Thursday, July 13, 2006

obstructive jaundice surgical anatomy

SURGICAL ANATOMY
Extra-hepatic Biliary system
Right, left and common hepatic duct:
The liver is drained by two duct systems- right and left. The right hepatic duct is formed by the union of anterior and posterior segmental ducts and the left hepatic duct is formed by the union of lateral and medial segmental ducts. The drainage of the caudate lobe is variable. The right and the left duct join soon after emerging from the liver to form the common hepatic duct (CHD). The junction lies 0.25-2.5 centimeters from the surface of the liver. The left duct is larger (1.7 centimeter, average) than the right duct (0.9 centimeters, average). In some instances, intrahepatic junction of two ducts is the result of liver enlargement.
The right and left duct join on the right side of porta hepatis in the transverse fissure of liver. Length of CHD varies from 1-3.5 centimeters depending upon the insertion of cystic duct which is highly variable. The CHD is said to be absent if the cystic duct enters at the junction of the right and left hepatic ducts. Three types of cysto-hepatic junctions have been described- angular, parallel, and spiral.
An aberrant hepatic duct is a normal hepatic duct that joins the biliary tract just outside the liver surface instead of jut within. It drains a normal portion of liver. Subvesicular bile ducts found in approximately 35% of individuals, are small, blind ducts emerging from right lobe of the liver and lying in the bed of the gall bladder. They could communicate with the gall bladder. Hepatocystic ducts drain bile from liver directly in to the body of gall bladder or into the cystic duct.
Cystic duct:
The cystic duct on an average is about 3 centimeters in length and its lumen is about 1-3 millimeters in diameter. It inserts on the right side of CHD forming the common bile duct (CBD). Occasionally it may be sessile. The mucosa of the cystic duct is arranged in spiral folds known as the Valves of Heister. Its wall is surrounded by a sphincteric structure called the Sphincter of Lutkens.
Gall bladder:
It is a pear shaped organ, about 7.5-12 centimeters in length, with a normal capacity of 5 milliliters, but capable of considerable distention in certain pathological conditions. The anatomical divisions are a fundus, a body, and a neck that terminates in a narrow infundibulum. The muscle fibers in the wall of the gall bladder are arranged in criss-cross fashion, being particularly well developed in its neck. The mucous membrane contains indentations of the mucosa that sink into the muscle coat. These are the Crypts of Luschka. A deformity of gall bladder seen in 2-6 % of individuals is the Phrygian Cap. Hartmann’s Pouch is probably a normal variation than a true deformity.
Common Bile Duct:
The common bile duct (CBD) begins at the union of the cystic duct with the common hepatic duct and ends at the Ampulla of vater. It varies in length (5-15 centimeters) depending upon the insertion of the cystic duct. The normal diameter varies from 4-10 millimeters.
The duct may be arbitrarily divided into 4 portions:
· Supraduodenal (0-4 centimeters; average 2 centimeters) – it lies in the free edge of the lesser omentum. The distal part is related to the retroduodenal artry.
· Retroduodenal (1-3.5 centimeters; average 1.5 centimeters) – lying behind duodenum, it curves to the right. It is related to the gastroduodenal artry on the left side.
· Pancreatic (1.5-6 centimeters; average 3 centimeters) – it extends from the upper margin of the head of the pancreas to the point of entrance into the duodenum. The CBD may be partly covered by a tongue of pancreas (44%), completely within the pancreatic substance (30%), uncovered on the pancreatic surface (16.5%), or completely covered by two tongues of pancreas (9%). Here it lies anterior to the IVC.
· Intramural (0.8-2.4 centimeters; average 1.4 centimeters) – this portion passes obliquely through the duodenal wall along with pancreatic duct to open in to the ampulla of vater. The ducts may open independently in about 10% of the cases.
Hepatocystic triangle of Calot’s
The Hepatocystic triangle of Calot’s is formed by the cystic duct and the gall bladder below, the right lobe of liver above, and the CHD medially. Contents of the triangle include- a) right hepatic artry, b) cystic artry arising from the right hepatic artry, c) cystic lymph nodes of Lund, and d) aberrant hepatic ducts.
Blood Supply
Arterial supply:
The gall bladder is supplied by the cystic artry, a branch of right hepatic artry, which is usually given off below the gall CHD. Occasionally an accessory cystic artry arises from the gastroduodenal artry. In 15% of the cases, the right hepatic and/or the cystic artry cross in front of the CHD and the Cystic duct. The most dangerous anomalies are where the hepatic artry takes a tortuous course in front of the origin of the cystic duct, or the right hepatic artry is tortuous and the cystic artry short. The tortuosity is known as the Caterpillar’s turn or the Moynihan’s hump.
The bile ducts are supplied by the branches of the posterior superior pancreaticoduodenal, retroduodenal, and right and left hepatic arteries. The blood supply of the supraduodenal bile duct is essentially axial. The major blood supply comes from below (60% from the retroduodenal artry) and the rest from above (38% from the right hepatic artry). The bile duct in the hilum and the retropancreatic bile duct have an excellent supply.
Venous drainage:
Several cystic veins enter the hepatic enter the hepatic parenchyma. An epicholedochal venous plexus drains the extra hepatic bile duct into the corresponding veins.
Lymphatics:
The lymphatic vessels of gall bladder (subserosal and submucous) drain into the cystic node of Lund (the sentinel node). The node lies in the fork created by the junction of the cystic duct and the common hepatic duct. Efferent vessels from this node go to the hilum of the liver and to the celiac lymph node. The subserosal lymphatic vessels of the gall bladder also connect with the subcapsular lymphatic channels of the liver.
Surgical Anatomy of Pancreas
Pancreas is a word of Greek origin (pan means all and kreas means flesh) Pancreas is a soft lobulated retroperitoneal gland which lies transversely across the upper abdomen over 2nd lumbar vertebra and then runs obliquely upwards to the splenic hilum. The approximate weight of the gland is 80 grams.
Anatomically and surgically pancreas is divided into several parts.
(i) Head: It's the part which lies in the C loop of the duodenum. It's anterior surface is adjacent to pylorus and transverse colon The post surface is close to the hilum of the right kidney and it's vessels, IVC, CBD, portal vein, the right crus of diaphragm, posterior pancreaticoduodenal arcade and gonadal vessels. CBD lies in the posterior part of the gland in a groove.
ii) Uncinate process: This is an extension of pancreas passing downward behind portal vein and superior mesenteric vessels and in front of aorta and IVC. It may be absent or it may completely encircle superior mesenteric vessels. Short vessels from SMA to the uncinate process need careful ligation during dissection.
iii) Neck: It is 1.5 to 2 centimeter long (Nyhus), is behind pylorus and overlies portal vein formation
iv) Body: Runs obliquely upwards covered by double layered peritoneum. Middle colic artery is an important landmark.
v) Tail: It is a relatively mobile structure in the splenic hilum. It is enclosed in the lienorenal ligament with splenic vessels.
Arterial Supply:
The arterial supply arises from both celiac trunk and the superior mesenteric artery.
Head of the pancreas is supplied by two pancreaticoduodenal arcades formed by anterior and posterior branches of superior pancreaticoduodenal artery ( branch of celiac axis) with anterior and posterior branches of the inferior pancreaticoduodenal: artery (branch of the SMA).
One dorsal pancreatic artery arises from the splenic artery at the neck, right branch of which supplies the head and joins the posterior arcade while few left branches supply body and tail.
One caudal pancreatic artery arises from left gastro epiploic or splenic artery
All the major arteries lie posterior to the ducts.
Venous drainage:
Venous supply parallels arterial supply and lies superficial to the arteries still deep to the ducts. Ultimate drainage is to the portal vein.

a) Right Hepatic Artery, b) Right Choledochal Artery, c) Retroduodenal Artery, d) Left branch of Hepatic Artery, e) Hepatic Artery, f) Left Choledochal Artery, g) Common Hepatic Artery, h) Gastroduodenal Artery
Left renal vessels
Inferior mesenteric artery
Lymphatic drainage:
Centrifugal type of drainage is seen. Chief groups include.
a) Splenic hilar nodes drain the tail.
b) Superior pancreatic, left gastric, inferior pancreatic, and superior mesenteric nodes drain the body & neck
c) Posterior and pancreaticoduodenal Lymph nodes drain the head.
d) Head drains directly to the Para aortic Lymph nodes in the inferior aspect.

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