 This is a quick demonstration of the celiac trunk and the structures in the extrapodic portal triad except the spleenic artery which we cannot see because it is hidden under the pancreas. So, where my instrument is pointing this is the origin of the celiac trunk from the abdominal aorta as an unpaired visceral branch it originates at the level of T12. The celiac trunk is very small and quite often it is absent also and immediately as it comes out from the abdominal aorta it divides into three branches. The largest is the spleenic artery which we can just see the beginning but we cannot see the rest because it is behind the pancreas. We shall show that in a separate dissection. The next largest is the one which I have picked up here this is the common hepatic artery. The common hepatic artery runs to the right and it makes a curve up almost 90 degrees. At the point where it is making a curve up the common hepatic artery gives a very big and an important branch and this is that branch which you can see this is the gastrodial artery and then it curves up and after that it is known as the hepatic artery proper and from the hepatic artery proper it gives rise to a branch the opening of which we can see here because we had to cut it and that is the right gastric artery and this is the stomach which we have reflected and this is the other cut end of the right gastric artery so this is the right gastric artery. This right gastric artery runs on the lesser curvature of the stomach from right to left so this is the next branch the hepatic artery. The third and the smallest branch is this one which I have lifted up here this is the left gastric artery. The left gastric artery again it runs in the lesser curvature of the stomach from left to right and this is the other cut end of the left gastric artery here. This left gastric artery which is running in the lesser curvature of the stomach and the right gastric artery which runs on the from the opposite side they anastomose they run in the layers of the lesser momentum or the hepato gastric the gastroepatic ligament and the anastomose in the lesser curvature. So this is the lesser curvature of the stomach which we have dissected open we have removed the lesser momentum and we can see the left gastric artery and the right gastric artery. Incidentally we can also see some of the branches of the vagus more specifically the posterior vagus which supplies the lesser curvature of the stomach. So this is the distribution of the gastric arteries. Now let's see what happens to this gastro-duodenal artery which I mentioned. The gastro-duodenal artery runs behind the first part of the duodenum and the first part of the duodenum is here this is the first part of the duodenum where my instrument is located and as it runs behind the first part of the duodenum it comes to the other surface and here I am turning the stomach over to show the continuation of the gastro-duodenal artery and we can see this is the gastro-duodenal artery it is now running behind the first part of the duodenum. When it reaches the opposite side it divides into two principal branches one of them is this one this is the right gastro epiploid or the right gastro-mental artery which runs on the greater curvature of the stomach from right to left and the other branch is this one which I have lifted up here this is the superior pancreatic o-duodenal this is the anterior this is the posterior superior pancreatic o-duodenal the pancreatic o-duodenal runs in the pancreatic o-duodenal junction from above downwards and it anastomosis with the inferior pancreatic o-duodenal which I showed in another dissection this is the inferior pancreatic o-duodenal which is coming from the superior mesentry and they supply the head of the pancreas the arsenate process of the pancreas and the sea loop of the duodenum so this is the distribution of the gastro-duodenal artery. Let's continue with the gastro-epiploid artery which is running in the greater curvature of the stomach from right to left this gastro-epiploid or the gastro-mental artery runs between the layers of the greater momentum and it gives gastric branches to the stomach and it gives o-mental branches to the greater momentum and it anastomosis with this artery that we see here this is the left gastro-epiploid artery which is the branch of the splenic artery and this runs from the left to right and this also runs in the layers of the greater momentum and it anastomosis with the right gastro-epiploid artery. These branches that we see these are the vasaprivia which are branches of the splenic artery they run in the gastro- splenically element. Now let me show you the structures which are located in the hepato-duodenal ligament. My finger has gone into this space here this is the epiploid foramen or the foramen of Winslow. In front of my finger these three structures are enclosed in a fold of petronium which is known as the hepato-duodenal ligament which actually is the right free margin of the lesser momentum and contained within the hepato-duodenal ligament we have the following three structures right on the right side and in front this is the structure which I have lifted up here this is the common bile duct front and to the left is this structure which I have picked up here this is the hepatic artery proper and we can see the opening of the right gastric artery here and behind is this structure which I am pointing this is the portal vein so duct artery vein these three are enclosed in the hepato-duodenal ligament and they constitute what is known as the extra hepatic portal triad and they all are entering into the portal hepatic of the liver. So this is about the extra hepatic portal triad my finger is in the epiploid foramen and when I push my finger further deep inside my finger has entered the space which is known as the omental bursa or the lesser side here we can do an important clinical maneuver when we are operating in the gallbladder or anywhere in this region and if the bleeding starts from the hepatic artery we can put one finger my index finger behind into the epiploid foramen and my thumb in front like this and I can compress the hepatic artery the way I am doing right now and by so doing I stop the bleeding from the hepatic artery and this procedure is called hogarth-pringle maneuver and it is a surgical maneuver which is done in clinical practice in surgical practice. Let me mention a few other things about this particular patient as we can see the liver is highly cirrhotic this is a patient who had chronic alcoholism and he's got alcoholic micro roller cirrhosis or lanix cirrhosis and we notice that accompanying the left gastric artery which I mentioned is this dilated incorced vein and in this case it is thrombosed this is the left gastric vein it is so big because this patient had portal hypertension and we can see that it is this is the opening of the esophagus and it is also forming esophageal varices. We know this because this left gastric artery we can see it is giving a branch to the esophagus so therefore the abdominal part of the esophagus receives a branch from the left gastric artery and it also gives a tributary the left gastric vein for this is an important site of portersystemic anastomosis and this is a proof of that portersystemic anastomosis in the form of an esophageal varices. In this particular patient we notice here one more thing this structure which I have turned around this is the falsiform ligament and in the free margin of the falsiform ligament is running this this is the round ligament of the liver it was enclosed in a fold of peritoneum we have dissected it out and we can see this this is the dilated para umbilical vein in case of cirrhosis the dilated para umbilical vein will communicate with the superficial veins of the umbilicus and produce what is known as scaffold medicine because the para umbilical vein communicates with the left branch of the portal vein in the liver and it communicates with the superficial veins of the umbilicus in the abdominal wall so this is another manifestation of portal hypertension. Another site of portersystemic anastomosis in places of portal hypertension is the bare area of the colon where there is portersystemic anastomosis the colon on either side has been removed and the fourth place of portersystemic anastomosis is between the superior rectal vein which is a portal circulation anastomosis with the middle and inferior rectal vein which are part of the systemic circulation and they can produce internal hemorrhoids so these are the four sites of portersystemic communication in a patient with cirrhosis with portal hypertension and these are the sites these are the manifestations of portal hypertension to be remembered that hemorrhoids can also occur independent of cirrhosis with portal hypertension they can idiopathic hemorrhoids which are more common the celiac artery can also be visualized i mean so the procedure known as celiac axis angiogram we cannulate the femoral artery also the cannulate the celiac artery and we inject the radiopic contrast and take the images to see the left gastric artery the hepatic artery and the screening artery this is a stair shot of a selective celiac axis angiogram to show its branches likewise the portal vein can be demonstrated by means of a portal venogram mr portal venogram and we can see the distribution of the portal and it's forming tributaries namely the sprenic vein and the supineum eccentric vein and this is another image to show a magnetic resonance portal venogram so that is all for now if there are any questions or comments please put them in the comment section below Dr. Sanjay Sanyal signing out have a nice day and please don't forget to subscribe