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The caudate lobe is the posterior projection of the liver bounded on the left by the fissure of the posterior extension of the falciform ligament and the ligamentum venosum and on the right by the groove for the inferior vena cava discount 10 mg crestor fast delivery cholesterol test how long do you fast. This lobe is also in the medial segment of the left lobe but is in the anatomical right lobe purchase crestor us cholesterol ratio diabetes. So there are altogether eight segmental lobes of the liver order beconase aq 200MDI amex, four in the right and four in the left lobe. Knowledge of the exact anatomy of the segments of the liver help in the segmental resection of the liver in case of neoplastic lesions. It is formed by the junction of the superior mesenteric and splenic veins behind the neck of the pancreas. Then it passes upwards posterior to the first part of the duodenum and passes through the right free margin of the lesser omentum slightly posterior to the common bile duct and the hepatic artery. In only 10% of cases it divides into two right branches going to the right lobe and one to the left lobe. There are certain areas where there is natural communication between the portal and systemic venous systems. These are : (1) The left gastric vein and short gastric veins, tributaries of portal vein send oesophageal tributaries and these communicate with the oesophageal venous plexus, tributaries of superior vena cava at the lower end of the oesophagus. This is the most important portal-systemic anastomosis and duri ng portal hypertension nature tries to divert blood through this anastomosis into the systemic circulation. The result is that the communicating veins become dilated and tortuous and is called oesophageal varix. This varix may rupture and bleed profusely to cause haematemesis in a patient with portal hypertension. These veins when dilated during portal hypertension will result in the formation of caput medusae. But it must be remembered that internal haemorrhoid which is dilatation of the superior haemorrhoidal veins is hardly caused by portal hypertension. This artery first forms the floor of epiploic foramen and then moves up through the right free border of the lesser omentum and ends into the right and left branches at the porta hepatis. The cystic artery usually arises (i) from the right hepatic artery, although there is some variability. The most common of which is origination of the cystic artery (ii) from the gastroduodenal artery, the next common is its origination (iii) from the left or common hepatic artery. Within the liver the right and left branches subsequently divide into smaller branches corresponding to the portal venous system and segmental anatomy. Due to abundant collaterals ligation of the hepatic artery proximal to the gastroduodenal artery can be performed without damage to the liver. Even ligation of the proper hepatic artery can often be performed without serious consequences due to rich collateral extrinsic blood supply from the superior mesenteric and inferior phrenic arteries. Ligation <5f the right or left hepatic artery usually results in enzymes elevation although with no clinical manifestations.
It is an advantage to commence the division from the left side as adhesions are least at this site order crestor online from canada hdl cholesterol in quail eggs. While division is started from the left side buy generic crestor from india cholesterol levels by age and gender, the left gastro-epiploic vessels and one or two short gastric vessels are divided between ligatures order online liv 52. Gradually the gastrocolic omentum is detached along the greater curvature towards the right side as far as the end of the first part of the duodenum. The main right gastro-epiploic vessels as they lie near the inferior border of the pylorus are divided between ligatures. The right gastric vessels are first identified, isolated and divided between ligatures just above the duodenal bulb and pylorus. Now the lesser omentum is detached from the lesser curvature of the stomach gradually towards the left between the pairs of artery forceps in the same fashion as done in case of greater omentum. This detachment operation of the lesser omentum should stop before reaching the left gastric artery. The posterior surface of the first part of the duodenum is dissected from the pancreas sharply or bluntly and if there are vascular adhesions, they have to be divided between ligatures. At this site, gastro-duodenal artery may have to be ligated, but the common bile duct and the hepatic artery should be identified and preserved. Two occlusion clamps are applied side by side at the site of proposed section of the duodenum. Sucker machine is switched on, the duodenum is divided between the clamps and the opened duodenum is sucked so that no intestinal juice can contaminate the abdominal contents. The proximal cut end, held in the clamp, is covered with a piece of gauze and turned towards the left side of the wound. This should be done very meticulously as the duodenal leakage is a serious postoperative complication. This closure can be done convention ally by an all-coats through-and- through suture and a seromuscular Lembert suture to invaginate the first layer. A second invaginating suture or a purse string is used to invert the stump within it. It is better to cover the stumps with peritoneum by means of a suture catching the ligated stumps of the right gastric and right gastro-epiploic vessels, the anterior wall of the duodenum and the peritoneum over the pancreas. The stomach is now held up with the help of the clamp so that the left gastric vessels are tense. With the fingers the pulsation of the left gastric artery is felt where it reaches the lesser curvature 2 to 3 cm below the cardia.