right part and a left part by the phalseiform ligament and the sub phrenic recess communicates with the rest of the paternal cavity the next space is on the under surface of the liver on the external surface of the liver this is referred to as the sub hepatic space and posterior continuation of the sub hepatic space is where my finger is gone in my finger has gone in very deep this is referred to as the hepato renal recess why is it called the hepato renal because this is the left kidney and this is the liver so therefore this is the hepato renal recess also referred to as the Morrison pouch let's come back to the sub phrenic space if i want to push my finger my hand does not go beyond a certain stage similarly on this side also my hand does not go beyond a particular stage what is blocking my hand the anterior layer of the coronary ligament is blocking my hand similarly if i want to push my hand in the hepato renal recess at a particular place my hand will not go any further so what is blocking my hand the posterior layer of the coronary ligament so these are the limits of the spaces and the hepato renal recess we can see very clearly here this is the hepato renal recess it is one of the two most dependent portions of the peritoneal cavity where abnormal fluid can collect when the patient is supine next so that brings me to the next that's the peritoneal spaces i've already referred to the lesser sag where my finger has gone in if the stomach was here then it would have been behind the stomach so the lesser sag is a space behind the lesser momentum the stomach this is the lesser sag it's a space between the stomach and the bed of the stomach so this lesser sag which is also referred to as the omenical bursar has got superior recess which also is going behind the liver but it is stopped by the posterior of the coronary ligament this lesser sag communicates through the omenical forearm where my fingers come and it communicates with the hepato renal recess and this lesser sag also communicates with the rest of the peritoneal cavity the rest of the peritoneal cavity is referred to as the greater sag there's a very important surgical correlation pertaining to the lesser sag the posterior boundary of the lesser sag is this structure here which is the pancreas in alcoholic or any other pancreatitis after the inflammation of the pancreas the subside fluid exudes and collects inside the lesser sag and it forms a big swelling behind the stomach and that is called the pseudo pancreatic cyst and when we have a patient with pseudo pancreatic cyst so any fluid collection what other surgical access do we have let me put back the colon here this was the location of the transverse colon and this is the greater incremental so this is a gastropolic ligament we can split the gastropolic ligament here and we can lift up this number and we can enter the lesser sag so this provides a surgical access to the lesser sag by splitting the gastropolic ligament now let's take a look at the rest of the peritoneal cavity which is the greater sag the portion above the transverse colon is called the supracolic compartment the portion below the transverse colon is the infracolic compartment and we can see that all of these spaces are in communication with each other fluid from the supracolic compartment and the interacolic compartment can travel on either side of the descending and descending colon and these depressions that we see here these are referred to as the paracolic cutters and from there they can track down and they can collect in the appendix when my finger is gone in so this is the second most dependent part of the peritoneal cavity the first being the epitoneal recess and the second being the peritoneal cavity so this is about the general peritoneal cavity and the peritoneal spaces and their intercommunications with each other now let's come to the port hepatitis port hepatitis is this structure the horizontal limb of the edge which I mentioned and we can see that entering the port hepatitis we have the common hepatic duct here next structure that is entering the port hepatitis is the hepatic artery and the third structure that is entering the port hepatitis is the portal wave all of which we'll divide into a right and left branch the port hepatitis itself is not covered by visceral peritoneum but the margins are attached by the hepatodontal ligament this port hepatitis is where the hepatodontal ligament is attached and the fissure for the ligament of venosa where my finger is gone in is where the hepatocastric ligament is attached so therefore the lesser momentum is attached to the liver in the form of an L shape so this is the attachment of the lesser momentum to the liver and the lesser momentum if you were to look at it in the stomach this is the portion which gives rise to the membranous part of the hepatogastric and this is the portion which gives rise to the hepatodontal part hepatodontal gets attached to the port hepatitis margins hepatogastric gets attached to the fissure for ligamentum venosa now let us take a look at this one special triangle which is used in gallbladder surgery this triangular space that we see here this is called the callot triangle or the colisus to hepatic triangle it is bounded by the common hepatic duct the cystic duct and the liver this is the callot triangle the most important content of the callot triangle is this artery here and that is the cystic artery which has to be ligated when we are doing a colisus to me or gallbladder surgery and it also contains a lymph node known as a cystic node so this is the importance of the callot triangle and finally when we are doing a gallbladder surgery or any surgery in this region suppose there is accidental bleeding from the hepatic artery what is the best way to stop it my one finger has gone into the epicoic for a minute my thumb is in front and i grip the structures of the portal drive between my two fingers and by so doing i'm compressing the hepatic artery when i do that it stops the bleeding and allows me to catch the bleeding point this procedure is a very important surgical maneuver and that is referred to as the Pringles maneuver this is a patient who has obviously got micro nodular cirrhosis he may have been an alcoholic this is also referred to as Lenic cirrhosis and the liver has got hobnane appearance so sometimes this is also referred to as a hobnane liver in such patients we can they can develop what is known as portal hypertension where the portal vein gets engorged that's called portal hypertension the blood pressure inside the portal vein increases then there are certain areas in the body where portal systemic communications become big one of that site is the lower end of the east of Vegas and we can see an engorged vein here this is a portal systemic anastomosis site another site is the para umbilical vein which runs in the free margin of the aciform ligament the third is the rectum and the fourth site is the retropatrial areas of the colon so these are the four sites of portal systemic anastomosis which become big in cases of cirrhosis with portal hypertension so this was a rather extensive coverage of the liver the patonal cavity the gallbladder surgery portal hypertension cirrhosis thank you very much for watching have a nice day Dr. Sanjay Sanyal