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Relevant hepatobiliary anatomy 159
Figure 10.11 Right hemihepatectomy. On the cut surface, the middle hepatic vein is exposed completely. The cut stumps of (a) vein
for ventral segment V (V5v); (b) vein for ventral segment VIII (V8v); (c) anterior fissure vein (AFV); (d) right hepatic vein (RHV);
(e) inferior RHV; (f) right hepatic artery (g) right portal vein; (h) right bile duct.
Figure 10.12 Left hemihepatectomy. On the cut surface, the middle hepatic vein is exposed completely. (a) vein for inferior segment IV
(V4a); (b) anterior fissure vein (AFV); the cut stumps of (c) vein for superior segment IV (V4b); (d) left hepatic vein; (e) vein for segment I.
160 Chapter 10
insertion. The MHV and LHV form a common trunk at the
caval insertion.
10.4 Anatomy for hepatic
segmentectomy
10.4.1 Hepatic segments
Couinaud’s segment receives the portal pedicle (P) containing branches of the portal vein, hepatic artery, and
bile duct and is defined by the hepatic veins or portal
fissures (Figure 10.13).
• Segment VIII is located at the cranial and ventral territory
between the MHV and RHV and has two branches, P8v
and P8d (75%), or three branches, P8v, P8d, and P8l
(20%). P8d is the first branch from the anterior portal
pedicle. A hepatic venous branch runs between P8v
and P8d. P8d occasionally supplies the right side of
segment I (Figure 10.14).
• Segment VII is located at the cranial side of the RHV and
has usually one thick branch (P7d). In patients with
several branches from the posterior portal trunk, the
border between segment VII and segment VI is unclear.
A superficial branch into the RHV is usually present.
• Segment VI is located at the caudal side of the RHV and
has 1–3 branches of P6v. The presence of the inferior
RHV is noted.
• Segment V is located at the caudal and dorsal territories
between MHV and RHV and has two branches, P5v and
P5d (60%), or three or more branches (40%). In the
latter case, counterstaining of P8d is useful to totally
identify segment V [35].
Figure 10.13 Segmental anatomy. Three-dimensional images showing the territory (green) of corresponding segment on virtual
clipping of the portal pedicle (P) with the hepatic vein (V). (a) Segment VIII: 1, P8v, 2, P8d, 3, P8l, 4, V8v, 5, V8d; (b) Segment VII:
1, P7d, 2, 3, V7; (c) Segment VI: 1, P6v, 2, V6; (d) Segment V: 1, P5v, 2, P5d, 3, V5v; (e) Segment IV: 1, P4 s, 2, P4i, 3, V4a;
(f) Segment III: 1, P3, 2, V3; (g) Segment II: 1, P2, 2, V2; (h) Segment I.
Relevant hepatobiliary anatomy 161
Figure 10.13 (Continued)
• Segment IV is located between the umbilical fissure and
the MHV. P4 commonly arises from the right top of the
umbilical portion and bifurcates superiorly (P4a) and
inferiorly (P4b). The umbilical fissure vein runs in this
segment when it drains into the MHV.
• Segment III is located at the left ventral side of the LHV.
The right margin corresponds to the umbilical fissure.
P3 branches at the left cranial top of the umbilical
portion.
• Segment II is located at the left dorsal side of the LHV. P2
branches next to P1 (Spiegel’s lobe) and is recognized at
the most proximal side of the umbilical portion. A
superficial branch into the RHV is usually present.
10.4.2 Intraoperative ultrasonography
The us e of intraoperative ultrasonography (IUS) in
routine practice includes the identification of intrahepatic vascul ar anatomy, the detection of tumors [36],
and US-guided diagnostic and the rapeutic procedures
(see also Chapter 15) [21]. During hepa tic resection,
the transection line can be visuali zed through air artifacts on US as a glittering line. The relation between the
transection and target vessels or tumors can be visualized by occasional identification of these air artifacts on
US, thereby facilitating accurate resection of the liver.
Ultrasound is of critical importance for advanced op en
and laparoscopic liver surgery, since the smallest surgical unit of the liver is Couinaud’s seg ment. However,
these segments cannot be accurately delineated in situ
because of the lack of landmarks on the hepatic surface
unless US is used.
In 1985, the concept of systematic segmentectomy
(Makuuchi’s procedure) was realized through the introduction of IUS to liver surgery, enabling segmental borders to be visualized by US-guided staining [3,21]. The
main branch of the portal vein is visualized by ultrasound,
162 Chapter 10
Figure 10.14 Segment VIII resection. The landmark vessels defining segment VIII are exposed, i.e. the middle hepatic vein (MHV),
right hepatic vein (RHV), and inferior vena cava (IVC). The cut stumps of (a) vein for ventr al segment VIII (V8v); (b) anterior fissure
vein (AFV) (c) vein for segment VII (V7); (d) vein for dorsal segment VIII (V8d); (e) portal pedicle for segment VIII ventral area
(P8v); (f) portal pedicle for segment VIII dorsal area (P8d); (g) portal pedicle for segment I.
and ultrasound-guided puncture of the relevant portal
pedicle using a 23 gauge needle is performed. The tip of
the needle is confirmed in the root of the portal vein using
IUS, and blue dye (5 mL of indigo carmine) is injected. The
liver transection can be performed along the borders of
the stained area.
• first defined the caudate lobe (classified as segment I) in
the 1950s as only the left dorsal part of the liver
(corresponding to Spiegel’s lobe);
• redefineditin1989asthe“do rsa l liver,” inc luding a
territory dorsal to the three hepatic veins, with
division into two subsegments (segment I right
and left);
• designated “segment I right” as segment IX in 1994;
10.5 Anatomy for caudate lobe
resection
• expanded segment IX to the periphery of the IVC and
subdivided it into d and b in 1998; and
• finally renamed segments d and b as segments IXR and
Confusion has surrounded the anatomy of the caudate
lobe because Couinaud’ sdefinition changed over the
years [37]. Couinaud
IXL respectively in 2000; and
• ultimately abandoned the concept of segment IX in
2002.
Relevant hepatobiliary anatomy 163
Figure 10.15 Caudate lobe division. Surgically, the caudate lobe is divided into Spiegel’s portion (red area), the process portion
(yellow area), and the caval portion (green area). IVC, inferior vena cava; LHV, left hepatic vein; MHV, middle hepatic vein;
PV, portal vein; RHV, right hepatic vein.
Such rapid changes in nomenclature made it extremely
difficult for the surgical community to maintain consistency in the definition of the caudate lobe.
For the purpose of clarity, we define the caudate lobe as
an independent hepatic segment which is located at the
centro-dorsal territory of the liver, at the left side of
segment VII, and under part of segments II, III, IV, V,
and VIII, like a fan (see Figure 10.13 h). In accordance
with Kumon’s classification [38], the caudate lobe is
surgically classified into three portions with defined landmarks (Figure 10.15) [4,11,41]:
• Spiegel’s portion (left protruding area from Arantius’
ligament)
• process portion (protruding area caudal to the right
portal pedicle)
• caval portion (paracaval area just below the RHV and
MHV).
The caudate lobe feeds the portal vein branches fanning
out in the posterior direction from the portal confluence
and the left and right portal veins, respectively. The
caudate lobe has 1–6 portal vein branches (Figure
10.16) [39]. The hepatic venous system consists of the
caudate lobe proper hepatic vein, the caudate processus
hepatic vein, and multiple accessory small hepatic
veins [40]. These caudate lobe hepatic veins drain directly
into the IVC and act effectively as a bypass of the hepatic
veins in patients presenting with Budd–Chiari syndrome.
The proper hepatic vein of the caudate lobe is a good
landmark, indicating the border between Spiegel’s portion and the caval portion. The external notch, usually
observed at the caudal edge of the caudate lobe, is also a
good landmark of this border (Figure 10.17).
Anatomical re section of the caudate lobe harboring a
tumor is challenging because of its dorsal location and
close attachment to the hepatic hilum, hepatic veins,
and IVC. A tumor in Spiegel’s portion or a process
portion can be removed by a limited resectio n. In
contrast, tumors located in the caval portion of the
164 Chapter 10
Figure 10.16 Caudate lobe vessels. (a–d), portal vein branches to the caudate lobe; Ant, anterior PV; CPHV, caudate processus
hepatic vein; LHV, left hepatic vein; MHV, middle hepatic vein; PrHVCL, proper hepatic vein of caudate lobe; PV, portal vein;
RHV, right hepatic vein. Asterisk, accessory hepatic vein of caudate lobe. Numbers refer to Couinaud’s segments.
liver (Couinaud’s segment IX) can be resected in combination with an adjacent segment or hemi-liver in
patients with adequate hepatic function. Such wider
anatomical resection provides op timal exposure of the
operative field and improves access to the tumor, facilitating resection [41]. Isolated total caudate lobe resection as des cribed by Takayama (“ high dorsal resection”)
(Figure 10.18) is a procedure of choice in se lected
patients with moderate cirrhosis [4,42]. After the procedure, landmarks such as the IVC and the posterior
surfaces of the RHV and MHV are e xposed on the raw
surface.
Figure 10.17 Proper hepatic vein. The
caudate lobe is split according to the line
indicated by the external notch (arrow).
The proper hepatic vein of the caudate
lobe (PrHVCL) is a landmark dividing the
caudate lobe into portions. AFH, appendix
fibrosa hepatis; CBD, common bile duct;
LHV, left hepatic vein; MHV, middle
hepatic vein; PCP, paracaval portion;
PVCL, portal vein branch of the caudate
lobe; RHV, right hepatic vein; SPL,
Spiegel’s lobe; Numbers refer to
Couinaud’s segments.
Relevant hepatobiliary anatomy 165
Figure 10.18 High dorsal resection. After isolated total caudate lobectomy (Takayama’s procedure), the landmark vessels are
exposed on the cut surface and include the right hepatic vein (RHV), middle hepatic vein (MHV), left hepatic vein (LHV), right
posterior portal pedicle (RPPP) and inferior vena cava (IVC). Reproduced with permission from Modorikawa and Takayama [42].
10.6 Important points
vascular anatomy and to recognize hepatic boundaries
intraoperatively [43–46].
To accomplish anatomical resection of the liver, it is
important to acquire a thorough knowledge of the
From a surgical point of view, there are notable landmarks that are visible from the hepatic surface, including
166 Chapter 10
Table 10.1 Surgical landmarks in anatomical liver resection
Resection Landmarks How to identify the unknown border
Right hemi-liver MHV, IVC Rex–Cantlie’s line by right P ligation
Left hemi-liver MHV, IVC Rex–Cantlie’s line by left P ligation
Segment VIII MHV, RHV, IVC Caudal border by P8 staining
Segment VII RHV, IVC Caudal border by P7 staining
Segment VI RHV Cranial border by P6 staining
Segment V MHV, RHV Cranial border by P5 staining
Segment IV UP, falciform ligament, MHV, IVC Right border by P4 ligation
Segment III UP, LHV Upper border by P3 ligation
Segment II LHV, IVC Lower border by P2 ligation
Segment I RHV, MHV, Arantius’ ligament, IVC Right border by P6 and P7 counterstaining
IVC, inferior vena cava; LHV, left hepatic vein; MHV, middle hepatic vein; P, portal pedicle; RHV, right hepatic vein; UP, umbilical portion of the
left portal vein.
the umbilical portion of the left portal vein, Rouviere’s
sulcus, Arantius’ ligament, the falciform ligament, and
the IVC. Intrahepatic structures, such as the hepatic veins
and portal pedicles, which comprise the borders of Couinaud’s segments, are critical landmarks for anatomical
resection. For example, total exposure of the cranial
portions of the MHV and RHV as well as the cranial
portion of the IVC on the transected plane guarantees
that segment VIII can be accurately resected.
resection (Table 10.1). The MHV is a remarkable landmark during parenchymal transection when resecting
the right or left hemi-liver and segment VIII, V, IV, or I.
The IVC is a target for transection when resecting the
right or left hemi-liver and segment VIII, VII, IV, II, or I.
Boundaries of the hemi-liver and segments IV, III, and II
can be identified by extrahepatic ligation of the relevant
portal pedicle(s), and the staining or counterstaining
technique is the procedure of choice to define the
territory of segments VIII, VII, VI, V, and I.
For successful liver surgery, a full understanding of the
10.7 Conclusion
hemihepatic or segmental anatomy of the liver and biliary
system is a clinical priority.
This chapter has summarized the essential surgical
landmarks that can be used in anatomical liver
KEY POINTS
• Clear understanding of hepatobiliary anatomy, stemming from Couinaud’s classification of the segmental liver anatomy, allows
for safer liver resection and is the basis for advanced laparoscopic liver resection.
• The major hepatic veins represent important landmarks and are crucial elements to be understood in order to perform
anatomical liver resection and partial liver transplantation.
• Because bile ducts and portal veins can be confusing, 3D CT reconstruction images at the confluence of the posterior bile duct or
left segmental duct before surgery may be helpful in avoiding injury at the level of the hilus.
• Intraoperative ultrasonography is of critical importance in advanced open and laparoscopic liver surgery. Through identification
of intrahepatic vascular anatomy and its relation between transection and target vessels, ultrasound accurately facilitates
advanced liver resections.
Relevant hepatobiliary anatomy 167
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Videos 1–19 will be of interest to readers of this chapter.
Visit the companion website at:
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