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Blood and bile – plumbing for beginners
Watch this video in which Dr Patricia Lalor uses an Anatomage Table, a fantastic visual display system to illustrate liver anatomy.
SPEAKER: In this video, we’re going to revisit some of the structures we mentioned in our earlier activities so that you can get a feel for the gross structure of the liver, how closely it is nestled between the other abdominal organs, and more importantly, the joints which need to be made when a donor liver is connected to the vascular supply of the recipient. The idea is to give you a feel for some of the technical challenges the procedure presents to the surgical teams. In this video, we were fortunate to be allowed to use a fantastic piece of equipment. It’s available for students learning anatomy at the medical school in Birmingham. This is called the Anatomage.
And it’s similar to a giant touchscreen tablet, or essentially, a six foot iPad that is preloaded with a medical image that you can interact with and modify in real-time. We have two in Birmingham, which were purchased along with some ultrasound machines and other teaching equipment, thanks to a generous bequest from Mr. Kenneth Foster. I’ve put a link to the Anatomage website below this video so that you can find out more about it. And I must admit, it was really interesting to be allowed to use it for a couple of hours.
You can see here, the Anatomage is preloaded with anatomical images and extra details, like MRI scans and x-ray images, that you can interact with to zoom in and out of key structures or to remove tissue layers like skin, fat, and muscle to see what lies beneath.
We’ll also, occasionally, show you Dave, our anatomical model who featured in our previous course on liver disease. He’s about a third real size and allows us to orient you as to where we are in the body when we use footage from the Anatomage. You can also add and remove his organs to see how everything fits together, which is quite useful. OK, so to start, we’re showing you the potential of the Anatomage. Let’s have a look at Dave. You can see nicely how the liver nestles in under the lungs. It’s the dark brown organ here, sitting just above the stomach.
The liver is on the left of this image and the stomach is on the right, as Dave is facing towards us. If you were looking at your own organs, the liver would be on your right-hand side. Now, I want you to imagine that we’re taking a slice horizontally just under the lungs, between the ribs, so that we can cut through the thick part of the liver. Let’s have a look and see what this looks like on the Anatomage.
OK, so here we have another male where we’ve taken a slice across his tummy, and he’s positioned head down. So we’re looking down into his body from the feet end. My hand comes in here, and you can see how we can move and manipulate the images. OK, so we have the spinal cord at the bottom, with ribs coming out to envelop the liver around it. The liver is to the left of the image. And you can see two major vessels, which are appearing as dark circles or tubes. We have the Inferior Vena Cava, or IVC, that the blood from the liver drains into. This is dark red. And then slightly to the right and paler, we have the aorta.
You can also see some of the hilum, where the vessels enter the liver. This looks like a hole in the centre of the tissue, surrounded by pale connective tissue. And also, you can see large vessel branches throughout the liver. Most of these will be branches of the portal vein. And next to these, will sit bile ducts and artery branches. But they’re a bit too small to see in this image. You can also see the spleen on the left. It’s unusually large, actually, which makes me think that this person used for this imaging might have had a medical condition. You can also see the gallbladder, which is pale pink and hollow-looking, to the right of the image.
We’ll also make the liver disappear so that you can see how the stomach, top right, is next to the gallbladder. The major vessels are also slightly more clearly visible now. And if we put the liver back in, you can imagine how snugly it fits in with all these other organs, and even more when we add back in the fatty tissue, muscle, and skin layers. You could see how much depth of tissue a surgeon would need to penetrate in order to gain access to a liver for transplantation surgery.
So we’re going to illustrate this a bit more clearly in our next Anatomage sequence. But firstly, back to Dave the dummy to illustrate the positioning of the liver in the abdomen again. Now, we’re going to imagine our patient lying on his back with his head, again, toward the left-hand side of the image. So now we’ve removed the skin and subcutaneous fat to expose those beautiful abdominal muscles. Underneath these is the peritoneum, which helps protect all those organs in the abdomen and hold them in place. If you remove this, you can see the liver again, large and red on the left, with the darker gallbladder poking out from underneath, and also a bit of stomach visible.
If we remove the liver again, you can see the stomach and oesophagus, where your food passes down into the stomach, going off to the top right of the image onto the ribs. If we then move the entire rest of the gastrointestinal tract, you can see the kidneys situated towards the back of the patient. And they sit quite low down, just above your hips. And you can see the urethra which drains urine from the kidneys into the bladder. So if we use Dave to illustrate the position of everything again, minus the liver, you can see how faithfully our simple anatomical dummy recreates the images of the full body scan.
We’ll build back in the peritoneum and muscle layers now to remind you of how it’s all held in place.
So the next thing I would like to show you is from a different angle again. I’ve taken Dave’s liver out to show you the back and the hilum, where all the vessels connect into the liver. You can see where the hepatic vein would connect to the large inferior vena cava in blue, on top of the liver. You can also see the gallbladder and common bile duct illustrated in green, to the bottom of the image.
So here’s the same as a section through the Anatomage specimen. And this time, I’ve highlighted the vessels, both within the tissue, and there’s a box where that hilum would be. And you can also see the inferior vena cava is a dark red structure within this box. Now, I’m going to show you this in a different way. Here we have a whole body image again. The head is top left. But now we’re going to slice down into the tissue, towards the back of your screen, if you like, so that you can follow the vessels through the liver tissue. I’ll turn the image slightly and point to the area where the vessels appear. You can also see the bile duct nicely here.
And also, as the liver disappears, both the aorta, which is more to the right, and the inferior vena cava, which is more to the left, behind the liver. We’ll see this even more clearly in the next image, where instead of chopping horizontally across Dave’s tummy, we’re going to take a vertical slice from head to toe. And we’ll move through the liver, up and down, to allow you to see the vessels. Arteries will be in blue and veins in red, while the lymphatic supply is green. And again, I will point out the hilum so that you can see how complex the vascular connections are between the abdominal organs.
There’s the hilum there.
You can also see the large vessels there. You can see all the connective tissue around the hilum. And you can see the common bile duct entering underneath the liver there. The lymphatics are illustrating a green really nicely in this image.
So to end this film, I’ve tried to show you how organised your abdominal organs are and how snugly they fit inside the body. So if we just turn our anatomical specimen here, we’re going to end with this beautiful image of the vessels connecting into the back of the liver, so that you’ll try and remember this when we chat to our liver surgeon about how organs are inserted and removed during transplantation. So if we just false color this image now– there we go– so you can see the colour. And you can see just where we’ve cut through that liver tissue. You can see the beautiful point at which all those vessels are coming in.
Your task: Watch this video in which Dr Patricia Lalor uses an Anatomage Table, a fantastic visual display system available in the Anatomy department at the University of Birmingham.
This equipment was bought thanks to a charitable bequest from Mr Kenneth Foster to the University and allows us to visualise the anatomy of the liver in more detail.
We show you how the blood supply and biliary system connect to the liver so you can see the structures that transplantation surgeons have to connect in a patient receiving a new liver.
Look out for mention of some of the cell types we mentioned in earlier activities. Reflect on any new information or ideas and share your thoughts with other learners in the comments area. We’d also like to express our thanks to Professor Joanne Wilton in the Anatomy Department at the University of Birmingham for allowing us to use the Anatomage and again acknowledge the bequest from Mr Kenneth Foster which allowed us to purchase the equipment.
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