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The right gastric artery takes off shortly thereafter and con- tinues within the lesser omentum along the lesser curve of the stomach. At this point the common hepatic artery is referred to as the proper hepatic artery.
The proper hepatic artery courses towards the hilum and soon divides into the right and left hepatic arteries. Prior to the bifurcation, a small cystic artery branches off to provide blood supply to the gallbladder. While coursing through the hepatoduodenal ligament the hepatic artery proper, common bile duct, and portal vein are enveloped Essential Hepatic and Biliary Anatomy for the Surgeon 7 Fig.
Caudate lobe anatomy. The caudate lobe is situated to the left of the inferior vena cava IVC. The ligamentum venosum, a rem- nant of the fetal umbilical vein, courses across the anterior surface of the caudate lobe to enter the left hepatic vein. Small venous tributar- ies drain the caudate lobe directly into to the IVC. On its medial surface, the caudate lobe is attached to the right liver by the caudate process.
The proper hepatic ar- tery bifurcates earlier than the common bile duct and portal vein. The posterior sectoral branch initially runs horizontally through the hilar transverse fissure of Gunz normally present at the base of Segment V and adjacent to the caudate process. The left hepatic artery runs vertically towards the umbilical fissure where it gives off a small branch often called the middle hepatic artery to Segment IV, before continuing on to supply Segments II and III.
Additional small branches of the left hepatic artery supply the 8 Heptobiliary Surgery Fig. Normal celiac axis anatomy. The sectoral and segmental bile ducts and portal veins follow the course of the hepatic artery branches. Intrahepatic branching of these structures will be discussed in more detail below. The blood supply to the common bile duct is varied and multiple.
Branches of the common hepatic, gastroduodenal, and pancreaticoduodenal arteries have all been shown to provide arterial supply at various levels. Hepatic Arterial Anomalies Variations in the arterial blood supply to the liver are common. Although the hepatic artery typically arises from the celiac axis, complete replacement of the main hepatic artery or its branches occur with variable frequency.
Similarly, duplication or accessory hepatic arterial branches, particularly an accessory left hepatic artery, may be more the norm than an anomaly.
In this situation, the replaced right hepatic artery usually arises from the superior mesenteric artery and runs lateral and posterior to the portal vein within the hepatoduodenal liga- ment. In rare instances, the entire common hepatic artery, or its indi- vidual branches may arise directly off the celiac trunk or aorta. Portal Venous Anatomy The portal vein is formed by a union of the superior mesenteric vein SMV and splenic vein behind the neck and body of the pancreas.
Hepatic arterial anomalies. Venous tribu- taries from the pancreas may also drain directly into the portal vein, and generally correspond to the arterial supply.
More precisely, there are anterior, posterior, superior 10 Heptobiliary Surgery and inferior pancreatic vessels. In addition, the left gastric vein and inferior mesen- teric vein typically drain into the splenic vein, but in rare instances these vessels may enter the portal vein directly.
Surgical dogma states that there are no venous branches on the anterior surface of the portal vein and, for the most part this is true—most veins enter the portal vein tangentially from the side.
However, having paid homage 1 to surgical dogma, the reality is that small anterior venous branches may exist, and any manipulation posterior to the pancreatic neck and anterior to the portal vein should be performed with maximum operative exposure and care. Access to the portal vein is typically obtained by identifying the superior mesen- teric vein on the inferior surface of the pancreas.
In some circumstances it is neces- sary to first locate the middle colic vein within the transverse mesocolon and follow it inferiorly to the SMV. The length of the SMV is highly variable, and may range from only a few millimeters up to 4 cm.
In many circumstances the SMV is made up of two to four venous branches that coalesce shortly before joining the portal vein rather than a single dominant vein. The inferior pancreaticoduodenal vein, which can be quite prominent, is the only vein that normally enters the SMV di- rectly. Proper identification of this vein is necessary to avoid injury and often sub- stantial blood loss.
All other pancreatic venous tributaries enter the portal vein rather than the SMV. Once a determination has been made regarding the resectability of the pancreatic lesion, we favor early transection of the common bile duct. If the tumor later proves unresectable, a palliative end to side bilioenteric bypass can be performed. In addition to those variants described above, there are additional but rare congenital anomalies of the portal vein with which the surgeon should be aware.
The importance of careful dissection around the portal vein cannot be overemphasized. Inadvertent injury or transection of the portal vein or a main tributary is difficult to correct and remains among the most lethal of surgical errors. Intrahepatic Arterial and Portal Venous Anatomy Throughout the course of the liver, the sectoral and segmental bile ducts, hepatic arteries and portal venous branches run together.
The Biliary Tract The extrahepatic biliary system consists of the extrahepatic portions of the right and left bile ducts that join to form a single biliary channel coursing through the posterior head of the pancreas to enter the medial wall of the second portion of the duodenum.
The gallbladder and cystic duct form an additional portion of this ex- trahepatic biliary system that typically joins with the terminal portion of the common Essential Hepatic and Biliary Anatomy for the Surgeon 11 hepatic duct to form the common bile duct.
In most instances, the confluence of the right and left bile ducts lies to the right of the umbilical fissure and anterior to the right branch of the portal vein. In contrast, the left hepatic duct has a relatively long extrahepatic course 1 cm along the base of the quadrate lobe Segment IV and enters the hepatic parenchyma at the umbilical fissure.
Lowering the hilar plate i. The common bile duct continues inferiorly positioned anterior to the por- tal vein and lateral to the common hepatic artery. Lowering of the hilar plate and exposure of the left hepatic duct. The left hepatic duct runs at the base of the quadrate lobe Segment 4 and is covered by the hilar plate a layer of connective tissue running between the hepatoduodenal ligament and the Glissonian capsule of the liver. Dividing this layer demonstrates the extrahepatic portion of the left hepatic duct arising from the umbilical fissure.
Numbers 2,3,4 and refer to segmental liver anatomy. Portal pedicles. This cutaway view of the right and left portal pedicles demonstrates the course of the right and left portal veins, hepatic ducts, and he- patic arteries as they enter the hepatic parenchyma. At the junction of the 1st and 2nd portions of the duodenum, the common bile duct ducks behind the duodenum posterior to the pancreatic head in order to enter the medial wall of the duodenum 2nd portion at the sphincter of Oddi.
The gallbladder is situated on the undersurface of the anterior inferior sector Segment V of the right lobe of the liver. In rare instances, the gallbladder is only loosely attached to the undersurface of the liver by a thinly veiled mesentery and may be prone to volvulus.
Variations in gallbladder anatomy are rare. These variations include a bilobed or double gallbladders, b septated gallbladders, or c gallbladder diverticula. The cystic duct arises from the infundibulum of the gallbladder and runs me- dial and inferior to join the common hepatic duct.
The cystic duct is typically mm in diameter and can range from 1 mm to 6 cm in length depending upon its union with the common hepatic duct. Spiral mucosal folds, referred to as valves of Heister, are present in the mucosa of the cystic duct.
Cystic duct abnormalities are uncommon and include a double cystic ducts very rare , b aberrant cystic duct entry sites, and c aberrant cystic duct union with the common hepatic duct.
Fig- ure 1. A angular union, B parallel union, and C spiral union. However, variations in the anatomy of the cystic artery are common. A careful intraoperative determination of cystic artery anatomy is important to prevent unnecessary hemorrhage during cholycystectomy. An understanding of intrahepatic ductal anatomy is obviously important and vital to the performance of high biliary anastomoses for cholangiocarcinoma Klatskin tumors , an intrahepatic bilioenteric bypass, and complex hepatic resections such as caudate lobectomy, and left and right trisegmentectomy.
The right and left lobes of the liver are drained separately by the right and left hepatic ducts. In contrast, 1—4 smaller ducts from either the right or left hepatic ducts drain the caudate lobe. Within the liver parenchyma, the intrahepatic biliary radicals parallel the major portal triad tributaries directed toward each hepatic segment of the liver.
More spe- cifically, bile ducts are usually situated superior to its complementary portal vein branch, while the hepatic artery lies inferiorly. The left hepatic duct drains all three segments of the left liver. In some textbooks Segment IV, the quadrate lobe, is futher sub-divided into sub-segments IVa, superior, and IVb, inferior so conceptually both the right and left hepatic ducts each drain four segments.
Biliary Surgical Management of hepatobiliary and pancreatic disorders 10 drainage is likewise into both the right and left hepatic ducts. However, the left dorsal duct can also join the segment II duct. The small hepatic veins of the caudate lobe drain directly into the IVC.
This independent isolation of the caudate lobe is clinically important in BuddChiari syndrome, if all three main hepatic veins are obliterated and the only hepatic venous drainage is through the caudate lobe, which then undergoes compensatory hyperplasia.
Anatomical classification of hepatectomies We would classify these as typical and atypical. Typical hepatectomies hepatectomies reglees are defined by resection of a portion of liver parenchyma following one or several anatomical portal or hepatic scissurae. These resections are called left or right hepatectomies, sectorectomies and segmentectomies. Atypical hepatectomies involve resection of a portion of hepatic parenchyma not limited by anatomical scissurae.
Such resections are usually inappropriate as they will leave behind devascularized residual liver and will probably also not adequately excise all the pathologically involved parenchyma. The usual typical hepatectomies can be considered in two groups.
First, right and left hepatectomies in which the line of transection is the main portal scissura separating the right and left livers along the middle hepatic vein as proposed by Couinaud. For some time the latter definition, proposed by Goldsmith and Woodburne, 9 has been the accepted convention in the Anglo-Saxon literature. We prefer to use the definition of Couinaud, since segment IV quadrate lobe is anatomically part of the left liver Fig. In certain pathologies multiple liver metastases or large tumours transgressing the main portal scissura hepatectomies can be extended Figure 1.
Therefore extended right Surgical anatomy of the liver and bile ducts 11 hepatectomy will also include resection of segment IV, taking portal structures to the right of the falciform ligament which Goldsmith and Woodburne describe as a right hepatic lobectomy 9 Fig.
Using this functional approach to liver anatomy, there are numerous other potential liver resections. One area of confusion in the definitions of hepatectomies comes in the simultaneous resection of segments II and III Fig.
Goldsmith and Woodburne describe this procedure as a left hepatic lobectomy. However, it is now accepted convention that resection of segments II and III is regarded as a left lateral segmentectomy. Sectorectomies of the right liver are easier to define. Resection of segments V and VIII between the main portal scissura middle hepatic vein and right portal scissura right portal vein on their pedicle of the anterior division of the right portal vein is defined as a right anterior sectorectomy, while resection of segments VI and VII posterior to the right portal scissura on the pedicle of the posterior division of the right portal vein is a right posterior sectorectomy Fig.
Similarly, segments V and VI can be resected en bloc right inferior hepatectomy and if there is a significant right inferior hepatic vein Figure 1. Surgical approach to the caudate lobe dorsal sector This is initially achieved by dissection of the coronary ligament up to the right of the IVC, but avoiding the right hepatic vein. The falciform ligament is then dissected to the IVC and the lesser omentum incised close to the liver.
Opening the left coronary ligament Surgical Management of hepatobiliary and pancreatic disorders 12 allows ligation of the inferior phrenic vein. The caudate veins to the IVC are now exposed and can be divided between ligatures as they run up the back of the caudate lobe.
After the hilar plate is lowered to expose the right and left portal pedicles, the portal inflow to both the right and left caudate segments can be identified, ligated and divided. However, the caudate segment is not defined macroscopically from segment VI. The biliary tract Accurate biliary exposure and precise dissection are the two most important steps in any biliary operative procedure and are both totally dependent on a thorough anatomical understanding of these structures.
Hepatobiliary Surgery Blumgart
Several authors have thoroughly described the anatomy of the biliary tract, 6 , 7 , 23 but unfortunately the surgical implications have been incompletely described and continue to be misunderstood by many surgeons. Intrahepatic bile duct anatomy The right liver and left liver are respectively drained by the right and the left hepatic ducts, whereas the caudate lobe is drained by several ducts joining both the right and left hepatic ducts.
There is variation in the anatomy of all three components of the portal triad structures, hepatic ducts, hepatic arteries and portal vein, but the latter of these shows the least anatomical variability.
In particular, the left portal vein tends to be consistent in location. Each branch of the intrahepatic portal vein corresponds to one or two intrahepatic bile ducts which converge Surgical anatomy of the liver and bile ducts 13 outside the liver to form the right and left hepatic ducts, in turn joining to form the common hepatic duct.
The left liver is divided between segments III and IV by the umbilical fissure, although this division may be bridged by a tongue of liver parenchyma of varying depth. The ligamentum teres passes through this umbilical fissure to join the left portal vein within the recessus of Rex Figs 1. However, all these biliary and vascular elements are liable to anatomical variation.
The duct draining segment III is found a little behind the left horn of the umbilical recess, from where it passes directly posteriorly to join the segment II duct to the left of the main portal branch to segment II.
At this point the left branch of the portal vein turns forward and caudally in the recessus of Rex 23 Fig. As the duct draining segment Figure 1. Surgical Management of hepatobiliary and pancreatic disorders 14 Figure 1.
Note the position of segment III duct above the corresponding vein and its relationship to the recessus of Rex. Note the horizontal course of the posterior sectoral duct and the vertical course of the anterior sectoral duct. III begins its posterior course it lies superficially in the umbilical fissure, often immediately under Glissons capsule. As such it is usually easily accessible at surgery to allow a biliary-enteric segment III hepaticojejunostomy anastomosis for biliary drainage if such access is not possible at the porta hepatis.
The left hepatic duct then Surgical anatomy of the liver and bile ducts 15 passes beneath the left liver at the posterior base of segment IV, lying just above and behind the left branch of the portal vein. After the left duct crosses the anterior edge of that vein it joins the right hepatic duct to form the common duct at the hepatic ductal confluence.
In this transverse portion, where it lies below the liver parenchyma, it receives one to three small branches from segment IV. The right posterior sectoral duct runs almost horizontally 26 and comprises the confluence of the ducts from segments VI and VII Fig.
The posterior duct joins the anterior sectoral duct formed by the confluence of the ducts from segments V and VIII as it descends vertically. The junction of the two main right biliary ducts usually occurs immediately above the right branch of the portal vein. The caudate lobe segment I has its own separate biliary drainage. This segment comprises two anatomically and functionally distinct portions, a caudate lobe proper which consists of a right and left part located at the posterior aspect of the liver and a caudate process passing behind the portal structures to fuse with the right liver.
In nearly half of individuals, three separate bile ducts drain these distinct parts, while in a quarter of individuals there is a common bile duct between the right portion of the caudate lobe proper and the caudate process, while the left part of the caudate lobe is drained by an independent duct.
However, the site of drainage of these ducts is variable. Many authors now advocate en bloc resection of the caudate lobe during resection of hilar cholangiocarcinoma, 31 since the tumour usually infiltrates these ducts draining the caudate lobe. Extrahepatic biliary anatomy The detail of this section will be confined to the upper part of the extrahepatic biliary tree, above the common bile duct, since the common bile duct is also covered in Chapter 2.
The right and left hepatic ducts converge at the right of the hilum of the liver, anterior to the portal venous bifurcation and overlying the origin of the right portal vein. The biliary confluence is separated from the posterior aspect of the base of segment IV by a fusion of connective tissue investing from Glissons capsule to form the fibrous hilar plate.
This hilar plate has no vascular interposition and, when opened behind the posterior aspect of the base of segment IV, will display the extrahepatic confluence of the right and left hepatic ducts Fig. Surgical Management of hepatobiliary and pancreatic disorders 16 Figure 1. Note the extension of Glissons capsule to invest the portal structures at the hilum hilar plate and extending over the hepatic surface of the gallbladder cystic plate.
Exposure of the extrahepatic left hepatic duct is achieved by incising the hilar plate at the base of segment IV medially as far as the umbilical fissure. The main bile duct is divided into its upper part, the common hepatic duct, and lower part, the common bile duct, by the entry of the cystic duct from the gallbladder. This point of entry is widely variable. The main bile duct normally has a diameter of 6 mm and passes downwards anterior to the portal vein in the right free border of the lesser omentum.
The bile duct is closely related to the hepatic artery as it runs upwards on its left side before dividing into its left and right branches, the right hepatic artery usually passing posteriorly to the bile duct. The cystic artery which usually arises from the right hepatic artery crosses the common hepatic duct as frequently anteriorly as it does posteriorly Figs 1. Calots triangle was originally defined by the common hepatic duct lying medially, inferiorly by the cystic duct and superiorly by the cystic artery.
The retropancreatic portion of the bile duct approaches the duodenum obliquely, accompanied by the terminal part of the duct of Wirsung see Chapter 2.
These two ducts join to enter the duodenum through the sphincter of Oddi at the papilla of Vater. Note the hepatic duct confluence anterior to the right hepatic artery and origin of the right portal vein.
Note also the course of the cystic artery, arising from the right hepatic artery and passing posteriorly to the common hepatic duct.
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The gallbladder lies within the cystic fossa on the underside of the liver in the main liver scissura at the junction between the right and left livers. It is separated from the hepatic parenchyma by the cystic plate, which is an extension of connective tissue from the hilar plate described previously.
The relationship of the gallbladder to the liver ranges from hanging by a loose peritoneal reflection to being deeply embedded within the liver substance.
The gallbladder varies in size and consists of a neck, body and fundus which usually reaches the free edge of the liver, still closely applied to the cystic plate.
Large gallstones impacting within the neck of the gallbladder may create a Hartmanns pouch, 33 and inflammation secondary to this can obscure the anatomical plane between the gallbladder and the common hepatic duct leading to damage of the latter during cholecystectomy. Its length varies widely but its lumen is usually between 1 and 3 mm. The mucosa of the cystic duct is arranged in spiral folds valves of Heister.
B The lymphatic drainage of the gallbladder towards the coeliac axis. Surgical anatomy of the liver and bile ducts 19 Gallbladder and cystic duct The gallbladder receives its blood supply by the cystic artery, the anatomy of which varies widely Fig. The most common variant arises directly from the right hepatic artery and then divides into an anterior and posterior branch.
The venous drainage of the gallbladder is directly through the gallbladder fossa to the portal vein in segment V Fig. Similarly, there are common variations of the intrahepatic biliary anatomy.
This duct does not drain any specific area of the liver and never communicates with the gallbladder, but may be damaged during cholecystectomy and therefore contribute to postoperative biliary leak. Anomalies of the accessory biliary apparatus Gross described a number of anomalies of the accessory biliary apparatus in Furthermore, the gallbladder may be abnormally positioned, either lying deep within the liver parenchyma or lying under the left liver.
Surgical Management of hepatobiliary and pancreatic disorders 22 Figure 1. The union of the cystic duct with the common hepatic duct may be angular, parallel or spiral.
Surgical anatomy of the liver and bile ducts 23 The arterial blood supply of the liver and bile ducts The hepatic artery The hepatic artery usually arises as one of the three named branches of the coeliac trunk along with the left gastric and splenic arteries Fig. The first named branch of the hepatic artery is the gastroduodenal artery and either of these arteries may then give rise to the right gastric and retroduodenal arteries Fig.
The hepatic artery then divides into right giving rise to the cystic artery and left hepatic arteries. In a small number of people other variations of these arrangements will occur Fig. However, these variations will be readily apparent to an experienced surgeon at operation and the authors do not advocate preoperative visceral angiography to delineate these anomalies before routine hepatectomy.
The blood supply of the extrahepatic biliary apparatus The extrahepatic biliary system receives a rich arterial blood supply, 46 which is divided into three sections. The hilar section receive arterioles directly from their related hepatic arteries and these form a rich plexus with arterioles from the supraduodenal section.
The Surgical anatomy of the liver and bile ducts 25 blood supply of the supraduodenal section is predominantly axial, most vessels to this section arising from the retroduodenal artery, the right hepatic artery, the cystic artery, the gastroduodenal artery and the retroportal artery. Usually, eight small arteries, each 0. The most important of these vessels run along the lateral borders of the duct and are referred to as the 3 oclock and 9 oclock arteries. The retropancreatic section of the bile duct receives its blood supply from the retroduodenal artery.
The veins draining the bile duct mirror the arteries and also drain the gallbladder. This venous drainage does not enter the portal vein directly but seems to have its own portal venous pathway to the liver parenchyma.
Although intraoperative ultrasound has made easier the location of dilated intrahepatic biliary radicals, surgical exposure of the extrahepatic biliary confluence and the segment III duct demands knowledge of precise anatomical landmarks. Biliary-enteric anastomosis necessitates precise bile duct exposure to facilitate the construction of a mucosa to mucosa apposition.
This manoeuvre will expose considerably more of the left hepatic duct than the right, which runs a shorter extrahepatic course.
Contraindications to this approach include patients with a very deep hilum which is displaced upwards and rotated laterally, 36 and those patients who have undergone removal or atrophy of either the right or left livers resulting in hilar rotation. In this situation the bile duct may come to lie behind the portal vein. Surgical Management of hepatobiliary and pancreatic disorders 26 Figure 1. The anatomy of biliary exposure When approaching the segment III duct segment III hepaticojejunostomy , follow the round ligament in which runs the remnant of the obliterated umbilical veins through the umbilical fissure to the point where it connects with the left branch of the portal vein within the recessus of Rex.
This junction may sometimes be deeply embedded within the parenchyma of the fissure. The bile ducts of the left liver are located above the left branch of the portal vein, whereas the corresponding arteries lie below the portal vein. Dissection of the round ligament on its left side allows exposure of either the pedicle or anterior branch of the duct from segment III.
This is achieved by mobilizing the round ligament and pulling it downwards, thereby freeing it from the depths of the umbilical fissure. This procedure usually requires the preliminary division of the bridge of liver tissue which runs between the inferior parts of segments III and IV. The umbilical fissure is then opened and with downward traction of the ligamentum teres an anterior branch of the segment III duct is exposed on its left side. Sometimes it may be necessary to perform a superficial liver split to gain access to this duct.
In the usual situation of chronic biliary obstruction with dilatation of the Surgical anatomy of the liver and bile ducts 27 intrahepatic bile ducts, the segment III duct is generally easily located above the left branch of the portal vein. However, in the situation of left liver hypertrophy, it may be necessary to perform a more extensive liver split to the left of the umbilical fissure in order to widen the fissure to achieve adequate access to the biliary system.
Access to the right liver system is less readily achieved than to the left as the anatomy is more imprecise. However, intraoperative ultrasonography greatly enhances the ability of the surgeon to locate these ducts at surgery. The ideal approach on the right side is to the segment V duct, 52 which runs on the left side of its corresponding portal vein.
The segment V duct should lie relatively superficially on the left aspect of the portal vein to that segment. Key points A full understanding of the lobar, sectoral and segmental anatomy of the liver and biliary system is an essential prerequisite for successful liver surgery.
The surgeon must appreciate the wide variation in extrahepatic biliary anatomy. Glisson F. Anatomia hepatis. London: Typ. DuGardianis, 2.
Rex Cited in Hobsley M. The anatomical basis of partial hepatectomy. Proc R Soc Med Engl ; 3. Cantlie J.
On a new arrangement of the right and left lobes of the liver. J Anat Physiol Lond ; 4. Schwartz SI.
Historical Background. Surgery of the liver. Boston: Blackwell Scientific Publications, 5. A report on the bilaterality of the liver. Arch Surg ; 6. Hjortsjo CH. The topography of the intrahepatic duct systems. Acta Anat ; 7. Ton That Tung. La vascularisation veineuse du foie et ses applications aux resections hepatiques.
These, Hanoi, 8. Anatomy of the biliary ducts within the human liver.
Arch Surg ; 9. Surgical anatomy pertaining to liver resection.
Surg Gynaecol Obstet ; Lau WY. The history of liver surgery. J R Coll Surg Edin ; Injuries of the liver in three hundred consecutive cases. Int Abstr Surg ; Dalton HC. Gunshot wound of the stomach and liver treated by laparotomy and suture of the visceral wounds.
Ann Surg ; Luis A. Di un adenoma del fegato. Centralblatt fur chirg ; Abstract from Ganzy, delle cliniche , 23, No 15 Langenbuch C. Ein Fall von Resektion eines linksseitigen Schnurlappens der Leber. Surgical Management of hepatobiliary and pancreatic disorders 28 Berl Klin Wosch ; Tiffany L.
The removal of a solid tumor from the liver by laparotomy. Maryland Med J ; Lucke F. Entfernung der linken Krebsiten Leber Lappens. Cantrallbl Chir Wendel W.
Beitrage zur Chirurgie der Leber. Arch Klin Chir Berlin ; Cattell RB. Successful removal of liver metastasis from carcinoma of the rectum.In regard to the last error, most surgeons learn humility through their failures and at the expense of their patients, while some never learn.
Finally, there is usually a thick fibrous band that envel- ops the vena cava high on the right side and runs posteriorly towards the lumbar vertebrae. See if you have enough points for this item.
An aberrant he- patic artery is called a replaced hepatic artery as it represents the only blood supply to a specific hepatic segment. All but the last of these errors are remediable with study and effort. Surface anatomy of the liver.
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