Gastrohepatic Ligament and Hepatoduodenal Ligament

The lesser omentum is subdivided into the gastrohepatic ligament and the hepatoduodenal ligament. The gastro-hepatic ligament extends between the lesser curvature of the stomach and the liver, attached in its upper portion deep within the fissure for the ligamentum ven-osum and more inferiorly with the porta hepatis. The subperitoneal areolar tissue of the gastrohepatic ligament continues into the liver as Glisson's capsule.13 The ligament is generally wedge-shaped and contains considerable adipose tissue, through which course the left gas tric artery, coronary vein, and the left gastric nodal chain14 (Fig. 4-4). Identification of the fissure for the ligamentum venosum immediately inferior to the esophagogastric junction determines the CT sections in which the gastrohepatic ligament is readily evident.14

The free edge of the gastrohepatic ligament is known as the hepatoduodenal ligament, extending from the flexure between the first and second portions of the duodenum to the porta hepatis and transporting the portal triad. After the common hepatic artery gives off its gas-troduodenal branch, the proper hepatic artery courses within the hepatoduodenal ligament anterior to the portal vein in most patients. The common bile duct also lies anterior to the portal vein, but is located lateral to the proper hepatic artery15-17 (Figs. 4-5 and 4-6). A fi-brofatty sheath of tissue invaginates the liverparenchyma from the porta hepatis and continues along the course of the portal vein, hepatic artery, and bile duct branches. It is thus evident that this "edge" is in truth a structure

Gastroepatic Ligament

Fig. 4—4. The gastrohepatic, hepatoduodenal, and gastrosplenic ligaments.

(a) The gastrohepatic ligament occupies the wedge-shaped area between the opacified stomach and the liver. The left gastric artery (arrows) as well as the coronary vein and accompanying lymphatics course through it. Posteriorly, the ligament inserts in relationship to the bulbous enlargement of the right diaphragmatic crus. At this level, it continues into the fissure for the ligamentum venosum.

(b) In another patient, multiple calcified lymph nodes (arrows), presumably from previous tuberculous infection of the abdomen, are localized in the hepatoduodenal ligament. Here, the ligament continues into the porta hepatis, also known as the transverse fissure of the liver. The gastrosplenic ligament is designated by the fatty tissue between the greater curvature of the stomach and the medial contour of the spleen. Another calcified nodal group (curved arrows) is seen in the splenorenal ligament.

Fig. 4—4. The gastrohepatic, hepatoduodenal, and gastrosplenic ligaments.

(a) The gastrohepatic ligament occupies the wedge-shaped area between the opacified stomach and the liver. The left gastric artery (arrows) as well as the coronary vein and accompanying lymphatics course through it. Posteriorly, the ligament inserts in relationship to the bulbous enlargement of the right diaphragmatic crus. At this level, it continues into the fissure for the ligamentum venosum.

(b) In another patient, multiple calcified lymph nodes (arrows), presumably from previous tuberculous infection of the abdomen, are localized in the hepatoduodenal ligament. Here, the ligament continues into the porta hepatis, also known as the transverse fissure of the liver. The gastrosplenic ligament is designated by the fatty tissue between the greater curvature of the stomach and the medial contour of the spleen. Another calcified nodal group (curved arrows) is seen in the splenorenal ligament.

Hepatoduodenal Ligament

Fig. 4—6. Contents and relationships of hepatoduodenal ligament shown by laparoscopic ultrasonography.

Longitudinal scan of the hepatoduodenal ligament through the liver shows the course and relationships of the portal vein (P), common bile duct (C), and hepatic artery (H). A lymph node (L) is adjacent to the hepatic artery. Its benign nature is indicated by its longitudinal shape and echogenicity.

(Reproduced from van Delden et al.17)

Fig. 4—5. The hepatoduodenal ligament.

(a) Anatomic cross-section demonstrates the relationships of the portal triad within the hepatod-uodenal ligament at its insertion in the liver. HA = hepatic artery; PV = portal vein; HD = hepatic duct; RLL = right lobe of the liver; LLL = left lobe of the liver; CL = caudate lobe; GHL = gastrohepatic ligament; GB = gallbladder; Ao = aorta; IVC = inferior vena cava.

(b) CT scan. The opacified hepatic artery (arrows) passes anteriorly to the portal vein (PV) as both structures, accompanied by the bile duct, course within the hepatoduodenal ligament. Immediately behind its free edge resides the epiploic foramen of Winslow, deep to which is the inferior vena cava (C). Right renal cysts are incidentally present. Ao = aorta.

(Reproduced from Meyers et al.9)

Fig. 4—6. Contents and relationships of hepatoduodenal ligament shown by laparoscopic ultrasonography.

Longitudinal scan of the hepatoduodenal ligament through the liver shows the course and relationships of the portal vein (P), common bile duct (C), and hepatic artery (H). A lymph node (L) is adjacent to the hepatic artery. Its benign nature is indicated by its longitudinal shape and echogenicity.

(Reproduced from van Delden et al.17)

Perivascular Echogenicity Coronary

of considerable thickness. Immediately behind it is the epiploic foramen of Winslow leading into the lesser sac.

On CT, identification of the sites of the left gastric artery and the hepatic artery permits precise localization of disease spread to the gastrohepatic and hepatoduodenal ligaments, respectively.

An exception to be noted in these relationships is the variant of an aberrant right hepatic artery that passes dorsal to the portal vein and ventral to the inferior vena cava just medial to the hilus of the liver18,19 (Fig. 4-7). This variant is to be distinguished from nodes of the foramen of Winslow, or portacaval space, which have an unusual morphology in that their transverse dimension is greater than their anteroposterior dimension20,21 (Figs. 4-8 and 4-9). Moreover, the medial papillary process of the caudate lobe of the liver, separated by a groove of variable depth from the lateral caudate process, can appear separate from the liver on transverse sections as it protrudes into the portacaval space (Fig. 4-10) and be mistaken for portacaval lymph nodes20-23 (Fig. 4-11).

Although the lymphatics of the gastrohepatic ligament are frequent sites of metastases in cases of carcinoma of the stomach, distal esophagus, pancreas, breast, and lung, they also may give rise to lymphoma. Discrete

Where Are Portacaval Lymph Nodes

Fig. 4—7. Course and relationships of an aberrant right hepatic artery.

(a and b) Contrast-enhanced CT scans in two different cases demonstrate the aberrant right hepatic artery (arrows) passing between the portal vein (PV) and inferior vena cava (C).

Fig. 4—7. Course and relationships of an aberrant right hepatic artery.

(a and b) Contrast-enhanced CT scans in two different cases demonstrate the aberrant right hepatic artery (arrows) passing between the portal vein (PV) and inferior vena cava (C).

Lymph Node Shape

Fig. 4—8. Normal portacaval lymph node.

Contrast-enhanced CT shows a discoid shape of normal-sized node (arrow) between the portal vein (P) and inferior vena cava (V). Some ascites along the course of the foramen of Win-slow is seen immediately anterior to this node in this patient with liver cirrhosis. (Reproduced from Auh and Ha.21)

Portacaval Lymphadenopathy

Fig. 4—9. Portacaval lymphadenopathy secondary to lymphoma.

Contrast-enhanced CT shows rectangular shape of enlarged nodes (arrowheads) in the portacaval space. A crevice (arrow) resulting from fluid collection in the region of the foramen of Winslow may separate a node originating from the hepatoduodenal ligament from that of the paraaortic space. (Reproduced from Auh and Ha.21)

Portacaval Lymph Nodes

Fig. 4—10. Papillary process simulates enlarged portacaval node.

Anatomic cross-section shows the papillary process (curved arrow), separate from the caudate process (straight arrow), protruding into the portacaval space, where it ends with a bulbous contour and mimics an enlarged lymph node. p = portal vein, v = inferior vena cava. (Reproduced from Auh and Ha.21)

Portacaval Space

Fig. 4—11. Papillary process of the caudate lobe.

(a and b) On contiguous CT scans, the papillary process (arrow) appears separate from the liver and presents an appearance mimicking lymph nodes.

Fig. 4—11. Papillary process of the caudate lobe.

(a and b) On contiguous CT scans, the papillary process (arrow) appears separate from the liver and presents an appearance mimicking lymph nodes.

nodal enlargement may be identifiable or there may be gross mass involvement expanding the area, separating the stomach and liver, and resulting in organ distortion (Figs. 4-12 and 4-13).

The upper portion of the stomach and the left lobe of the liver bear an intimate relationship connected by the gastrohepatic ligament, the areolar tissue of which is continuous with that constituting Glisson's capsule and its intrahepatic perivascular extensions. This brief pathway permits invasion of the left hepatic lobe by carci noma of the fundus and pars media of the stomach. The CT findings in such cases include loss of the fat plane and consequent lack of a definite boundary between the two organs25 (Figs. 4-14 through 4-16). In MR imaging, the extent of hepatic invasion is apparent during the early phase27 (Fig. 4-17).

Rarely, intraperitoneal involvement of the gastrohe-patic ligament can be mimicked by anterior extension of a retroperitoneal process, most commonly pancreatic carcinoma.28

Hepatoduodenal Ligament PictureGastrohepatic Ligament

Fig. 4—13. Nodal mass within the gastrohepatic ligament.

Lymphomatous mass (M) occupies the wedge-shaped site of the gastrohepatic ligament, mildly separating the stomach and the liver.

Fig. 4-12. Nodal metastases within the gastrohepatic ligament.

Extensive spread of tumor to nodes (N) in the gastrohepatic ligament from a carcinoma of the gastric antrum. There is also tumor in the porta hepatis (arrow) transmitted by the hepatoduodenal ligament and ascites (A). (Reproduced from Gore and Meyers.24)

Fig. 4—13. Nodal mass within the gastrohepatic ligament.

Lymphomatous mass (M) occupies the wedge-shaped site of the gastrohepatic ligament, mildly separating the stomach and the liver.

Hepatoduodenal Ligament

Fig. 4—14. Anatomic cross-section demonstrates the intimate relationship of the stomach (St) and the left lobe of the liver (LL).

The upper portion of the gastrohepatic ligament extends from the lesser curvature of the stomach to the fissure for the ligamentum venosum. Its areolar tissue is continuous with Glisson's capsule.

Fig. 4—14. Anatomic cross-section demonstrates the intimate relationship of the stomach (St) and the left lobe of the liver (LL).

The upper portion of the gastrohepatic ligament extends from the lesser curvature of the stomach to the fissure for the ligamentum venosum. Its areolar tissue is continuous with Glisson's capsule.

Fig. 4—16. Direct extension of gastric carcinoma to liver.

In a patient with diffusely infiltrating carcinoma of the stomach (St), CT demonstrates the tumor mass (M) invades the gastrohepatic ligament, penetrates the fissure for the ligamentum venosum, and invades the left hepatic lobe (arrowheads) and the caudate lobe (arrows). (Reproduced from Arenas et al.26)

Ligamentum Venosum

Fig. 4—15. Hepatic invasion across the gastrohepatic ligament.

CT in a patient with an infiltrating polypoid carcinoma of the stomach (St), shown as a soft-tissue mass (m) projecting into its lumen, demonstrates direct invasion of the overlying left lobe of the liver (LL). (Reproduced from Meyers et al.9)

Pic Maglient Gastrohepatic Mass

Fig. 4—17. Hepatic invasion by advanced gastric carcinoma.

Early-phase of dynamic MR imaging demonstrates marked enhancement of invasion of the liver (arrow) across the gastrohepatic ligament by a cancer of the stomach.

(Reproduced from Oi et al.27)

The hepatoduodenal ligament, when thickened, may be seen directly on CT coursing from its intraperitoneal relationships to its extraperitoneal insertion (Fig. 4-18). The portal structures pass into the retroperitoneum through the hepatoduodenal ligament. Lymphadenop-athy is readily identifiable by CT15,29-33 (Fig. 4-19) and by ultrasonography31,34-36 (Fig. 4-20). Malignant invasions may be further indicated by the demonstration of prominent collateral vessels (Figs. 4-20 and 4-21). Lymphatic drainage from the gallbladder is initially to cystic and common bile duct nodes, then into the pancreati-

coduodenal system with later potential spread into the rest of the celiac axis or aortic nodes.37-40

Essentials of Human Physiology

Essentials of Human Physiology

This ebook provides an introductory explanation of the workings of the human body, with an effort to draw connections between the body systems and explain their interdependencies. A framework for the book is homeostasis and how the body maintains balance within each system. This is intended as a first introduction to physiology for a college-level course.

Get My Free Ebook


Responses

  • sayid iggi
    How to draw cross section of hepatoduodenal ligament?
    5 years ago
  • Hannele Harila
    What are symptoms of gastrohepatic ligament?
    3 years ago
  • gioacchina lucchesi
    What does enlarged prominent lymph hepatogastic ligament mean?
    1 year ago
  • hunter bruce
    What is heptoduodenal ligament?
    12 months ago
  • Martti
    What is soft tissue gastrohepatic?
    9 months ago
  • jonas mueller
    What causes gastrohepatic ligament inflammation?
    8 months ago
  • Rose Boffin
    What is porta hepatis hepatoduodenal lymphadenopathy?
    11 days ago

Post a comment