Relations Of The Liver

The superior surface lies in contact with the diaphragm, except the portion extending about 7.5 cm. (3 in.) below the xiphosternal junction in the median line and sometimes the small projecting edge beyond the ribs, which lies in contact with the abdominal wall. The posterior surface lies over the tenth and eleventh thoracic vertebrae, the crura of the diaphragm, the oesophagus, aorta, vena cava, and right suprarenal gland. The inferior surface to the left rests on the cardiac end and upper surface of the stomach and gastrohepatic omentum. Beneath the quadrate lobe is the pylorus and beginning of the duodenum. Beneath the caudate lobe is the foramen of Winslow, of which it forms the upper boundary. Farther to the right are the depressions for the hepatic flexure of the colon and the right kidney and suprarenal gland (Fig. 430).

The size of the liver varies, being small in atrophic diseases and much enlarged in others; therefore, alterations in the area of dulness are frequent. It moves with respiration and sometimes hangs lower than normal (ptosis).

Wounds And Injuries Of The Liver

The liver is frequently ruptured in falling or by being struck by some body from without. The rupture may involve its anterior edge or upper surface. In all examinations it should not be forgotten that the right and left sides are separated completely by the falciform ligament. On account of the walls of the vessels being imbedded in the liver tissue they do not readily collapse and hemorrhage is often fatal. Rupture of the posterior nonperi-toneal surface is not so dangerous as elsewhere.

Abscesses may be either one or two large ones or multiple small ones. Pus on the upper surface of the liver, between it and the diaphragm, is called subdiaphragmatic abscess. It may originate either from the liver or other viscera below, or the lung and pleura above. Maydl gives gastric ulcer as the most frequent cause and then affections of the intestines and appendix: we have seen it arise from calculous disease of the kidney. The pus may discharge outward between the ribs, or upward into the pleural cavity, lung, or pericardial sac. In incising for subdiaphragmatic abscess the tenth rib in the axillary line can be resected without opening the pleura, but if the eighth or ninth is chosen the pleural sac may be opened and the two layers of pleura should be stitched together before the incision through the diaphragm into the abscess cavity is made. If the abscess points at the inferior surface it may break into the stomach, duodenum, or colon. It may be reached by an incision through the abdominal walls to the right of the median line. The position of the falciform ligament, about 4 cm. (1 1/2 in.) to the right of the median line, should be remembered, and if the left lobe of the liver is to be treated the incision should be made to the left of the ligament.

Multiple abscesses are started in the liver by conveyance of infection through the portal vein, as occurs in appendicitis, or by direct extension up the common duct from the intestine, or from an inflamed gall-bladder or bile-ducts through the hepatic duct and its ramifications.