This contain detail description of liver anatomy, both physiological and surgical anatomy.

1. SEGEMENTAL ANATOMY
OF LIVER
PRESENTED BY DR. BIKASH CH. SAH
SURGERY RESIDENT
DEPARTMENT OF SURGERY

3. HISTORICAL PERSPECTIVE
• The surface anatomy of the liver was described as early as
2000BC by the ancient Babylonians.
• Even Hippocrates understood and described the
seriousness of liver injury.
• In 1654, Francis Glisson was the first physician to describe
the essential anatomy of the blood vessels of the liver
accurately.
• Hogarth Pringle in 1908, described digital compression of
the hilar vessels to control hepatic bleeding from traumatic
injuries.

4. LIVER
• Liver is the largest gland in human body after skin
• It weighs 1.2-1.5 kg
• It comprises of 2.5% of the total body weight
• In a mature fetus it may even serve as an Hematopoietic
organ

5. LOCATION OF LIVER
• Liver lies mainly in right upper quadrant of abdomen under
cover of 7-11 ribs on right side occupying predominantly
right Hypochondrium and Epigastrium

6. SUPPORTS OF LIVER
• Primary Supports:
◦ IVC
◦ Hepatic Veins
◦ Coronary and triangular
ligaments
• Secondary Support:
◦ Right kidney
◦ Right colonic angle
◦ Duodenopancreatic complex
• Tertiary supports: attachment of
liver to the anterior abdominal wall and diaphragm by falciform
ligament.

7. ANATOMIC FEATURES
• Surfaces
◦ Diaphragmatic/antero superior
◦ Visceral/postero inferior
• Lobes :
• Major lobes
Right
Left
• Accessory lobes
Caudate
Quadrate

8. SURFACES OF LIVER

9. RECESSES OF LIVER
• Diaphragmatic surfaces of liver are the sub phrenic and
hepato-renal recesses.
• Sub phrenic recess separates the diaphragmatic surface of
the liver from the diaphragm, Right and Left areas are
divided by the falciform ligament.

10. • Hepatorenal recess is a part of the peritoneal cavity
on the right side between the liver and right kidney and right
suprarenal gland

11. BARE AREA OF LIVER
• Presents on the diaphragmatic surface of liver
and is directly in
contact with the
undersurface of
diaphragm devoid
of peritoneum.

12. LIGAMENTS OF LIVER
• Falciform ligament
• Anterior coronary ligament
• Posterior coronary ligament
• Round ligament
• Ligamentum venosum
• Lessser omentum has 2 parts:
Hepatogastric ligament
Hepatoduodenal ligament

13. Falciform ligament

17. HEPATOGASTRIC LIGAMENT
• Extends from Porta
Hepatis to lesser
curvature of
Stomach

18. HEPATODUODENAL LIGAMENT
• Extends from Porta
Hepatis to superior
part of duodenum
and contains
common bile duct,
proper hepatica and
hepatic portal vein.

19. PORTA HEPATIS
• Porta hepatis serves as the point of entry into the liver for the hepatic arteries
and the portal vein, and the exit point for the hepatic ducts
• Mickey Mouse View: The ultrasound image of hepatic artery, bile duct and portal vein
is in a configuration, referred as
Mickey Mouse View

20. Mickey Mouse View

21. HEPATIC ARTERY

22. HEPATIC VEINS
Basis for modern lobar and segmental anatomy.
◦Used as dividers
Portal Veins feed centrally
◦ Used to name segments
MHV divide the liver into right and left lobe.
RHV divide the right lobe into anterior and posterior
segments.
LHV divide the left lobe into
medial and lateral segment.

23. Caudate Lobe
• Caudate lobe (segment I), lies between the left portal vein
and the IVC and extends to the hepatic venous confluence
Caudate lobe is unique
• It receives blood supply from both the right and left portal
pedicles
• Bile drain into both right and left hepatic duct
•

25. MAJOR LOBES OF LIVER
Liver is composed
of two anatomical
lobes namely Right
and Left

26. Lobes of Liver

27. FUNCTIONAL DIVISION OF LIVER
• Current understanding of the functional anatomy of the
liver is based on Couinaud’s division of the liver into eight
(subsequently nine) functional segments, based upon the
distribution of portal venous branches and the location of
the hepatic veins in the parenchyma (Couinaud 1957).
• Segment IX is a recent subdivision of segment I, and
describes that part of the segment that lies posterior to
segment VIII

28. • The liver is divided into four portal sectors by the four main
branches of the portal vein. These are right lateral, right
medial, left medial and left lateral (sometimes the term
posterior is used in place of lateral and anterior in place of
medial).
• The three main hepatic veins lie between these sectors as
intersectorial veins. These intersectoral planes are also
called portal fissures (scissures). The fissures containing
portal pedicles are called hepatic fissures.
• Each sector is sub-divided into segments (usually two)
based on their supply by tertiary divisions of the vascular
biliary sheaths.

29. Schematic Depiction of the Segemental Anatomy

30. Fissures of the Liver
Major
• Main portal fissure
• Left portal fissure
• Right portal fissure
Minor
• Umbilical fissure
• Venous fissure
• Fissure of Gans

31. • Main portal fissure
• Extends from the tip of the GB back to the midpoint of IVC and contains the middle
(main) hepatic vein.
• Separates liver into right and left hemi-livers.
Segments V and VIII lie to the right and segment IV to the left of the fissure.

32. Left portal fissure
• Divides left hemi-liver into medial (anterior) and lateral (posterior) Sectors
• Extends from the mid point of the anterior edge of the liver between
falciform ligament and left triangular ligament to the point, which marks the
confluence of the left and middle hepatic veins.
• Contains left hepatic vein
• Separates the left anterior and left posterior sectors: segment III lies
anteriorly and segment II posteriorly

33. Right portal fissure
Divides right hemi-liver into lateral (posterior) and medial (anterior) sectors.
• Plane of right fissure is the most variable amongst the main fissures
• The fissure divides right anterior sector to its left (segments V and VIII) from
right posterior sector to its right (segments VI andVII) Contains right hepatic
vein
• Right fissure marks the thickest point of liver parenchyma, which is
commonly transected during liver resection.

34. • Umbilical fissure
Umbilical fissure separates segment III from segment VI within left anterior
sector and contains a main branch of left hepatic vein
(umbilical fissure vein).
• It is marked by attachment of falciform ligament and sometimes covered by
a ridge of liver tissue extending between the segments: it is often avascular and
can be divided safely with diathermy during a surgical approach.
• It contains umbilical portion of left portal vein and the final divisions of left
hepatic duct and left hepatic artery branches.

35. Venous fissure
Venous fissure is a continuation of umbilical fissure on under
surface of liver
• Contains ligamentum venosum
• It lies between caudate lobe and segment IV.
• The deeper continuation of this plane is the dorsal fissure.

36. Fissure of Gans
Fissure of Gans lies on undersurface of right lobe of liver
behind GB fossa.
• Contains portal pedicle to right posterior sector

37. FUNCTIONAL DIVISION OF LIVER

38. Sectors and segments of the liver:
• The sectors of the liver are made up of between one and three segments:
• right lateral sector = segments VI and VII; right medial sector= segments V
and VIII; left medial sector = segments III and IV (and part of I); left lateral
sector = segment II.
• Segments are numbered in an ante-clockwise spiral centered on the portal
vein with the liver viewed from beneath, starting with segment I up to
segment VI, and then back clockwise for the most cranial two segments VII
and VIII.

39. CANTLIE’S LINE
• Grossly divides liver into left and right lobe using a plane
from gall bladder fossa to IVC
• The MHV lies in the
Cantlie’s Line

40. Segmental Anatomy (Couinaud
System)
• Caudate Lobe
Segment I
• Left Lobe
Segments II – IV
• Right Lobe
Segments V-VIII

41. Couinaud’s Classification of Liver
Segments
Branching of the portal vein and the
hepatic veins defines these segmentsQ

43. Segmental anatomy of the liver
• True morphological and physiological division by a line
extend from fossa of GB to fossa of I.V.C each has its own
arterial blood supply, venous drainage and biliary drainage
• No anastomosis between divisions
• 3 major hepatic veins Rt, Lt & central
• 8 segments based on hepatic and portal venous segments

47. Source: HPB 2000; 2(3):333-39
Terminology Committee of the International Hepato-Pancreato-
Biliary Association

51. Credit for the first anatomic liver resection is usually given to Lortat-Jacob, who
performed a right hepatectomy in 1952 in France
Operative mortality rates in excess of 20% were common and usually related to
massive hemorrhage.
Many surgeons were reluctant to perform hepatic surgery because of these
results, and understandably, many physicians were reluctant to refer patients for
hepatectomy.
With the courage of patients and their families as well as the persistence of
surgeons, safe hepatic surgery has now been realized.

52. Advances in anesthesia, intensive care, antibiotics, and
interventional radiologic techniques have also contributed
tremendously to safety of major hepatic surgery.
Total hepatectomy with liver transplantation and live donor
partial hepatectomy for transplantation are now performed
routinely in specialized transplantation centers.
Partial hepatectomy for large number of indications is now
performed throughout the world in specialized centers, with
mortality rates of 5% or less.
Partial hepatectomy on normal livers is now consistently
performed, with mortality rates of 1% to 2%.

53. The role of robotics in liver surgery is rapidly evolving.
Thermal ablative techniques to treat hepatic tumors, including
radiofrequency and microwave ablation, have exploded in popularity.
Finally, techniques to improve the safety of liver resection further, such as
portal vein embolization to induce preoperative hypertrophy of the
future liverremnant (FLR), have been developed and are now being used.

54. THANK YOU