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9.4 The Prevailing Anatomical Structures Are theStructures Commonly Seen inanIndividual. TheLess Commonly Seen Patterns…
Fig. 9.8 Using
arterioarteries
anastomosis or a carrel
patch before
reconstruction. (a, b) The
two carrel patches are
sutured together to form
one opening to
anastomose with the
recipient superior
mesenteric artery or
sutured as in (c, d). The
alternative method is
shown in (e, f) the
divided hepatic artery is
anastomosed to the
splenic artery is
anastomosed to the
stump of the spleen
artery, or to the
gastroduodenal artery
d
c
87
f
e
88
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Fig. 9.9 Extrahepatic
anomalies of the biliary
system
9 Anatomy Relevant toLiver Transplantation
Fig. 9.10 Piggyback liver transplantation
the donor to support his health and his life. Thus, liver transection needs to be carried out not only precisely along the
pre-planned plane so as to avoid leaving behind necrotic liver
tissues, but also to leave behind enough lengths of the hepatic
arterial, portal venous, hepatic venous and biliary structures
for reconstruction (Fig.9.11).
9.5 Intrahepatic Structures: Prevailing
Pattern andAnomalies
It is also important to know the important intrahepatic vascular
and biliary structures in the prevailing pattern and in the common anomalies to avoid getting into problems after liver
transection.
In the use of a right hemiliver as a donor organ for living
donor liver transplantation, it is still controversial as to whether
the whole, part or no part of the middle hepatic vein should be
kept in the donor’s or the recipient’s part of the liver. Those
who advocate keeping the middle hepatic vein for the donor
argue that segment 4 of the remnant liver of the donor will not
RHV
sacrificing middle hepatic vein
9.5 Intrahepatic Structures: Prevailing Pattern andAnomalies
89
a
Fig. 9.11 Liver transection in liver transplantation. (a) Operative photograph; (b) Diagrammatic representation
MHV
LHV
b
become congested. However, the recipient may receive a liver
with congested segments 5 and 8. The solution is to connect a
vein graft to drain into the inferior vena cava to relieve the
congestion. A compromise is to transect the middle hepatic
vein as shown in Fig.9.12 to preserve the segment 4 branch of
the middle hepatic vein which drains the liver segment 4.
Sg 8 br
9.5.1 Intrahepatic Anomalies oftheHepatic
Sg 4 br
Venous System
Sg 5 br
b
a
transection line of right hepatectomy
preserving middle hepatic vein
transection line of right hepatectomy
Fig. 9.12 Preserving part of the middle hepatic vein to preserve drainage of segment 4 through the segment 4 branch
In some patients with anomalies of the intrahepatic venous
branches (57.4% of individuals have segment 4 vein anomaly,
and 60% of individuals have umbilical vein anomaly), the middle hepatic vein can be kept in the donated part of the right liver
without causing congestion of segment 4in the donor because
these anomalous veins drain the liver segment 4 (Fig.9.13).
Another important anomaly is the right inferior hepatic
vein. This vein can be seen on CT scans in 10% of individuals because it is large. Transection of a large right inferior
hepatic vein can lead to congestion of segment 6in the donor
liver. The solution is to do a vascular drainage into the inferior vena cava using a vascular graft if the congested area in
segment 6 is large (Fig.9.14).
90
a
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9 Anatomy Relevant toLiver Transplantation
Middle hepatic vein
Accessory right
hepatic vein
Right
hepatic
vein
Segment 8 branch
c
Segment 4 vein
7
8
5
Segment 4 branch
Segment 5 branch
Umbilical vein
Left hepatic vein
2
Segment 2
3
4
Segment 3 branch
branch
b
Fig. 9.13 (a) Diagrammatic representation; (b) Anomalous segment 4 vein; (c) Anomalous segment 4 vein and umbilical vein
9.5.2 Intrahepatic Anomalies ofthePortal
Venous System
9.5.3 The Prevailing andCommon Anomalies
oftheIntrahepatic Biliary System
(Fig. 9.19)
The prevailing and the common anomalies of the intrahepatic portal venous system are shown in Fig.9.15.
For trifurcation of the portal venous system, it is important not to transect the portal vein too near to the trifurcation,
or a stricture will develop after operation (Fig.9.16).
For the anomaly with the anterior sectoral portal venous
branch draining into the left portal vein (Fig. 9.17) or the
other less commonly seen anomalies (Fig.9.18), they are not
suitable for living donor liver transplant.
For the trifurcation type, transection of the intrahepatic duct
should not be carried out too close to the trifurcation, or a
stricture will develop after operation (Fig.9.20). The anomaly with the right posterior sectoral duct draining into the left
hepatic duct is not suitable for living donor liver transplantation (Fig.9.21).
A
9.5 Intrahepatic Structures: Prevailing Pattern andAnomalies
91
a b
RIHV
RHV
MHV
LHV
c
Fig. 9.14 Large right inferior hepatic vein (RIHV). (a) Diagrammatic representation; (b) Radiological feature; (c) Operation ndings. RIHV right
inferior hepatic vein. RHV right hepatic vein. MHV middle hepatic vein, LHV left hepatic vein
A
A
P
P
P
Fig. 9.15 Prevailing and common anomalies of the intrahepatic portal vein
92
a
VI
VII
ab
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9 Anatomy Relevant toLiver Transplantation
IV
III
b
VI
V
up
VIII
hp
I
II
PV
VII
Fig. 9.16 Trifurcation of portal vein. PV portal vein, hp transverse portion of portal vein, up umbilical portion of portal vein. I, II, III, IV, V, VI,
VII, VIII portal vein branches to live segments 1, 2, 3, 4, 5, 6, 7, 8. (a) Diagrammatic representation; (b) Radiological feature
a
V
IV
b
III
VIII
up
hp
II
I
PV
Fig. 9.17 Anterior sectoral portal vein branch into left portal vein. (a) Diagrammatic representation; (b) Radiological feature
LPV
PV
Fig. 9.18 Other less commonly seen anomalies. (a) Single right portal
vein supplying whole liver. (b) Single left portal vein supplying whole
liver
9.5 Intrahepatic Structures: Prevailing Pattern andAnomalies
93
A
P
A
P
A
P
Bc
A
Fig. 9.19 Prevailing and common anomalies of the intrahepatic biliary system
A
A
Bc
P
A
P
Bc
P
P
Fig. 9.20 Trifurcation of intrahepatic ducts
94
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9 Anatomy Relevant toLiver Transplantation
a
Fig. 9.21 The anomaly with the right posterior sectoral duct draining into the left duct and is not suitable for living donor liver transplantation.
(a) A small right posterior sectoral duct; (b) Anomalous right posterior sectoral duct
9.6 Conclusion
b
Further Reading
Extra- and intrahepatic anomalies can affect the results of
liver transplantation. It is important to identify these anomalies before and during liver transplantation. Threedimensional reconstruction of vessels and bile ducts helps to
understand the important extra- and intrahepatic anatomical
structure better.
Blumgart LH, Hann LE.Chapter 1: Surgical and radiologic anatomy of
the liver and biliary tract. In: Blumgart LH, Fong Y, editors. Surgery
of the liver and biliary tract, vol. 1. 3rd ed. London: W.B.Saunders;
2000. p.3–33.
Fan ST. Living donor living transplantation. Hong Kong, China:
Takungpao Publishing Co., Ltd.; 2007.
Jamieson G, Launois B. Chapter 2: Liver resections and liver trans-
plantation: the anatomy of the liver and associated structures. In:
Jamieson GG, editor. The anatomy of general surgical operation.
2nd ed. Edinburgh: Elsevier Churchill Livingstone; 2006. p.8–23.
Defining theCouinaud’s Liver Segments
Clinically
10
Couinaud divided the liver into two hemilivers, four sectors
and eight segments (or nine segments). Each segment is an
individual unit with its own arterial and portal venous supply,
and biliary and hepatic venous drainage. Each segment can
be resected individually or in combination with adjacent
segment(s) (see Chaps. 2 and 3).
10.1 Surgical Exposure oftheLiver
Adequate exposure of the liver during surgery requires the
use of a good incision. Commonly used incisions are shown
in Fig.10.1. For patients who are thin, a right subcostal incision with midline extension is adequate. A right thoracoabdominal incision is seldom required, even with a big tumour
with diaphragmatic involvement. The bilateral subcostal
incision with midline extension can have the midline incision extended to split the sternum in operations for patients
with hepatocellular carcinoma with tumour thrombus
extended up the inferior vena cava into the right atrium.
The modern retractor retracts the rib cages in an upward,
outward and forward direction, thus fully exposing the dia-
phragmatic and superior surfaces of the liver. Access to the
suprahepatic inferior vena cava is not a problem with the use
of modern incisions and retractors (Fig.10.2).
10.2 Preoperative Imaging toDene
theCouinaud’s Segments
Preoperative ultrasound denes the inferior vena cava and
the right, middle and left hepatic veins with ease. The middle
hepatic vein (MHV) divides the liver into the right and left
hemilivers. On the right side, the right hepatic vein (RHV)
divides the right hemiliver into the right anterior sector (segments 5, 8) and the right posterior sector (segments 6, 7)
(Fig.10.3).
The main portal vein (MPV) can be seen easily. By tracing the right portal vein branches, the right anterior portal
vein (RAPV) can be traced which divides into the segment 5
and 8 branches with segment 8 being superior, and segment
5 inferior. Similarly, the right posterior portal vein (RPPV)
divides into the branch to segment 7 superiorly and the
branch to segment 6 inferiorly (Fig.10.4).
Fig. 10.1 Common incisions for liver surgery
© Springer Nature Singapore Pte Ltd. and People’s Medical Publishing House Co. Ltd. 2021
W. Y. Lau, Applied Anatomy in Liver Resection and Liver Transplantation, https://doi.org/10.1007/978-981-16-0800-1_10
95
96
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10 Dening theCouinaud’s Liver Segments Clinically
RAPV
LPV
RPPV
MPV
IVC
Fig. 10.4 Ultrasound showing the Main Portal Vein and its Right
Sectoral Branches. IVC inferior vena cava, MPV main portal vein, LPV
left portal vein, RAPV right anterior portal vein, RPPV right posterior
portal vein
Fig. 10.2 Adequate exposure of liver with a retractor
LHV
MHV
IVC
RHV
Fig. 10.3 Ultrasound showing inferior vena cava and the hepatic
veins. IVC inferior vena cava, LHV left hepatic vein, MHV middle
hepatic vein, RHV right hepatic vein
In the left hemiliver, the left hepatic vein (LHV) divides
the left hemiliver into the left lateral sector (segment 2) and
left medial sector (segments 3 and 4) (Fig.10.3).
The left portal vein (LPV) can be traced from its transverse portion (T) to the umbilical portion (U). Branches
then come off from the umbilical portion to supply segment
4 on the right side and segments 3 and 2 on the left side
(Fig.10.5).
4
U
T
P
CL
IVC
Fig. 10.5 Ultrasound showing left portal vein and its branches. CL
Caudate Lobe, IVC inferior vena cava, P portal vein, T transverse portion of portal vein, U umbilical portion of portal vein, 2,3,4 portal vein
branches to live segments 2, 3, 4
3
2
The caudate lobe (CL) can be seen on the transverse section to be surrounding the inferior vena cava (IVC)
(Fig.10.6). The lesser omentum (LV) can be seen as a white
hyperechoic line in front of the caudate lobe (CL). A vein
draining the caudate lobe (white arrows) directly into the
inferior vena cava can be seen in Fig.10.7.
Thus, the three hepatic veins divide the liver into four sectors and the portal vein branches dene the seven segments
(2–8). The caudate lobe can be dened easily on ultrasound
to be around the inferior vena cava.
Similarly, on preoperative computed tomography or
magnetic resonance imaging, the middle hepatic vein
divides the liver into the right and left hemilivers, and the
right and the left hepatic veins divide the liver into four sectors. The portal vein denes segments 2–8, and the caudate
can be identied because of its size and shape (Figs.10.8,
10.9 and 10.10).
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