The liver (Greek hepar: liver) is the largest gland of the body, occupying much

of the right upper part of the abdominal cavity. It consists of both exocrine
and endocrine parts. The liver performs a wide range of metabolic activities
necessary for homeostasis, nutrition, and immune response. Its main functions
are:
1. It secretes bile and stores glycogen.
2. It synthesizes the serum proteins and lipids.
3. It detoxifies blood from endogenous and exogenous substances (e.g., toxins,
drugs, alcohol, etc.) that enter the circulation.
4. It produces hemopoietic cells of all types during fetal life.

LOCATION
The liver almost fully occupies the right hypochondrium, upper part
of the epigastrium, and part of the left hypochondrium up to the
left lateral (midclavicular) line. It lies mostly under cover of the ribs
and costal cartilages immediately below the diaphragm. It extends
upward under the rib cage as far as the 5th rib anteriorly on the
right side (below the right nipple) and left 5th intercostal space
anteriorly on the left side (below and medial to the left nipple). In
the midline, the upper border lies at the level of the xiphisternal
joint. The sharp inferior border crosses the midline at the level of
transpyloric plane (at the level of L1 vertebra; Fig. 8.1).
SHAPE, SIZE, AND COLOUR

Shape
The liver is wedge shaped and resembles a four-sided pyramid laid on
one side with its base directed towards the right and apex directed
towards the left.

Weight
In males: 1.4 to 1.8 kg.
In females: 1.2 to 1.4 kg.
In newborn: 1/18th of the body weight.
At birth: 150 g.
Proportional weight: In adult 1/40th of the body weight.

Colour
It is red-brown in colour.

EXTERNAL FEATURES
The wedge-shaped liver presents two well-defined surfaces,
diaphragmatic and visceral and one well-defined border, inferior
border. The diaphragmatic surface is convex and extensive. It faces
upwards, forward, to the right and backwards. The visceral surface
is relatively flat and faces inferiorly. These two surfaces meet in
front at the sharp inferior border. Conventionally the diaphragmatic
surface is further subdivided into superior, anterior, right lateral,
and posterior surfaces, but there is no distinct demarcation between
these surfaces

Diaphragmatic Surface
The dome-shaped diaphragmatic surface includes smooth peritoneal areas
which face superiorly, anteriorly and to the right and a rough bare area
(devoid of the peritoneum) which faces posteriorly.
*The inferior vena cava (IVC) is embedded in the deep sulcus in the
left part of the bare area. In most cases, this sulcus is roofed by
the fibrous tissue termed ligament of IVC which may contain hepatic
tissue converting the sulcus into the tunnel.
*The peritoneal ligaments are coronary, left and right triangular and
falciform ligaments.

Visceral Surface (Inferior Surface)

The visceral surface is relatively flat or concave. It is directed downward

backward, and to the left. It is separated in front from the diaphragmatic
surface by the sharp inferior border and behind from the diaphragm by
the posterior layer of coronary ligament. The notable features on the
visceral surface are:
*Fossa for the gallbladder.
*Fissure for the ligamentum teres hepatis.
*Porta hepatis.
The visceral surface is covered by the peritoneum except at the fossa
for gallbladder and the porta hepatis.
Inferior Border
The features of the inferior border are as follows:
1. It separates the diaphragmatic surface from the visceral surface.
2. It is rounded laterally where it separates the right lateral surface
from the inferior surface.
3. It is thin and sharp medially where it separates the anterior surface
from the inferior surface.
4. It presents two notches:
(a) Notch for ligamentum teres or interlobar notch: It is located just to
the right of the median plane.
(b) Cystic notch: It is located about 5 cm to the right of the median
plane and often corresponds to the fundus of the gallbladder.
5. In the epigastrium, it extends from the right 9th costal cartilage to
the 8th left costal cartilage, thus it ascends sharply to the left.
6. In the median plane, it lies in the transpyloric plane.

LOBES OF THE LIVER

The lobes of the liver are classified into two types:
(a) anatomical lobes and
(b) physiological (functional) lobes.

Anatomical Lobes
*On the diaphragmatic surface, the liver is divided into two lobes, right
and left, by the attachment of the falciform ligament (Fig. 8.6A). The
right lobe which forms the base of the wedge-shaped liver is
approximately six times larger than the left lobe.
*On the visceral surface, the liver is divided into four lobes: (a) right
lobe, (b) left lobe, (c) quadrate lobe, and (d) caudate lobe by fissures and
fossae present on this
surface (Viz. fissures for ligamentum teres and ligamentum venosum,
porta hepatis, groove of the IVC and fossa for the gallbladder).
These fissures and fossae form an H-shaped figure
(a) Right lobe to right of the fossa for gallbladder.
(b) Left lobe to the left of the fissures for ligamentum teres and ligamentum
venosum.
(c) Quadrate lobe, between the fossa for gallbladder and the fissure for
ligamentum teres below the porta hepatis.
(d) Caudate lobe, between the groove for IVC and the fissure for ligamentum
venosum above the porta hepatis.
Physiological Lobes/Functional Lobes/True Lobes (Fig. 8.7)

The division of the liver into lobes is based on the intrahepatic

distribution of branches of the bile ducts, hepatic artery, and portal
vein. The liver is divided into right and left physiological lobes by an
imaginary sagittal plane/line (Cantlie’s plane/line). On the
posteroinferior surface this plane passes through the fossa for
gallbladder, to the groove for IVC. (Note: Caudate lobe is equally
shared between the right and left lobes.) On the anterosuperior
surface of the liver, this plane passes from the IVC to the cystic notch
present a little to the right of the falciform ligament. The physiological
right and left lobes are approximately equal in size. Each true lobe of
the liver has its own primary branch of the hepatic artery and portal
vein and is drained by its own hepatic duct.
HEPATIC SEGMENTS (SEGMENTS OF THE LIVER)

These are structural units of the liver. There are eight hepatic segments. They
are deduced as follows. The right physiological lobe is divided into anterior and
posterior parts, and the left physiological lobe into medial and lateral parts.
Each of these parts is further divided into upper and lower parts and form
eight surgically resectable hepatic segments. The veins draining the hepatic
segments are intersegmental, i.e., they drain more than one segment.
On the surface of the liver, there is no identifiable demarcation between
anterior and posterior segments of the right lobe. The fissures for ligamentum
teres and ligamentum venosum mark the junction between the medial and
lateral segments of the left lobe. The caudate and quadrate lobes are
incorporated into the upper and lower areas of the medial segment of left lobe.

Couinaud’s segments: According to nomenclature of Couinaud, the hepatic

segments are numbered I to VIII (Fig. 8.8), I to IV in the left hemiliver and V
to VIII in the right hemiliver. According to this nomenclature, the segment I
corresponds to the caudate lobe and segment IV corresponds to the quadrate
lobe.
Segment I to IV of the left lobe are supplied by the left branch of hepatic
artery, left branch of portal vein and drained by left hepatic duct. The
segments V to VIII of right lobe are supplied by right hepatic artery, right
branch of portal vein and drained by right hepatic duct.
PERITONEAL RELATIONS

Most of the liver is covered by the peritoneum. The areas which are not
covered by the peritoneum are:
1. Bare area of the liver: It is a triangular area on the posterior aspect
of the right lobe (details on p. 115).
2. Fossa for gallbladder, on the inferior surface of the liver between right
and quadrate lobes.
3. Groove for IVC, on the posterior surface of the right lobe of the liver.
4. Groove for ligamentum venosum.
5. Porta hepatis.

LIGAMENTS

Ligaments of the liver are of two types:

(a) false and (b) true.
False Ligaments
The false ligaments are actually peritoneal folds and include:
1. Falciform ligament.
2. Coronary ligament.
3. Right triangular ligament.
4. Left triangular ligament.
5. Lesser omentum.

True Ligaments
The true ligaments are actually the remnants of fetal structures
and include:
1. Ligamentum teres hepatis.
2. Ligamentum venosum

Falciform Ligament
It is a sickle-shaped fold of the peritoneum connecting the liver
to the undersurface of the diaphragm and the anterior
abdominal wall up to the umbilicus
Coronary Ligament
It is a triangular fold of the peritoneum connecting the bare area of the
liver to the diaphragm.

Right Triangular Ligament

It is a small triangular fold of the peritoneum which connects the right
lateral surface of the liver to the diaphragm.

Left Triangular Ligament

It is a very-very small triangular fold of the peritoneum which connects
the upper surface of the left lobe to the diaphragm

Lesser Omentum
It is the fold of peritoneum connecting the lesser curvature of the
stomach and proximal 1 inch (2.5 cm) of duodenum to the visceral
surface of the liver

Ligamentum Teres Hepatis

It is the remnant of the obliterated left umbilical vein and extends
from the umbilicus to the left branch of the portal vein.

Ligamentum Venosum
It is the remnant of the obliterated ductus venosus which in fetal life
connects the left branch of the portal vein with the IVC.
BLOOD SUPPLY
The liver is a highly vascular organ. It receives blood from two sources.
The arterial blood (oxygenated) is supplied by the hepatic artery and
venous blood (rich in nutrients) is supplied by the portal vein. In a
normal adult (in the recumbent position), nearly one-third of the
cardiac output passes through the liver. About 80% of this is delivered
through the portal vein and 20% is delivered through the hepatic
artery.

VENOUS DRAINAGE
Most of the venous blood from liver is drained by three large hepatic
veins: (a) left hepatic vein between medial and lateral segments of the
left true lobe, (b) middle hepatic vein between true right and left true
lobes, and (c) right hepatic vein between anterior and posterior
segments of the right true lobe. These veins do not have the
extrahepatic course. They emerge in the upper part of the groove for
IVC and open directly in the IVC, just below the central tendon of the
diaphragm. The three veins may enter the IVC independently but the
left and middle veins usually join, so that only two major veins join the
IVC.
 LYMPHATIC DRAINAGE
A network of superficial lymphatics exists in the capsule of the liver
underneath the peritoneum. The superficial lymphatics from the posterior
aspect of the liver converge toward the bare area of the liver and
communicate with the extraperitoneal lymphatics which perforate the
diaphragm and drain into the posterior mediastinal lymph nodes. The
superficial lymphatics from the anterior aspect of the liver drain into
three or four nodes that lie in the porta hepatis (hepatic nodes). The
nodes also receive the lymphatics from the gallbladder. Efferents from
these nodes run downward along the hepatic artery to coeliac nodes.
The lymphatics accompanying the portal triads constitute the deep
lymphatics. The deep lymphatics form two trunks. The ascending trunk
enters the thorax through the vena caval opening and terminates in the
nodes around the IVC. The descending trunk empties in hepatic nodes
located in the porta hepatis

NERVE SUPPLY
The liver is supplied by both sympathetic and parasympathetic
fibres. The sympathetic fibres are derived from the coeliac plexus.
They run along the vessels in the free margin of the lesser
omentum and enter the porta hepatis. The parasympathetic fibres
are derived from the hepatic branch of the anterior vagal trunk,
which reaches the porta hepatis through the lesser omentum. Pain
occurring due to distension of the hepatic capsule and hepatic
peritoneum due to inflammation and swelling of the liver (hepatitis)
run along the sympathetic fibres. The pain is often referred to the
epigastrium and sometimes to the shoulder.
FACTORS KEEPING THE LIVER IN POSITION
These are as follows:
1. Hepatic veins connecting the liver to the IVC.
2. Intra-abdominal pressure maintained by the tone of abdominal
muscles.
3. Peritoneal ligaments connecting the liver to the abdominal
walls.
MICROSCOPIC STRUCTURE
In a classical description, the liver consists of hexagonal lobules
(classical liver lobules) made up of anastomosing cords of hepatocytes
radiating away from the central vein, a radicle of hepatic vein. At the
periphery of the lobules in the corners of hexagon are portal triads/
tracts. Each triad contains three structures viz. radicle of bile duct
(hepatic ductal), hepatic artery (hepatic arteriole), and portal vein
(portal venule) (Fig. 8.11A). The plates/cords of hepatocytes are
separated by vascular spaces called sinusoids which connect the portal
vein of the triad to the central vein of the lobule. The blood flow in
the sinusoids is from the periphery of the lobule toward the central
vein.
The sinusoids intervening between the cords of hepatocytes are lined
by endothelial cells, which present frequent intercellular spaces/
fenestrations. The fenestrations allow plasma (but not the blood cells)
to leave the sinusoids and enter the perisinusoidal spaces (spaces of
Disse) between the endothelial lining and hepatocytes. Many of the
cells of endothelial lining are capable of phagocytic activities (Kupffer
cells).
The bile produced by hepatocytes first enters the bile canaliculi
situated between the opposite sides of adjacent hepatocytes. The bile
canaliculi drain into the bile ductules of the portal triads which in
turn unite to form the larger intrahepatic ducts.
The portal triads are embedded in the perilobular connective tissue
which pervades the liver and is continuous with the capsule of the
organ.
DEVELOPMENT
The liver develops from a diverticulum (hepatic bud) from the distal
end of the foregut. The hepatic bud elongates cranially and gives rise
to a small accessory bud on its right side called pars cystica which
forms cystic duct and gallbladder. The main bud called pars hepatica
grows into the septum transversum. It bifurcates and gives rise to
right and left hepatic ducts and liver parenchyma. The septum
transversum contains the vitelline veins and umbilical veins before the
hepatic bud invades it. These vessels subdivide to form sinusoids which
invade the liver parenchyma breaking it up into hepatic cords. The bile
canaliculi and ductules are formed in the liver parenchyma and
establish connections with the extrahepatic bile ducts at a later stage.

Clinical correlation

Segmental resection of liver:

The hepatic segments are not well defined as the bronchopulmonary
segments. The anatomy of hepatic segments is still of controversial
usefulness in partial resection of the liver. Therefore, a true lobe rather
than a segment should be resected in most instances of partial
hepatectomy. A large volume of liver (80%) can be removed safely because
healthy hepatocytes have great capacity of regeneration. The liver can
regrow to its original size within 6–12 months.
*Surgical importance of the bare area of the liver:
The bare area of the liver is indirect contact with the diaphragm, which
separates it from the right pleural cavity. Surgically, it is important because
it encloses the right extraperitoneal subphrenic space. In amoebic hepatitis,
the pus may collect in this space and form a subphrenic abscess which may
burst into the right pleural cavity through the diaphragm. A potential
anastomosis of venous capillaries exists in the region of bare area between
the liver and the diaphragm. It becomes functional under certain
pathological conditions (e.g., portal hypertension).

• Needle biopsy of the liver (Fig. 8.10): In needle biopsy of the liver, the
needle is inserted in the midaxillary line through 9th or 10th intercostal
space. The needle passes through the chest wall, costodiaphragmatic recess
of the pleura, diaphragm, and right anterior intraperitoneal space to enter
the liver. Needle inserted above the 8th intercostal space will injure the
lung.

*Cirrhosis of the liver:

The hepatocytes sometimes may undergo necrosis following their injury
and death caused by infection, toxins, alcohol, and poisons. The dead
hepatocytes are replaced by fibrous tissue by the proliferation of the
perilobular connective tissue. The resultant hepatic fibrosis is clinically
termed cirrhosis of the liver. The patient develops jaundice due to
obstruction of bile flow. Resistance to blood flow through cirrhotic liver
is increased which leads to increase of pressure in the radicles of
portal vein in the triads. Since portal vein and its tributaries are devoid
of valves, the increased venous pressure in the portal vein causes
engorgement and distension of all its tributaries, as well as of spleen.
This clinical condition is called portal hypertension.