 So this is going to be a clinical demonstration of the liver. I'm holding the eviscerated liver in front of me Just to bring up to speed. This is an anatomical right lobe, anatomical left lobe Now let's mention a few clinical coalitions pertaining to the portal vein itself This is the portal vein that I have lifted up here Portal vein is the posterior most structure in the extrapatic portal triad and we can see it is dividing into a Right branch and a left branch. So how is this portal vein formed? This is the other end of the portal vein This is the liver end of the portal vein and this is the Intestinal end of the portal vein. The portal vein is formed by the union of these two veins This is the superebicentric vein and this is the splinic vein. The splinic vein and the superebicentric vein unite behind the neck of the pancreas Which has been removed and then it forms a portal vein Which runs obliquely up and to the right and this continues and enters into the portal hepatitis So this is the portal vein. How do we investigate the portal vein? In the earlier days We used to do what is a very traumatic procedure called a screeno-porto-veno-gram But nowadays we don't do that. Instead, we do what is known as magnetic resonance Porto-veno-gram and that way we can outline the entire portal venous system So this is the splinic vein. This is the inferebicentric vein opening into the splinic vein This is the superebicentric vein opening into the splinic vein to form the portal vein This is an MR portal venogram to show the portal venous structure and the inferebicentric vein This is yet another MR portal venogram to show the inferebicentric vein opening far from the screen Alcoholic cirrhosis The portal vein pressure becomes high and that is referred to as portal hypertension And the blood flow in the portal vein gets reversed This is the picture of a cirrhosis from another cadaver dissection Once we have identified the abnormalities of the portal vein The most common surgery performed nowadays is to decompress the portal hypertension Especially the esophageal varices The latest technique nowadays is what is called What is the principle of this procedure? Let's take a look at this structure here This is the right brachioscephalic This is the left brachioscephalic Two of them unite to form the superebina keba Brachioscephalic is formed by the internal jugular and the subclavian So we use the right side The right internal jugular, right brachioscephalic and the superebina keba They're almost in a straight line So we put a canal through the right internal jugular vein Through the right brachioscephalic vein, through the superebina keba Through the atrium and we enter into the inferior vina keba And we enter into the liver And then we do a shunt with the systemic circulation And that is referred to as trans jugular intra hepatic portal systemic shunt That is to decompress the esophageal varices Which is the source of hematomasis In the earlier days, there are 40 or 50 different shunt procedures Which used to be done The most common and the oldest one used to be What is referred to as a proto-caval shunt Anastomosing part of the portal vein with the inferior vina keba Then there's to be another procedure called splino renal shunt Anastomosing the splinic vein with the renal vein Left renal vein because they're very close by In this correction, I would like to mention one very special selective shunt procedure Which has been devised in Japan And that is referred to as inokuchi shunt So this is the splinic vein This is the inferior miscentric vein opening into the splinic vein To form the portal vein And we can see this vein here The left gastric vein In cases of esophageal varices The left gastric vein becomes dilated Dilated left gastric vein is also referred to as the coronary vein There's a surgical procedure called coronary cable shunt The anastomose, the dilated left gastric vein With the inferior vina keba And that procedure was devised in Japan And it is also referred to as the inokuchi shunt So these are some shunt procedures Which are done to decompress the esophageal varices In cirrhosis with portal hypertension Now let's quickly mention the surgical subdivisions of the liver The easiest to understand is of course the anatomical subdivisions Formed by the phalseiform ligament into a right anatomical lobe And the left anatomical lobe But that is of no functional significance The surgical subdivision of the liver is more practically useful And for that we make use of this fissure here Where my finger is tracing This is the inferior vina keba Group for the inferior vina keba And this is the group for the gallbladder which has been removed So this groove here is referred to as the main portal fissure And if you were to look on the superior surface The main portal fissure will run like this Where my finger is tracing and go to the inferior vina keba This imaginary line which is being traced by my finger Is referred to as cantile line If we were to make an incision through this line Going through this fissure, main portal fissure We will reach the middle hepatic vein That's why it is referred to as the main portal fissure And that is the one which divides the liver Into a right surgical lobe and a left surgical lobe Having done that, then we use another fissure Which is already present and that is this fissure here This is the fissure for the round ligament of the liver And if you were to trace it further here We can see yet one other fissure This is the fissure for the ligament of venosum Which contains the ductus venosis Which shunted blood directly to the inferior vina keba in fetal life Now it is a ligament Incidentally the lesser omentum is attached here So if we were to make an incision through this fissure This is referred to as the left portal fissure That will divide the left surgical lobe into two parts Likewise, if we were to make yet one more incision Lateral to the cantile line which I mentioned Across here, this is an imaginary line That will contain the right hepatic vein And that will also divide the right surgical lobe into two parts So these are the surgical subdivisions of the liver And then if we make a transverse incision across like this And like this Then we divide the entire liver into eight surgical segments This is the principle of surgical hepatic segmentectomy I am going to turn the liver now This lobe that we see here Between the ligament of venosum And the inferior vina keba This is referred to as the cordate lobe This is given as hepatic segment number one This is called the cordate process Then we see another part of the liver here Between the round ligament of the liver And the fissure for the gallbladder This is called the cordate lobe This is part of hepatic segment number four So this is how the hepatic segments are numbered And there are totally eight hepatic segments Which form the basis of hepatic segmental resection Before I conclude This is the surface of the liver which was in contact with the ribs And we can see the rib markings here The costal markings So whenever there is any trauma to the right hypochondrium Or a rib fracture of the right hypochondrium It can produce tear of the liver In my clinical practice I have seen And the bleeding from the ruptured liver Is very horrendous And it is very difficult to stop So therefore we must remember That whenever a patient presents with Fracture of seventh to the eleventh ribs On the right side We must think of liver injury 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 Sanyan signing out Dr. Gomthi Chandilal is the camera person If you have any questions or comments Feel free to leave them in the comment section below Have a nice day