Management of Liver Injuries

Falciform ligament

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  Attaches the anterior surface of the liver to the anterior abdominal wall

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  Free edge of the Falciform ligament contains the remnant of umbilical vein and known as round ligament of the liver. It is also called the ligamentum of teres.

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  Round ligament divides the left lobe of the liver into a medial section (segment 4) and lateral sections (segments 2 and 3).

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  The left hepatic bile duct, left hepatic artery, and left portal vein enter the undersurface of the liver near the falciform ligament.

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  The portal venous supply to the medial segment of the left lobe can be injured during dissection of the falciform ligament.

Coronary ligament (anterior and posterior folds)

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  Attaches the superior surface of the liver to the inferior surface of the diaphragm

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  Demarcates the bare area of the liver

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  The anterior and posterior folds fuse to form the triangular ligaments on the right and left lobes of the liver.

Triangular ligaments (left and right)

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  The left triangular ligament is formed by the union of the anterior and posterior layers of the coronary ligament and attaches the left lobe of the liver to the diaphragm.

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  The right triangular ligament is formed in a similar fashion adjacent to the bare area and attaches the right lobe of the liver to the diaphragm.

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  The right triangular ligament is divided for mobilization of the right lobe of the liver. The retrohepatic inferior vena cava (IVC) and the retrohepatic veins should be protected during mobilization of the right lobe of the liver.

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  The left triangular ligament is divided for mobilization of the left lobe of the liver. The phrenic vein should be protected during mobilization of the left lobe of the liver.

Lesser omentum

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  Attaches the liver to the lesser curvature of the stomach and the first part of the duodenum

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  Consists of the hepatoduodenal ligament (extends from the duodenum to the liver) and the hepatogastric ligament (extends from the stomach to the liver)

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  The hepatoduodenal ligament surrounds the portal triad (hepatic artery, common bile duct, and portal vein).

Eight functionally independent segments of the liver

Each segment has its own vascular inflow, outflow, and biliary drainage.

An imaginary line from the left of the inferior vena cava, just left of the gallbladder fossa through the liver

Separates the liver into right and left lobes

The middle hepatic vein is situated within this line.

Separates segment 4 from segments 5 and 8

Approximately 5-cm-long transverse deep fissure in the liver extending transversely beneath the left portion of the right lobe of the liver

Separates the quadrate lobe (segment 4) from the caudate lobe (segment 1)

Fissure in the liver between the right lobe and the caudate process

This sulcus should be identified during laparoscopic cholecystectomy before the dissection in Calot’s triangle and considered as an important landmark for safe cholecystectomy.

It is recommended that all dissection should be performed above or anterior to this sulcus to prevent injury to the common bile duct at the porta hepatis.

Hepatic artery (proper hepatic artery)

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  Branch from common hepatic artery

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  Common hepatic artery is a branch from the celiac trunk.

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  The hepatic artery divides into right and left hepatic arteries.

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  The cystic artery is a branch from the right hepatic artery.

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  Variation in hepatic artery

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    Seen in 40%–60% of people

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    Accessory hepatic artery

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      Additional artery to the liver along with normal hepatic arteries

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      Accessory left hepatic artery: a branch from left gastric artery and the most common accessory hepatic artery

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    Replaced hepatic artery

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      Anomalous origin of hepatic arteries

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      The right hepatic artery arising from the superior mesenteric artery (SMA) and the replaced left hepatic artery arising from the left gastric artery are commonly replaced hepatic arteries.

Portal vein

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  Supplies approximately 75% of total blood to the liver

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  Formed by the superior mesenteric vein (SMV) and the splenic vein.

Hepatic vein

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  Three hepatic veins (right, middle, and left) drain to the IVC.

Grade I

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  Hematoma

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    Subcapsular <10% surface area

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  Laceration

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    Capsular tear or parenchymal laceration <1 cm deep

Grade II

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  Hematoma

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    Subcapsular 10%–50 % of the surface area

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  Laceration

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    Intraparenchymal <10 cm diameter

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    Capsular tear or parenchymal laceration 1–3 cm deep, <10 cm in length.

Grade III

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  Hematoma

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    Subcapsular >50% surface area

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    Ruptured subcapsular or parenchymal hematoma

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    Intraparenchymal hematoma >10 cm or expanding hematoma

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  Laceration

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    3-cm-deep parenchymal laceration

Grade IV

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  Laceration

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    Parenchymal disruption involving 25%–75% hepatic lobe or 1–3 Couinaud’s segments

Grade V

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  Laceration

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    Parenchymal disruption >75% hepatic lobe or >3 Couinaud’s segments within a single lobe

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  Vascular

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    Juxtahepatic venous injury (retrohepatic vena cava/central major hepatic veins)

Grade VI

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  Vascular

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    Hepatic avulsion. Advance one grade for multiple injuries up to grade III .