Common hepatic artery.
Nose
The common hepatic artery can be ligated because adequate collateral circulation is possible through the gastric and gastroepiploic arteries.
The proper hepatic artery can be ligated for a long time only proximal to the branch of the right gastric artery. Venous blood supply to the liver carried out by the portal vein (v. portae), 11-49). which is formed behind the pancreas at the confluence of the superior mesenteric vein with the splenic vein and carries blood from the stomach and intestines (Fig.
It goes through the oven nocturnal duodenal ligament(lig. hepato-duodenal), located to the left of the common bile duct(ductus choledochus), but to the right of the proper hepatic artery(a. hepatica propria), and is divided into the right and left lobar portal veins (vv. portae lobares dextra et sinistra),
which enter the portal of the liver. The branches of these veins end in the venous sinuses of the liver. The portal vein can be clamped during surgery for no longer than 30 minutes. Venous drainage 11-50) from the liver (Fig. carried out into the inferior vena cava (v. cava inferior), which leaves a groove in the extraperitoneal field of the liver, where three hepatic veins flow into it(vv. hepaticae).
When the hepatic veins are damaged, intense venous bleeding is observed, which cannot be stopped by squeezing the hepatic-duodenal ligament. Rice. 11-50. Diagram of blood circulation in the liver.
1 - hepatic vein, 2 - hepatic duct, 3 - portal vein, 4 - proper hepatic artery.
Lymphatic drainage
Lymphatic vessels leaving the liver neither together with the vascular-secretory pedicle, pour into the hepatic lymph nodes(nodi lymphatici hepatici), located in the hepatoduodenal ligament, and further into the celiac lymph nodes
(nodi lymphatici coeliaci).
Lymphatic drainage from the diaphragmatic surface
the liver is possible in the posterior mediastinal The lymph nodes(nodi lymphatici medio-stinales posteriores).
Innervation (Fig. 11-51) Branches of the sympathetic hepatic plexus(plexus hepaticus),
located on the portal vein and proper hepatic artery. Hepatic branches of the vagus nerves
(rami hepatici pp. vagi),
approaching the gate of the liver.
Branches of the right phrenic nerve(n. phrenicus dexter)
from the bottom side
the top of the diaphragm approaches the bottom
vena cava and then go to the gate
liver.
Extrahepatic bile ducts ways They begin with the right and left hepatic ducts emerging from the porta hepatis, which lie between the layers of the hepatoduodenal ligament and, merging, form the common hepatic duct (Fig. 11-52).
Left hepatic duct (ductus hepaticus
sinister) collects bile from the left and quadrate lobes, as well as the left half of the caudate lobe of the liver.
Right hepatic duct (ductus hepaticus
dexter) collects bile from the right lobe and the right half of the caudate lobe of the liver.
Common hepatic duct (ductus hepaticus
communis) has a length of 2-4 cm and stretches to
fusion with the cystic duct.
Cystic duct(ductus cysticus) located between the layers of the upper part of the hepatoduodenal ligament and connects the gallbladder with the common hepatic duct to form the common bile duct. The length of the cystic duct varies, but on average is 1-2 cm. It connects with the common hepatic duct at a more or less acute angle and has a spiral fold on the mucous membrane (plica spiralis).
Gallbladder (vesica felled) located in the fossa of the same name on the visceral surface of the liver and is projected at the intersection of the right costal arch with the lateral edge of the rectus abdominis muscle. Its length is 6-10 cm, width 3.5-4.5 cm, volume 30-50 ml. The gallbladder consists of a fundus (fundus), body (corpus) And
 |
| 6 7 |
Rice. 11-51 Diagram of the zone of irradiation of pain in diseases of the liver and biliary tract (a) and innervation of the liver (b). 1 - duodenum, 2 - common bile duct, 3 - gallbladder, 4 - liver, 5 - great splanchnic nerve, 6 - phrenic nerve, 7 - spinal ganglion, 8 - seventh-tenth thoracic nodes of the sympathetic trunk, 9 - vagus nerve , 10 - sensory fibers of the greater splanchnic nerve, 11 - sympathetic fibers of the greater splanchnic nerve, 12 - proper hepatic artery, 13 - celiac trunk, 14 - common hepatic artery, 15 - gastroduodenal artery. (From: Netter F.H.
cervix (collum) having an extension - a pocket of the neck of the gallbladder (recessus colli vesicae felleae), or pocket Hartmann, and passing into the cystic duct. The gallbladder most often lies mesoperitoneally and is covered by peritoneum from below, but sometimes an intraperitoneal position is observed (with the formation of a mesentery), and extremely rarely it can be covered by liver parenchyma on all sides and may not have peritoneal cover.
Common bile duct(ductus choledochus) has a length of 8-10 cm and a diameter of up to 1 cm.
Parts of the common bile duct Supraduodenum (pars supraduodenalis) lies in the hepatoduodenal ligament (lig. hepatoduodenale) together with the portal vein (v. portae) and the own hepatic artery (a. hepatica propria). The common bile duct is located on the right in the pre-
affairs of the free edge of the hepatic-duodenal ligament, the proper hepatic artery is located in the hepatic-duodenal ligament on the left, and the portal vein is located between the proper hepatic artery and the common bile duct and somewhat behind them (Fig. 11-53).
Retroduodenal part (pars retroduodenalis) passes behind the upper part of the duodenum.
Pancreas (pars pancreatica) passes behind the head or through the head of the pancreas, has a sphincter (sphincter ductus choledochi) and merges with the pancreatic duct (ductus pancreaticus). The following options for connecting the common bile duct and the pancreatic duct are possible (Fig. 11-54):
Rice. 11-52. Extrahepatic bile ducts. 1 -
right and left hepatic ducts, 2 - common hepatic duct, 3 - cystic duct, 4 - common bile duct, 5 - pancreatic duct, 6 - accessory pancreatic duct, 7 - hepatopancreatic ampulla, 8 - descending part of the duodenum intestines, 9 - bottom of the gallbladder, 10 - body of the gallbladder, 11 - neck of the gallbladder, 12 - pocket of the neck of the gallbladder (Hartmann).(From: Moore K.L.
Rice. 11-53. Formations occurring in the hepatoduodenal ligament. 1 - bile duct located to the left of the common bile duct 2 - portal vein (v. carried out by the portal vein (v. 3 - own hepatic artery (a. hepatica propria), 4 - common hepatic duct (ductus hepaticus communis), 5 - right hepatic artery (a. hepatica dextra), 6 - left hepatic artery (a. hepatica sinistra).
♦ the common bile duct and the pancreatic duct merge at the head of the pancreas;
♦ the common bile duct and the pancreatic duct merge in the wall of the duodenum;
♦ The common bile duct and the pancreatic duct open into the duodenum at separate orifices.
Hepatic-pancreatic ampoule(ampulla hepatopancreatica) is formed in approximately 65% of cases and is formed by the fusion of the common bile duct and the pancreatic duct (Fig. 11-55). It pierces the wall of the descending part of the duodenum in an oblique direction at a distance of 3-8 cm from the pylorus, opens on the large duodenal (Vaterov) papilla (papilla duodeni major) and has the same sphincter (sphincter ampullae hepatopancreaticae; sphincter of the major duodenal papilla, sphincter Oddie).
Blood supply, innervation, blood and lymph drainage
Blood supply
The common hepatic and supraduodenal part of the common bile duct are supplied with blood by the branches of the proper and right hepatic arteries (a. hepatica propria et a. hepatica dextra)(rice. 11-56).
The retroduodenal and pancreatic parts of the common bile duct are supplied with blood by branches of the posterior superior pancreaticoduodenal artery (a. pancreaticoduodenalis superior posterior).
The gallbladder is supplied with blood by the cystic vesicle
artery (a. cystica), arising most often from the right hepatic artery (a. hepatica dextra). Cystic artery, common hepatic duct (ductus hepaticus communis) and cystic duct (ductus cysticus) form a triangle Kahlo.
Bleeding from the gallbladder and the supraduodenal part of the common bile duct occurs along the gallbladder vein (v. cystica) into the portal vein (v. portae). Blood outflow from the retroduodenal and pancreatic parts of the common bile duct is carried out through the pancreaticoduodenal veins (vv. pancreaticoduodenalis) into the superior mesenteric vein (v. mesenterica superior).
Rice. 11-55. Sphincters of the common bile and pancreatic ducts, hepatopancreatic ampulla. 1 -
sphincter of the hepatopancreatic ampulla, 2 - sphincter of the common bile duct, 3 - sphincter of the pancreatic duct.
1 - hepatic vein, 2 - hepatic duct, 3 - portal vein, 4 - proper hepatic artery. from the gallbladder and extrahepatic bile ducts to the hepatic lymph nodes (nodi lymphatici hepatici), located in the hepatic-duodenal ligament, and further into the celiac lymph nodes located in the hepatoduodenal ligament, and further into the celiac lymph nodes
Innervated extrahepatic bile ducts by branches of the vagus nerve (p. vagus), celiac (plexus coeliacus) and hepatic (plexus hepaticus) plexus.
The branches of the vagus nerve carry prenodal parasympathetic and sensory nerve fibers. Under the influence of the vagus nerve and as a result of the influence of cholecystokinin, the sphincter of the hepatopancreatic ampulla relaxes.
The celiac and hepatic plexuses receive
prenodal sympathetic and sensory nerve fibers as part of the greater splanchnic nerve (n. splanchnicus major). The branches of these plexuses contain post-nodal sympathetic nerve fibers and sensory fibers of the 6-8th thoracic segments of the spinal cord, as a result of which pain arising from pathology of the gallbladder and extrahepatic bile ducts is projected onto the right hypochondrium and epigastric region.
Atresia of the gallbladder and bile ducts
This is a fairly rare developmental defect, manifested by increasing jaundice and discolored stools from the moment of birth. Forms of atresia of the extrahepatic bile ducts (Fig. 11-57):
Atresia of the common bile duct;
Atresia of the common bile duct and gallbladder;
Atresia of the common bile duct and gallbladder and common hepatic duct;
Atresia of the gallbladder, common bile, common hepatic, right and left hepatic ducts.
PANCREAS
Pancreas (pancreas) develops from the ventral and dorsal primordia, which are protrusions of the epithelium of the embryonic intestine, merging with each other (Fig. 11-58).
Rice. 11-57. Forms of atresia of the extrahepatic bile ducts, a - atresia of the common bile duct, b - artesia of the common bile duct and gallbladder, c - artesia of the gallbladder, common bile duct and common hepatic duct, d - artesia of the gallbladder, common bile duct, common hepatic duct, right and left hepatic duct. (From: Doletsky S.Ya., Isakov I.F. Pediatric surgery. - M., 1970.)
From the dorsal primordium, most of the pancreatic parenchyma (body and tail) and the accessory duct of the pancreas are formed. .
A smaller part of the pancreatic parenchyma (head) and the pancreatic duct are formed from the ventral primordium. .
Disturbances in the fusion of the ventral and dorsal pancreatic buds can lead to changes in the shape of the pancreas and congenital stenosis of the duodenum (Fig. 11-59).
Options for changing the shape of the pancreas
The ring-shaped pancreas covers the descending part of the duodenum.
The claw-shaped head of the pancreas partially encloses the descending part of the duodenum.
 |
Rice. 11-58. Development of the pancreas and its ducts.
1 - common bile duct, 2 - ventral pancreatic bud, 3 - dorsal pancreatic bud, 4 - duodenum, 5 - accessory pancreatic duct, 6 - pancreatic duct. (From: Moore K.L. Clinically oriented Anatomy, 1992.)
The accessory lobule of the pancreas may be located in the submucosa of the duodenal wall. The pancreas is both an exocrine and an endocrine gland. Produced by islet cells Langer-hansa insulin and glucagon are involved
Rice. 11-59. Anomalies of the development of the pancreas.
a - ring-shaped pancreas, b - claw-shaped head of the pancreas, c - accessory lobe of the pancreas. (From: Bairov G.A., Doroshevsky Yu.L., Nemilova T.K. Atlas of operations in newborns. - P., 1984.)
in the regulation of carbohydrate metabolism, and the secretion of the exocrine pancreas contains enzymes necessary for the digestion of proteins, fats and carbohydrates.
Anatomical structure, location of the pancreas and its relationship to the peritoneum
The pancreas is projected onto the anterior abdominal wall within the epigastric and left hypochondrial regions. Its length is 15-20 cm, vertical size is about 4 cm with a thickness of about 2 cm, weight is 70-80 g (Fig. 11-60).
Parts of the pancreas
Head (caput) located to the right of the body
I lumbar vertebra and is surrounded above, right and below, respectively, by the upper, descending and lower horizontal parts of the duodenum. She has:
♦ front surface (facies anterior), covered with parietal peritoneum, to which the antral part of the stomach is adjacent above the mesentery of the transverse colon, and below - the loops of the small intestine;
♦ back surface (facies posterior), to which the right renal artery and vein, the common bile duct and the inferior vena cava are adjacent;
♦ top and bottom edges (margo superior et inferior);
♦ uncinate process (processus unci-natus), separated by pancreatic notch (incisura pancreatis).
At the border of the head and body, the neck of the pancreas is sometimes isolated.
Body (corpus) located in front of the body
I lumbar vertebra and has:
 |
Rice. 11-60. Pancreas and duodenum. 1 - head of the pancreas, 2 - descending part of the duodenum, 3 - superior flexure of the duodenum, 4 - upper part of the duodenum, 5 - body of the pancreas, 6 - groove of the splenic artery, 7 - tail of the pancreas, 8 - duodenum - jejunal flexure, 9 - jejunum, 10 - ascending part of the duodenum, 11 - uncinate process of the pancreas, 12 - lower horizontal part of the duodenum, 13 - lower flexure of the duodenum. (From: Kishsh-Sentagotai. Anatomical atlas of the human body. - Budapest, 1973. - T. II.)
♦ front surface (facies anterior), covered by the parietal peritoneum of the posterior wall of the omental bursa, to which the posterior wall of the stomach is adjacent;
♦ back surface (facies posterior), to which the aorta, splenic and superior mesenteric vein are adjacent;
♦ bottom surface (facies inferior), to which the duodenojejunal flexure is adjacent below (flexura duodeno-jejunalis);
♦ top, bottom and front edges (margo superior, inferior et anterior).
Tail (cauda) It has:
♦ front surface (facies anterior), To
which the fundus of the stomach is adjacent to;
♦ back surface (facies posterior), adjacent to the left kidney, its vessels and adrenal gland.
Pancreatic ducts(rice. 11-61). The pancreatic duct passes through the entire gland from the tail to the head. (ductus pancreaticus), which, connecting with the bile duct or separately from it, opens into the descending part of the duodenum on the major duodenal papilla (papilla duodeni major). Sometimes on the small duodenal papilla (papilla duodeni minor), located approximately 2 cm above the large one, the accessory pancreatic duct opens (ductus pancreaticus accessorius).
Peritoneum and ligaments(rice. 11-62)
 |
Rice. 11-62. Peritoneal cover of the pancreas. 1 - kidney, 2 - descending part of the duodenum, 3 - parietal peritoneum of the subhepatic bursa, 4 - pylorus, 5 - diaphragmatic-splenic ligament (crossed), 6 - parietal peritoneum of the posterior wall of the omental bursa, 7 - mesentery of the transverse colon (crossed) , 8 - duodenojejunal flexure, 9 - parietal peritoneum of the left longitudinal canal, 10 - jejunum, 11 - superior mesenteric artery, 12 - superior mesenteric vein, 13 - uncinate process, lined with the parietal peritoneum of the right mesenteric sinus. (From: Sinelnikov R.D. Atlas of human anatomy. - M., 1972. - T. II.)
| (a. gastroduodenalis), located between the head of the pancreas and the upper and descending parts of the duodenum. ♦ Anterior and posterior inferior pancreatoduodenal arteries (aa. pancreaticoduodenales, inferioris anterior et posterior) arise from the superior mesenteric artery (a. mesenterica superior), located between the head of the pancreas and the lower horizontal and descending parts of the duodenum. The body and tail of the pancreas are supplied by the pancreatic branches of the splenic artery (rr. pancreatici a. lienalis). The blood outflow of the pancreas is carried out through the veins of the same name, flowing into the superior mesenteric and splenic veins (v. mesenterica superior et v. lienalis). Innervation (Fig. 11-64). Branches of the celiac muscle take part in the innervation of the pancreas (plexus coeliacus), hepatic Branches of the sympathetic hepatic plexus splenic (plexus lienalis), intermesenteric (plexus intermesentericus) and renal (plexus renalis) plexuses entering the gland mainly along the vessels and carrying postnodal sympathetic nerve fibers and sensory fibers from the 7-11th thoracic segments of the spinal cord and branches of the right vagus nerve (p. vagus), carrying prenodal parasympathetic and sensory nerve fibers. Prenodal |
The mesentery of the transverse colon is attached along the lower edge of the body of the pancreas; on the right, the root of the mesentery passes in the middle of the head. The head and body of the pancreas are covered with peritoneum only in front, i.e. located retroperitoneally, the tail of the pancreas is located between the layers of the splenorenal ligament (lig. lienorenale) and lies intraperitoneally.
Gastropancreatic ligament (lig. gastro-pancreaticum)- transition of the peritoneum from the upper edge of the pancreas to the posterior surface of the body, cardia and fundus of the stomach; the left gastric artery runs along its edge (a. gastrica sinistra).
Pylorogastric ligament (lig. pylo-
ropancriaticum)- transition of the peritoneum from the upper edge of the body of the pancreas to the antrum of the stomach.
Blood supply (Fig. 11-63)
The head of the pancreas has in common
blood supply to the duodenum.
♦ Anterior and posterior superior pancreatoduodenal arteries (aa. pancreatico-duodenales superioris anterior et posterior) arise from the gastroduodenal artery
 |
Rice. 11-63. Blood supply to the pancreas and duodenum. 1 - celiac trunk (truncus coeliacus), 2- common hepatic artery (a. hepatica communis), 3 - gastroduodenal artery (a. gastroduodenalis), 4 - superior posterior pancreaticoduodenal artery (a. pancreaticoduodenalis superior posterior), 5 - superior anterior pancreaticoduodenal artery (a. pancreaticoduodenalis superior anterior), 6 - inferior posterior pancreaticoduodenal artery (a. pancreaticoduodenalis inferior posterior), 7 - inferior anterior pancreaticoduodenal artery (a. pancreaticoduodenalis inferior anterior), 8 - dorsal pancreatic artery (a. pancreatica dorsalis), 9 - artery of the tail of the pancreas (a. caudae pancreatis), 10 - splenic artery (a. lienalis), 11 - superior mesenteric artery (a. mesenterica superior), 12 - great pancreatic artery (a. pancreatica magna), 13 -inferior pancreatic artery a. pancreatica inferior).(From: Netter F.H. Atlas of human anatomy. - Basle, 1989.)
 |
sympathetic and sensory nerve fibers enter the plexuses as part of the large and small splanchnic nerves (pp. splanchnici majores et minoris).
SPLEEN
Spleen - an unpaired parenchymal organ located in the upper floor of the abdominal cavity deep in the left hypochondrium at the level of the IX-XI ribs along the mid-axillary line (Fig. 11-65). Its approximate size is 12x7x3 cm, weight is about 150 g. The spleen has diaphragmatic and visceral surfaces (facies diaphragmatica et visceralis), front and rear ends (extremitas anterior et posterior), gates (hilum lienis). The spleen is covered by peritoneum on all sides, with the exception of a small area of visceral surface in the hilum area.
Rice. 11-65. Skeletotopy of the spleen, a - low, b - high position of the spleen. (From: Shevkunenko V.N. A short course in operative surgery with topographic anatomy. - M., 1947.)
The rudiment of the spleen is located between the layers of the dorsal mesentery of the stomach, which, after turning the stomach and moving the spleen to the left hypochondrium on the left, limits the splenic recess of the omental bursa (recessus lienalis) and turns into the gastrosplenic and splenorenal ligaments.
Gastrosplenic ligament (lig. gastro-lienale) goes from the greater curvature of the stomach to the hilum of the spleen, contains the left gastroepiploic vessels (a. et v. gastroepiploicae sinistrae) and short gastric arteries and veins (a. et v. gastrici breves).
Splenorenal (diaphragmatic-splenic) ligament stretches from the lumbar part of the diaphragm, from the left kidney to the hilum of the spleen and contains the splenic artery and vein between its leaves (a. et v. lienalis) and the tail of the pancreas.
The phrenic-colic ligament plays an important role in fixing the spleen. (lig. phrenicocolicum), limiting the blind recess of the spleen (saccus caecus lienis), in which, like in a hammock, lies the spleen.
Blood supply, innervation, blood and lymph drainage
Supplies blood spleen artery of the same name (a. lienalis), which arises from the celiac trunk (truncus coeliacus), passes along the upper edge of the pancreas, giving off pancreatic branches for its blood supply (rr. pancreatici), along the splenorenal ligament (lig. lienorenale) approaches the hilum of the spleen and gives off the splenic branches (rr. lienalis). The terminal branch of the splenic artery is the left gastroepiploic artery (a. gastro-epiploica sinistra), exiting along the gastrosplenic ligament (lig. gastroliennale) to the greater curvature of the stomach (Fig. 11-66).
Bleeding from the spleen it is carried out along the vein of the same name (v. lienalis), which goes slightly below the artery of the same name and passes behind the pancreas, where it flows into the portal vein (v. portae).
Lymphatic vessels the spleens leave the parenchyma in the area of its hilum and enter the splenic lymph nodes , efferent vessels of which along the course of the splenic artery reach the celiac lymph nodes located in the hepatoduodenal ligament, and further into the celiac lymph nodes
Innervate spleen branches of the splenic plexus (plexus lienalis), which is located on the splenic vessels and receives prenodal sympathetic and sensory nerve fibers of the large splanchnic nerve (n. splanchnicus major), as well as prenodal parasympathetic and sensory nerve fibers of the vagus nerve (p. vagus) through the celiac plexus (plexus coeliacus).
 |
Rice. 11-66. Blood supply to the spleen.
I - celiac trunk, 2 - aorta, 3 - left celioepiploic artery, 4 - short gastric branches, 5 - spleen, 6 - left gastric artery, 7 - adrenal gland, 8 - kidney, 9 - splenic branches, 10 - splenic vein , 11 - tail of the pancreas, 12 - splenic artery, 13 - duodenojejunal flexure. From: Forged V.V. Operative surgery and topographic anatomy. - M., 1985.)
SMALL INTESTINE
Below the pyloric opening (ostium pyloricum) small intestine begins (intestinum renue), in which the digestion of food coming from the stomach is completed, and selective absorption of digestion products into the blood and lymph occurs. Small intestine, starting with the descending part of the duodenum (pars descendens duodeni), located in the lower floor of the abdominal cavity (see Fig. 11-60).
Duodenum
The initial part of the small intestine is the duodenum (duodenum), curving like a horseshoe around the head of the pancreas. The duodenum is divided into upper, descending, lower horizontal and ascending parts.
Top part (pars superior) extends horizontally from the pyloric opening (ostium pyloricum) to the top bend (flexura duodeni
superior) at the level of the first lumbar vertebra (see Fig. 11-61).
♦ It is located in the upper floor of the abdominal cavity: intraperitoneal - in the initial part, where the hepatoduodenal ligament fits (lig. hepatoduodenale), being the right part of the lesser omentum (omentum minus), limiting the stuffing box (foramen epi-ploicum) anteriorly and containing the common bile duct located to the left of the common bile duct portal vein (v. portae) and own hepatic artery (a. hepatica propria)(see Fig. 11-53), mesoperitoneally - in the middle part and retroperitoneally - in the area of the upper bend.
♦ The upper part of the duodenum contacts:
On top with the gallbladder;
From below with the head of the pancreas;
Posteriorly with the body of the first lumbar vertebra
In front with the antrum of the stomach.
Descending part (pars descendens) coming ver
tickly from the upper to the lower bends,
(flexura duodeni superior et inferior) to the right of the spine at level L 1 -L ii.
♦ It is located retroperitoneally; the peritoneum, when passing from the right and above to the right kidney, forms the duodenal-renal ligament (lig. duodenorenale, BNA).
♦ On the mucous membrane of the posterior internal surface there are: small duodenal papilla (papillae duodeni minor), located about 6 cm from the pylorus, where the accessory pancreatic duct opens ; large duodenal (vaterov) papilla (papillae duodeni major), located at a distance of about 8 cm from the pylorus, where the hepatopancreatic ampulla opens (ampulla hepatopancreatica).
♦ The descending part of the duodenum contacts:
On the left with the head of the pancreas;
Posterior and right with the right kidney, right renal vein, inferior vena cava and ureter;
In front with the mesentery of the transverse colon and below its attachment with the loops of the small intestine.
Bottom horizontal part (pars horizontalis
inferior) comes from the bottom bend (flexura duodeni inferior) to the intersection with the superior mesenteric vessels at level Liii.
♦ It is located retroperitoneally, its anterior wall lifts the parietal peritoneum of the right mesenteric sinus of the lower floor of the abdominal cavity.
♦ The lower horizontal part of the duodenum contacts:
Above with the head of the pancreas;
Rising part (pars ascendens) comes from
intersections with the superior mesenteric
ships at level Liii to the left and up to two
duodenojejunal flexure (flexura
duodenojejunalis), located at the level
Lii, and fixed by a hanging connection
which duodenum (lig. sus-
pensorium duodeni).
♦ The suspensory ligament of the duodenum extends from the duodenum-jejunal flexure (flexura duodenojejunalis) to the right leg of the diaphragm, contains not only collagen, but also muscle fibers, called the muscle that suspends the duodenum (i.e. suspensorium duodeni), and, lifting the peritoneum, forms the superior duodenal fold (plica duodenalis superior), in which passes the inferior mesenteric vein (v. mesenterica inferior). This ligament is an important landmark when performing surgical interventions.
♦ The ascending part of the duodenum is located mesoperitoneally, it contacts:
From above with the lower surface of the body of the pancreas;
Posteriorly with the inferior vena cava and abdominal aorta;
In front and below with loops of the small intestine.
Blood supply duodenum by the vessels of the celiac trunk and superior mesenteric artery (see Fig. 11-63). Common hepatic artery (a. hepatica communis) arises from the celiac trunk (truncus coeliacus), goes to the right along the upper edge of the pancreas to the hepatoduodenal ligament, where it divides into the proper hepatic artery (a. hepatica propria) and the gastroduodenal artery (a. gastro-duodenalis).
The supraduodenal artery takes part in the blood supply to the upper part of the duodenum (a. supraduodenalis) and retroduodenal arteries (aa. retro-duodenales), originating most often from the gastroduodenal artery, but sometimes from the common hepatic or right gastric artery. The supraduodenal artery may be absent.
The upper half of the descending part of the duodenum is supplied by the duodenal branches of the anterior and posterior superior pancreaticoduodenal arteries (rr. duodenales aa. pancreaticoduodenales superiores anterior et posterior), originating from the gastroduodenal artery.
The lower half of the descending, horizontal and ascending parts of the duodenum
The colon is supplied with blood by the duodenal branches of the anterior and posterior inferior pancreatoduodenal arteries (rr. duodenales aa. pancreaticoduodenales inferiores anterior et posterior), arising from the superior mesenteric artery (a. mesenterica superior).
Anterior and posterior superior pancreatoduodenal
nal arteries at the level of the middle lower part
walking part of the duodenum
anastomose with the lower ones of the same name
vessels.
Bleeding carried out through the veins of the same name into the portal vein system.
1 - hepatic vein, 2 - hepatic duct, 3 - portal vein, 4 - proper hepatic artery. from the duodenum is carried out to the upper and lower pancreatoduodenal lymph nodes (nodi lymphatici pancreaticoduodenalis superiores et inferiores) and further to the celiac lymph nodes located in the hepatoduodenal ligament, and further into the celiac lymph nodes
Innervate duodenum branches of the vagus nerves (pp. vagi), carrying parasympathetic and sensory fibers through the celiac plexus (plexus coeliacus), in the formation of which the large splanchnic nerves also take part (pp. splan-chnici majores), carrying sympathetic and sensory fibers from segments Th 7 - 9 of the spinal cord, as a result of which, in pathology of the duodenum, pain is noted in the epigastric region (see Fig.
Common hepatic artery, A. hepatica communis, - a more powerful branch, has a length of up to 4 cm. Moving away from the celiac trunk, it runs along the right leg of the diaphragm, the upper edge of the pancreas from left to right and enters the thickness of the lesser omentum, where it divides into two branches - the proper hepatic and gastroduodenal arteries.
1) Proper hepatic artery, a. hepatica propria, moving away from the main trunk, goes to the gate of the liver in the thickness of the hepatoduodenal ligament, to the left of the common bile duct and somewhat anterior to the portal vein, v. portae. Approaching the portal of the liver, the proper hepatic artery divides into left And right branches, while it departs from the right branch gallbladder artery, a. cystica.
Right gastric artery, a. gastrica dextra, is a thin branch that arises from the proper hepatic artery, sometimes from the common hepatic artery. It is directed from top to bottom to the lesser curvature of the stomach, along which it runs from right to left, and anastomoses with a. gastrica sinistra. The right gastric artery gives off a number of branches that supply blood to the anterior and posterior walls of the stomach.
At the gate of the liver right branch, r. dexter, the proper hepatic artery sends to the caudate lobe , and arteries to the corresponding segments of the right lobe of the liver: to the anterior segment - artery of the anterior segment, a. segmenti anterioris, and to the posterior segment – artery of the posterior segment, a. segmenti posterioris.
Left branch, r. sinister, gives off the following arteries: artery of the caudate lobe, a. lobi caudati, And arteries of the medial and lateral segments of the left lobe of the liver, a. segmenti medialis et a. segmenti lateralis. In addition, a non-permanent branch departs from the left branch (less often from the right branch) intermediate branch, r. intermedius, supplying the quadrate lobe of the liver.
2) Gastroduodenal artery, a. gastroduodenalis, is a fairly powerful trunk. It is directed from the common hepatic artery downwards, behind the pyloric part of the stomach, crossing it from top to bottom. Sometimes it comes from this artery supraduodenal artery, a. supraduodenalis, which crosses the anterior surface of the head of the pancreas.
The following branches depart from the gastroduodenal artery:
- posterior superior pancreaticoduodenal artery, a. pancreaticoduodenalis superior posterior, passes along the posterior surface of the head of the pancreas and, heading down, gives along its course pancreatic branches, rr. pancreatici, And . At the lower edge of the horizontal part of the duodenum, the artery anastomoses with inferior pancreaticoduodenal artery, a. pancreaticoduodenalis inferior(branch of the superior mesenteric artery, a. mesenterica superior) (see Fig.,);
- anterior superior pancreaticoduodenal artery, a. pancreaticoduodenalis superior anterior, located in an arcuate manner on the anterior surface of the head of the pancreas and the medial edge of the descending part of the duodenum, directed downwards, giving off on its way duodenal branches, rr. duodenales, and pancreatic branches, rr. pancreatici. At the lower edge of the horizontal part of the duodenum, it anastomoses with the inferior pancreaticoduodenal artery, a. pancreatoduodenalis inferior (branch of the superior mesenteric artery) (see Fig.,);
- right gastroepiploic artery, a. gastroepiploica dextra, is a continuation of the gastroduodenal artery. Directs to the left along the greater curvature of the stomach between the leaves of the greater omentum, sends branches to the anterior and posterior walls of the stomach - gastric branches, rr. gastrici, and omental branches, rr. epiploici, to the greater omentum. In the area of the greater curvature, it anastomoses with the left gastroepiploic artery, a. gastroepiploica sinistra (branch of the splenic artery, a. splenica);
- retroduodenal arteries, aa. retroduodenales, are the right terminal branches of the gastroduodenal artery. They surround the anterior surface of the right edge of the head of the pancreas.
The hepatic artery is a branch of the celiac trunk. It passes along the upper edge of the pancreas to the initial part of the duodenum, then goes up between the leaves of the lesser omentum, located in front of the portal vein and medial to the common bile duct, and at the porta hepatis it divides into right and left branches. Its branches also include the right gastric and gastroduodenal arteries. Additional branches are often found. Topographic anatomy has been carefully studied on donor livers. With abdominal trauma or catheterization of the hepatic artery, its dissection is possible. Embolization of the hepatic artery sometimes leads to the development of gangrenous cholecystitis.
Clinical manifestations
The diagnosis is rarely made while the patient is alive; There are few works describing the clinical picture. Clinical manifestations are associated with an underlying disease, for example, bacterial endocarditis, periarteritis nodosa, or are determined by the severity of upper abdominal surgery. Pain in the epigastric region on the right occurs suddenly and is accompanied by shock and hypotension. There is pain on palpation of the right upper quadrant of the abdomen and the edge of the liver. Jaundice increases rapidly. Typically, leukocytosis, fever, and biochemical blood tests reveal signs of cytolytic syndrome. Prothrombin time increases sharply, bleeding appears. When large branches of the artery are occluded, a coma develops and the patient dies within 10 days.
It is necessary to carry out hepatic arteriography. It can be used to detect hepatic artery obstruction. Intrahepatic collaterals develop in the portal and subcapsular areas. Extrahepatic collaterals with neighboring organs are formed in the ligamentous apparatus of the liver [3].
Scanning.Infarctions are usually round or oval, occasionally wedge-shaped, located in the center of the organ. In the early period, they are detected as hypoechoic foci during ultrasound examination (ultrasound) or poorly demarcated areas of reduced density on computed tomograms that do not change with the introduction of a contrast agent. Later, heart attacks look like confluent foci with clear boundaries. Magnetic resonance imaging (MRI) allows you to identify infarcts as areas with low signal intensity on T1-weighted images and with high intensity on T2-weighted images. With large infarcts, the formation of “lake” of bile, sometimes containing gas, is possible.
Treatment should be aimed at eliminating the cause of the damage. To prevent secondary infection during liver hypoxia, antibiotics are used. The main goal is the treatment of acute hepatocellular failure. In case of arterial injury, percutaneous embolization is used.
Damage to the hepatic artery during liver transplantation
When the bile ducts are damaged due to ischemia, they speak of ischemic cholangitis.It develops in patients who have undergone liver transplantation due to thrombosis or stenosis of the hepatic artery or occlusion of the paraductal arteries |8[. Diagnosis is complicated by the fact that the picture when examining biopsy specimens may indicate obstruction of the bile ducts without signs of ischemia.
After liver transplantation, hepatic artery thrombosis is detected using arteriography. Doppler examination does not always reveal changes; moreover, correct assessment of its results is difficult [b]. The high reliability of spiral CT has been shown.
Hepatic artery aneurysms
Hepatic artery aneurysms are rare and account for one fifth of all visceral vessel aneurysms. They may be a complication of bacterial endocarditis, periarteritis nodosa, or arteriosclerosis. Among the causes, the role of mechanical damage is increasing, for example due to road traffic accidents or medical interventions such as biliary tract surgery, liver biopsy and invasive X-ray examinations. False aneurysms occur in patients with chronic pancreatitis and pseudocyst formation. Hemobilia is often associated with false aneurysms. Aneurysms are congenital, intra- and extrahepatic, ranging in size from the head of a pin to a grapefruit. Aneurysms are identified by angiography or discovered incidentally during surgery or autopsy.
Clinical manifestations varied. Only a third of patients have the classic triad: jaundice |24|, abdominal pain and hemobilia. A common symptom is abdominal pain; the period from their appearance to the rupture of the aneurysm can reach 5 months.
In 60-80% of patients, the reason for the initial visit to the doctor is the rupture of a modified vessel with the leakage of blood into the abdominal cavity, biliary tract or gastrointestinal tract and the development of hemoperitoneum, hemobilia or hematemesis.
Ultrasound allows you to make a preliminary diagnosis; it is confirmed using hepatic arteriography and contrast-enhanced CT (see Fig. 11-2). Pulsed Doppler ultrasound can detect turbulence of blood flow in the aneurysm.
Treatment. For intrahepatic aneurysms, vessel embolization is used under angiography control (see Fig. 11-3 and 11-4). In patients with aneurysms of the common hepatic artery, surgical intervention is necessary. In this case, the artery is ligated above and below the site of the aneurysm.
Hepatic arteriovenous fistulas
Common causes of arteriovenous fistulas are blunt trauma to the abdomen, liver biopsy or tumors, usually primary liver cancer. Patients with hereditary hemorrhagic telangiectasia (Randu-Weber-Osler disease) have multiple fistulas, which can lead to congestive heart failure.
If the fistula is large, a murmur can be heard over the right upper quadrant of the abdomen. Hepatic arteriography can confirm the diagnosis. Embolization with gelatin foam is usually used as a therapeutic measure.
Proper hepatic artery(a. hepatica propria) has, depending on the place of its division into the right and left branches or the place where the right gastric artery departs from it, a length of 2.5 - 5 cm. Its diameter also varies from 2.5 to 5 mm.
The division of the proper hepatic artery into right and left branches most often occurs at the lower edge or at the middle of the caudate lobe of the liver at an acute angle. From the site of division, the right hepatic branch goes to the porta hepatis, located anterior to the common hepatic duct and posterior to the cystic duct.
The proper hepatic artery can also divide into branches in the upper or middle third of the hepatoduodenal ligament, where its right branch is located anterior and to the left of the portal vein and posterior to the common hepatic duct. When the proper hepatic artery is divided into three branches in the upper third of the ligament, the right hepatic branch goes anterior to the portal vein and the common bile duct, and the left and middle ones run along the edges of the left branch of the portal vein.
Right proper hepatic artery(ramus dexter a. hepaticae propriae) has a length in adults of 3.5 - 4.5 cm. Its diameter in adults is 3 - 4.2 mm. It varies greatly in the place of origin and most often begins from the proper hepatic artery, but can also arise from the common hepatic artery, from the celiac trunk, from the abdominal aorta, from the superior mesenteric artery.
The right branch of the proper hepatic artery can be double, with both of its trunks originating either from the common hepatic artery or from different sources.
The right branch of the proper hepatic artery is divided into first-order branches in the substance of the right lobe of the liver. With the bifurcation variant of the division of the right branch of the proper hepatic artery, its anterior and posterior branches may be of the same diameter or one of them may be larger than the other. Hence, the areas of blood supply to the liver are unequal in size depending on the diameter of the 1st order branches.
The anterior branch of the right branch of the proper hepatic artery branches in the anterior and middle parts of the right lobe; posterior - in the diaphragmatic edge of the liver and also to its middle section.
With the trifurcation division of the right branch of the proper hepatic artery into branches of the 1st order of equal diameter (anterior, middle and posterior), even before division, branches extend from it to the anterior edge of the liver, to the quadrate lobe and the gall bladder.
Left branch of the proper hepatic artery(ramus sinister a. hepaticae propriae) has a diameter of 2.5 - 3.5 mm. More often it goes with one trunk, less often with two. It can arise from the proper hepatic artery or from the common hepatic artery.
The left branch of the proper hepatic artery, which departs from the proper hepatic artery, is most often divided into two branches of the 1st order, less often into three branches of the 1st order, before entering the left lobe.
Cystic artery(a. cystica) has a diameter of 1.5 - 2 mm. The cystic artery usually arises from the left edge of the right hepatic branch.
The gallbladder artery has been studied in detail in connection with frequent surgical interventions on the biliary tract. The artery varies both in the place of its origin and in the number of branches going to the neck of the gallbladder. The erroneous idea among doctors that the cystic artery always follows one trunk can cause severe complications when they forget to ligate the accessory cystic branch, which also often has an atypical position. Double cystic artery is relatively common (10–15% of cases). Usually the cystic artery divides at the neck of the gallbladder, but it can also divide at the very beginning or in the middle of its length.
The triangle of Callot, well known to surgeons, the apex of which is formed by the confluence of the cystic and hepatic ducts, and the base by the cystic artery,
How is the liver supplied with blood? Blood enters the liver from two sources: the portal vein and the hepatic artery, and flows out through the hepatic veins. Thus, the liver has two afferent and one efferent system of blood vessels. Most of the blood (70-75%) enters the liver through the portal vein. Up to 1.5 liters of blood per minute flows through the vascular bed of the liver, i.e. about 25% of the total minute volume of blood flow. The volumetric flow rate of blood through the liver is 50-80 ml of blood per 100 g of liver per minute. In the hepatic sinusoids, blood flow is significantly slowed down, since their cross-sectional area approaches 400 m2, exceeding the cross-sectional area of the capillaries of the lungs. The pressure in the hepatic artery is 120 mmHg. Art., in the portal vein - 8-12 mm Hg. Art., in the hepatic veins - from 0 to 5 mm Hg. Art. In portal and venous vessels, pressure is usually measured in mmH2O, which more accurately reflects the dynamics of small changes (ratio mmHg/mmH2O = 1/13.5). More than 20% of the circulating blood volume can be deposited in the liver. During shock, up to 70% of the total blood volume sometimes accumulates in the vessels of the portal system.
Portal blood differs from venous blood not only in the breakdown products it contains of nutrients absorbed from the intestines and transported to the liver, but also in its higher oxygenation. The oxygen content in portal blood on an empty stomach is on average only 1.9 vol.% lower than in arterial blood (in venous blood it is lower on average by 7 vol.%). The portal vein delivers 50-70% of all oxygen entering the liver, and this amount in most cases is sufficient to satisfy the minimum need for it by liver cells in case of acute disruption of the arterial blood supply to the liver (ligation of the hepatic artery). A decrease in systemic blood pressure leads to a decrease in the oxygen content in portal blood.
Blood supply to the liver: Hepatic artery
The topographic anatomy of the blood supply to the liver by arterial vessels is highly variable. Nevertheless, we can conditionally identify the typical, most common (40–80%) variant of the formation and location of the hepatic arteries. In most cases, a vessel with a diameter of 5–7 mm, called the common hepatic artery (a. hepatica communis), originates from the celiac trunk (truncus celiacus). At the level of the upper edge of the pylorus or duodenum in the hepatoduodenal ligament anterior to the portal vein, it is divided into the gastroduodenal artery (a. gastro-duodenalis) and the proper hepatic artery (a. hepatica propria). The latter has a diameter of 3–5 mm, is located between the leaves of the hepatoduodenal ligament medially from the common bile and hepatic ducts and is divided into the right and left hepatic arteries (aa. hepaticae dextra et sinistra), which penetrate the liver. The right gastric artery (a. gastrica dextra) departs from the proper or common hepatic artery, and the cystic artery (a. cystica) departs from the right hepatic artery to the gallbladder.
Internally, the blood supply to the liver is divided by arteries as follows. The right hepatic artery gives off a branch to the caudate lobe, then the paramedian artery branches off, dividing into arteries to segments V and VIII. The continuation of the main trunk is the artery of the lateral sector, which is divided into arteries of the VI and VII segments. The left hepatic artery gives off branches to segments I and IV, then divides into branches to segments II and III. In most cases, the branches of the left hepatic artery do not follow the course of the branches of the portal vein. Often the blood supply to the IV segment is from the right hepatic artery (the so-called transposition of the segmental artery from left to right). A variant of the architectonics of the left hepatic artery, corresponding to the architectonics of the left branch of the portal vein, occurs in 14% of cases. At the subsegmental level, the portal vessel is usually accompanied by two arterial branches.
Among the variety of other anatomical options for the arterial blood supply to the liver, it is necessary to highlight those that are more common or that complicate surgical interventions on the organs of the hepato-pancreatoduodenal zone.
The common hepatic artery arises from the superior mesenteric (1–4%), from the aorta (2–7%) or is absent.
The proper hepatic artery is absent (up to 50%), while the right and left hepatic arteries begin directly from the common hepatic artery or from other sources.
The proper hepatic artery forms three branches, one of which, the middle hepatic artery, separately provides blood supply to the quadrate lobe of the liver.
The right branch of the proper hepatic artery passes in front of the common bile or hepatic duct (5–15%) or behind the portal vein (13%). This makes it difficult to intervene on the extrahepatic bile ducts or to locate and isolate the artery.
The right hepatic artery arises from the superior mesenteric artery (12–19%). In this case, it is located behind the pancreas and duodenum, and then along the outer edge of the hepatoduodenal ligament and to the right of the gallbladder behind its neck. The likelihood of damage to such a vessel during cholecystectomy increases.
The left hepatic artery arises from the left gastric artery (12%). This vessel is called the left gastrohepatic trunk. In 2% of cases, it provides an isolated blood supply to the left lobe of the liver. Ligation of it proximal to the origin of the hepatic branch when performing gastric resection can lead to disruption of the blood supply to segments II–III of the liver. (Areas of the liver deprived of arterial inflow become dark purple in color.)
In addition to the main arteries, blood supply to the liver can be carried out using additional vessels, which most often arise from the left gastric, superior mesenteric, and gastroduodenal arteries. V.V. Kovanov and T.I. Anikina (1974) distinguishes between accessory and accessory vessels. Unlike accessory arteries, accessory arteries are the only sources of arterial blood supply to the autonomous regions of the liver (usually in the left half), and ligation of such vessels can lead to severe ischemic damage to the corresponding segments.