Editing Liver (section)

== '''Attachments''' ==

** ''These      'ligaments' are really peritoneal duplications on the liver surface''
** Coronary (and triangular)      ligaments
*** Peritoneal reflections
*** Attaches the posterior       surface of the liver to the diaphragm
*** Need to be taken down early       to avoid bleeding when mobilising the liver
**** Be wary of right hepatic        vein and IVC for mobilising the superior leaf
**** Be wary of IVC for the        inferior leaf
*** Right
**** Superior and inferior        leaflets of the right coronary ligament run laterally
**** The lateral aspect,        including both superior and inferior ligaments, is called the right        triangular ligament
*** Left
**** A mirror of the right, but        smaller
**** Really just the triangular        ligament on this side
*** The 'bare area' lies within       the coronary/triangular ligaments - liver surface up against diaphragm       without a peritoneal covering. Liver attached to diaphragm by       fibro-alveolar tissue, which is not avascular, and varies in the density       of the fibrous component.
**** IVC and hepatic veins lie        within the bare area
** Falciform ligament
*** Formed by fusion of left       and right anterior coronary ligaments
*** Vestige of the ventral       mesogastrium
*** Suspends liver to anterior       diaphragm, and then extends down the abdominal wall as far as the       umbilicus
*** Ligamentum teres runs in       the free edge
*** The superior-posterior part       of the falciform ligament attachment to the liver also serves as a guide       to the IVC - there is a slight depression in the middle, with left       hepatic vein on one side and right hepatic vein on the other
***
** Ligamentum teres hepatis
*** Runs from umbilicus to       inferior margin of the liver as the inferior edge of falciform ligament,       where it enters the umbilical fissure and joins the left branch of the       portal vein
*** Remnant of obliterated left       umbilical vein - supposedly a fibrous cord
*** In reality it is generally ''closed'' rather than ''obliterated'' and it can be dissected at       the umbilicus, dilated and used to access the left portal vein in 50% of       patients
*** This channel occasionally       opens up in portal hypertension, forming a collateral channel to bypass       hepatic circulation, and in such situations can become quite large
*** Surgical significance
**** Can get in the way during        upper abdominal operations - may need to be divided. If so, ensure to        ligate the small para-umbilical veins carefully before dividing, which        can link with the portal system.
**** Can be divided near the        liver or near the umbilicus, with the free end being used as an anchor        - e.g. as a sling to anchor the oesophagus intra-abdominally
**** As a guide to the ductal        system of segment III for biliary enteric drainage procedures, by        following ligamentum teres down in the fissure between segment III and        IV
***
** Ligamentum venosum
*** Remnant of obliterated       ductus venosum/sinus venosus
*** Runs from left PV in the       porta hepatis to left hepatic vein and IVC, allowing fetal blood to       bypass the liver
*** Also runs in a fissure
*** Needs to be divided for       safe dissection of left hepatic vein
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