 My name is Dr. Sanjeev Sanyal, Professor of Department Chair. I'm going to demonstrate the contents of the Extravagatic Portal Trial and a few words about each of them including their clinical correlations. My finger has encircled the structures of the Extravagatic Portal Trial. These are the structures of the Extravagatic Portal Trial. This space that we see here under the Extravagatic Portal Trial, this is the epiploid for a man of wind slow. We have removed the structures and we are seeing only the three structures of the Extravagatic Portal Trial. So let's quickly name them. Anteriorly, we have the Common Bioduct. The right, then we have the upper hepatic artery to the left and posteriorly, we have the portal wing. So these are the three structures which constitute the Extravagatic Portal Trial. So let's say a few quick words about each of them. Let's start with the Common Bioduct. The Common Bioduct starts from the Portiopadis as the right and left hepatic ducts which we cannot see and the right and left hepatic ducts then unite. To form the Common Hepatic Duct. And the Common Hepatic Duct then receives the Cystic Duct which is this structure here. And once it meets with the Cystic Duct, then it becomes the Common Bioduct. And the Common Bioduct then runs behind the first part of the Diode Lump and it enters the pancreas. We have seen the pancreas from behind and it runs within the pancreas and inside the pancreas it meets with the main pancreatic duct of Virsoom and forms a Common Hepatopancreatic Ampula which then opens in the Major Diodenal Papilla which we see here in the second part of the Diode Lump. So this is the Major Diodenal Papilla. This is the opening. Let's mention a few clinical correlations put into the biliary duct. At the junction where the right and the left hepatic ducts meet, we can get a special type of Polyangiocarcinoma which is the carcinoma of the Bioduct and that is called the Clatskin Tumor. The Common Bioduct is a very common site of stone dislodged from the gallbladder and then it produces gallstone colic. We can also get interpreted attacks of the infection in the Common Bioduct and that is known as Colangiitis. And in a classical example of Colangiitis ascending up from the Diodenum that is known as ascending Colangiitis, we can get what is known as Sharpo's Triad. The patient has got the three symptoms namely fluctuating jaundice, recurrent biliary pain and intermittent fever with rigors. Mental status and sepsis have been added by rainouts. In some Asian countries, a particular Helminth can also produce infection and that is known as Asiatic Colangiohepiditis and that is caused by Clonarchis sinensis. Common Bioduct stone is not very uncommon and then it can produce gallstone colic as I mentioned earlier. In which case, when we do surgery, we have to explore the Common Bioduct, remove the stone and then after we have to put in what is known as a T-tube which comes out through the abdomen. And 14 days later, we do a T-tube Colangiogram to see if the passage is patented and if it is patented then we remove the T-tube. Yet there is another investigation that we can do and that is done usually before surgery. We cannulate through by means of a diodenoscope, we cannulate the Hepatopancreatic duct, the main pancreatic duct of Virso and we inject the dye so that it outlines the pancreatic duct which is here and it also outlines the Common Bioduct and that procedure is known as Endoscopic Retrograde Colangiopancrotogram. So a common rule of thumb to be remembered is ERCP is to be done before surgery and T-tube Colangiogram is done after Common Bioduct exploration. Now let's take the next component of the Extrapathic Portal Trial that is the Hepatic Artery Proper. The Hepatic Artery Proper, it starts as the Common Hepatic Artery from the C-Electrum. Initially, it runs to the right horizontally and then it becomes vertical. At the place where it changes direction, it gives off a major branch and this is the Gastrodial Artery and after that it runs up as the Hepatic Artery Proper. From the Hepatic Artery Proper, we can see one branch coming out and this is the right Gastric Artery which runs on the lesser curvature of the stomach in the lesser momentum from right to left. This is the lesser momentum which has been removed. So this is the branch of the Hepatic Artery Proper. The Hepatic Artery, once it reaches the Porta Hepatis, it divides into a right branch and a left branch and we can see the right branch of the Hepatic Artery. Normally, the classical textbook description is that the right Hepatic Artery runs behind the Common Hepatic Duct but in front of the Portal Bay. But there are lots of variations and in this case we notice that the right Hepatic Artery is running in front of the Common Hepatic Duct. The right Hepatic Artery gives rise to the Cystic Artery to the gallbladder. The Cystic Artery is located in the Callot Strangle which is bounded by the Cystic Duct, the Common Hepatic Duct and the Liver. When we are operating in the gallbladder, accidentally we endure the Cystic Artery and produce hemorrhage. Or in any other surgery, if the Hepatic Artery gets injured and there is profuse bleeding, then it becomes very difficult to see the site of bleeding and control it. Then we do what is known as the Pringles Velover. My finger is in the Epipyroic Foremen of Winslow. So in front of my finger are these three structures of the Extrapathic Porta Triad which by the way were enclosed in the Hepatodeodontal ligament which has been removed. And my thumb is in the anterior margin of the Epipyroic Foremen of Winslow. And I compress like this. I am effectively compressing the proper Hepatic Artery. And therefore once we compress it, the bleeding stops and then we can locate the source of bleeding and we can ligate it. This procedure is known as Hogarth Pringle Manoeuvre. This is for stopping bleeding after Hepatic Artery is injured. Now let's take a look at the third component of the Extrapathic Porta Triad and that is the Portal Veil. The Portal Veil is formed by the union of the Sprenic Veil and the Superior Vicentric Veil. This is the Sprenic Veil which is coming from the spleen and this is the Superior Vicentric Veil. This union takes place behind the neck of the pancreas. The pancreas has been lifted up here and this is the head of the pancreas and this constricted portion is the neck of the pancreas. And thereafter it becomes known as the Portal Veil. And the Portal Veil then runs up in the posterior aspect of the Extrapathic Porta Triad within the Hepatitudinal Legament and enters the liver through the Porta Hepatitis and there it divides into a right and a left branch. The left branch of the Portal Veil receives the Parambilical Veils which come from the Ambilicus and which constitutes for the site of Porta Systemic Anastomosis. The Portal Veil also receives the Inferior Vicentric Veil via the Sprenic Veil. But in this case the Inferior Vicentric Veil is opening a little more immediately. In the earlier days the way to visualize the Portal Veil was by injecting a dye through the spleen and that procedure was known as the Splenoportovenogram, SPV. But that used to be a traumatic procedure and it was an invasive procedure. Nowadays a much more effective method is what is known as MR Portal Venogram. And by that means we can visualize the Portal Veil we can visualize the Sprenic Veil the Sprenic Vicentric Veil and Inferior Vicentric Veil and locate whether any abnormalities. This is especially done in suspected cases of Portal Hypertension when we have to do any surgical procedure and Portal Hypertension is usually a sequel of alcoholic cirrhosis. So let's say a patient has come to us with reading isoplegial viruses or other complications of Portal Hypertension we may have to do what is known as Shunt surgery to decompress the Portal Veil. This as I mentioned is a Sprenic Veil which is running exactly behind the pancreas. And just below that we have the left renal vein and we can see anatomically they are not very far away. So one procedure which is performed is what is known as the Splenorenal Shunt and that way we can decompress the Portal Hypertension. There are two subcomponents of the Splenorenal Shunt. In one we remove the spleen and we attach this portion to the renal vein that is known as the proximal or the central Splenorenal Shunt. The other one we retain this spleen we separate it here and we attach this end to the renal vein that is known as the Distal Splenorenal Shunt or Warren Shunt. This DSRS Distal Splenorenal Shunt is also referred to as what is known as the Selective Shunt that it is it selectively decompresses the Portal Veil and these vagal varices but it also allows some blood to pass through the liver. So these are some clinical aspects about the structures in the Estrapiotic Portal triad. Thank you very much for watching. Ladies and gentlemen, if you have any questions or comments put them in the comment section below. Have a nice day. Dr. Sanjay Sanyal signing out.