liver segmental anatomy...펌

Correspondence between anatomic lobes and Couinaud segments

Segment*	Couinaud segments
Caudate	1
Lateral	2, 3
Medial	4a, 4b
Right	5, 6, 7, 8
* or lobe in the case of the caudate lobe. Each number in the list corresponds to one in the table. Caudate Superior subsegment of the lateral segment Inferior subsegment of the lateral segment Superior subsegment of the medial segment Inferior subsegment of the medial segment Inferior subsegment of the anterior segment Inferior subsegment of the posterior segment Superior subsegment of the posterior segment Superior subsegment of the anterior segment

 

Liver: Segmental Anatomy

by Robin Smithuis

Radiology Department of the Rijnland Hospital, Leiderdorp, the Netherlands

Segmental anatomy Couinaud classification Segments numbering Transverse anatomy Caudate lobe Other Classifications and Variants Classical Anatomy Bismuth's classification Variations	back to overview    print Publicationdate: 7-5-2006 Liver anatomy can be described using two different aspects: morphological anatomy and functional anatomy. The traditional morphological anatomy is based on the external appearance of the liver and does not show the internal features of vessels and biliary ducts branching, which are of obvious importance in hepatic surgery. C. Couinaud (1957) divided the liver into eight functionally indepedent segments. This classification will be presented here with several illustrations.
	Segmental anatomy
Segmental anatomy according to Couinaud	Couinaud classification The Couinaud classification of liver anatomy divides the liver into eight functionally indepedent segments. Each segment has its own vascular inflow, outflow and biliary drainage. In the centre of each segment there is a branch of the portal vein, hepatic artery and bile duct. In the periphery of each segment there is vascular outflow through the hepatic veins. Right hepatic vein divides the right lobe into anterior and posterior segments. Middle hepatic vein divides the liver into right and left lobes (or right and left hemiliver). This plane runs from the inferior vena cava to the gallbladder fossa. Left hepatic vein divides the left lobe into a medial and lateral part. Portal vein divides the liver into upper and lower segments. The left and right portal veins branch superiorly and inferiorly to project into the center of each segment. Because of this division into self-contained units, each segment can be resected without damaging those remaining. For the liver to remain viable, resections must proceed along the vessels that define the peripheries of these segments. This means, that resection-lines parallel the hepatic veins, The centrally located portal veins, bile ducts, and hepatic arteries are preserved.
Clockwise numbering of the segments	Segments numbering There are eight liver segments. Segment 4 is sometimes divided into segment 4a and 4b according to Bismuth. The numbering of the segments is in a clockwise manner (figure). Segment 1 (caudate lobe) is located posteriorly. It is not visible on a frontal view.
On a frontal view of the liver the posteriorly located segments 6 and 7 are not visible.	The illustrations above are schematic presentations of the liversegments. In reality however the proportions are different. On a normal frontal view the segments 6 and 7 are not visible because they are located more posteriorly. The right border of the liver is formed by segment 5 and 8. Although segment 4 is part of the left hemiliver, it is situated more to the right. Couinaud divided the liver into a functional left and right liver (in French 'gauche et droite foie') by a main portal scissurae containing the middle hepatic vein. This is known as Cantlie's line. Cantlie's line runs from the middle of the gallbladder fossa anteriorly to the inferior vena cava posteriorly. On this illustration it looks as if the medial part of the left lobe is separated from the lateral part by the falciform ligament. However it actually is the left hepatic vein, that separates the medial part (segment 4) from the lateral part (segments 2 and 3). The left hepatic vein is located slightly to the left of the falciform ligament.
LEFT: above the level of the left portal vein. RIGHT: at the level of the left portal vein	Transverse anatomy The far left figure is a transverse image through the superior liver segments, that are divided by the hepatic veins. The right figure shows a transverse image at the level of the left portal vein. At this level the left portal vein divides the left lobe of the liver into the superior segments (2 and 4A) and the inferior segments (3 and 4B). The left portal vein is at a higher level than the right portal vein.
LEFT: at the level of the right portal vein. RIGHT: at the level of the splenic vein.	The image on the far left is at the level of the right portal vein. At this level the right portal vein divides the right lobe of the liver into superior segments (7 and 8) and the inferior segments (5 and 6). The level of the right portal vein is inferior to the level of the left portal vein. At the level of the splenic vein, which is below the level of the right portal vein, only the inferior segments are seen (right image).
Hypertrophy of caudate lobe in a patient with livercirrhosis. Notice the small lobulated right hemiliver.	Caudate lobe The caudate lobe or segment 1 is located posteriorly. The caudate lobe is anatomically different from other lobes in that it often has direct connections to the IVC through hepatic veins, that are separate from the main hepatic veins. The caudate lobe may be supplied by both right and left branches of the portal vein. On the left a patient with cirrhosis with extreme atrophy of the right lobe, normal volume of the left lobe and hypertrophy of the caudate lobe. Due to a different blood supply the caudate lobe is spared from the disease process and hypertrophied to compensate for the loss of normal liverparenchyma.
	Other Classifications and Variants
	There are many other anatomical and functional descriptions of the liver anatomy. In the classical description the external appearance of the liver is used to describe the anatomy. However there are many differences between this classical model and the fuctional models, as popularized by Couinaud and Bismuth. A more detailed discussion of the various models is given in reference 4.
	Classical Anatomy The classical description of the liver anatomy is based on the external appearance. On the diaphragmatic surface, the ligamentum falciforme divides the liver into the right and left anatomic lobes, which are very different from the functional right and left lobes (or right and left hemiliver). In this classical description, the quadrate lobe belongs to the right lobe of the liver, but functionally it is part of left lobe.
	Bismuth's classification This classification is very similar to the Couinaud classification, although there are small differences. It is popular in the United States, while Couinaud's classification is more popular in Asia and Europe. According to Bismuth three hepatic veins divide the liver into four sectors, further divided into segments. These sectors are termed portal sectors as each is supplied by a portal pedicle in the centre. The separation line between sectors contain a hepatic vein. The hepatic veins and portal pedicels are intertwined, as are the fingers of two hands. The left portal scissura divides the left liver into two sectors: anterior and posterior. Left anterior sector consists of two segments: segment IV, which is the quadrate lobe and segment III, which is anterior part of anatomical left lobe. These two segments are separated by the left hepatic fissure or umbilical fissure. Left posterior sector consists of only one segment II. It is the posterior part of left lobe.
	Variations In the Couinaud classification little attention is given to the high prevalence of anatomical variations which occur, especially in the right hemiliver. Using volumetric acquisition techniques, such as magnetic resonance imaging or spiral computed tomography scanning, detailed insight into the individual segmental anatomy can now be obtained in a non-invasive manner (2,3). The significance of this anatomical insight lies in the planning of anatomical resections, whereby the relationship between tumour and individual segmental anatomy can be depicted in a three-dimensional format. Three dimensional liver imaging is of most practical value if a resection of one or more segments or sectors is considered, especially in the right hemiliver. In these cases, 3D liver imaging can demonstrate the precise location of the scissuras to the surgeon pre-operatively.

References

1. Traditional Surgical Viewpoint of Liver Anatomy and Definition of the Couinaud Segments
   3-D tutorials of the Division of Physiologic Imaging, Dept. of Radiology, Univ. of Iowa
2. Portal venous and segmental anatomy of the right hemiliver: observations based on three-dimensional spiral CT renderings
   MS van Leeuwen, J Noordzij, MA Fernandez, A Hennipman, MA Feldberg and EH Dillon
   Department of Radiology, University Hospital Utrecht, The Netherlands
3. Planning of liver surgery using three dimensional imaging techniques.
   van Leeuwen MS, Noordzij J, Hennipman A, Feldberg MA.
   Department of Radiology and Surgery, University Hospital Utrecht, The Netherlands.
4. Clinical and anatomical basis for the classification of the structural parts of liver
   Saulius Rutkauskas et al.
   Clinic of Radiology, Institute of Anatomy, Clinic of Surgery, Kaunas University of Medicine, Lithuania