Merseyside laparoscopic cholecystectomy course, Royal Liverpool Academy.

1. LIVER AND BILIARY TRACTANATOMY:
FUNDAMENTALS FOR GALLBLADDER SURGEON
Raimundas Lunevicius
Consultant Surgeon & Honorary Senior Lecturer
Emergency, Trauma, Biliary, Hernia Surgery
Aintree University Hospital NHS Foundation Trust, Liverpool, England
13th July 2018
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2. Classical names of 5 ligaments in Latin
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Lig. teres hepatis
Lig. falciforme hepatis
Lig. coronarium hepatis
Lig triangulare dextrum
Lig. triangulare
sinistrum
Rex–Cantlie plain (line)
or
Midplane of the liver

3. Longest imaginary line / plain
Rex – Cantlie line
Rex - Cantlie plain
Midplain of the liver
through
Main portal fissure
by both Couinaud’s and
Healey & Schroy nomenclatures
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4. Segmental anatomy of visceral surface of the liver
(from available website: errors?)
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5. Know the terminology to describe an individual bile
duct when it is needed
It is based on most common classifications of the
anatomical units of the liver:
• Couinaud’s (1952) liver anatomy system
• Healey & Schroy’s (1953) liver anatomy system
• Brisbane system (2000) for classification and
nomenclature
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6. Couinaud’s
classification and nomenclature
• Livers: 2 (not lobes)
• Sectors: 5 (not segments)
• Segments: VIII (not subsegments)
• Subsegments: not specified as a subsegment is a piece of
the liver less than segment
• Planes: 3
• The main portal fissure
• The right portal fissure
• The left portal fissure (not ‘the umbilical fissure’)
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7. Healey & Schroy
classification and nomenclature
• Lobes: 2
• Segments: 4
• Subsegments: 8
• The planes: 3
• The main portal fissure
• The right portal fissure
• The umbilical fissure (not ‘the left portal fissure’)
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8. Brisbane
• Hemilivers: 2 (not lobes, not livers):
• First-order division bile ducts: RHD and LHD
• Sections: 4 (not segments, not sectors)
• Second-order division bile ducts:
• Anterior bile duct (not sectorial, not segmental)
• Posterior bile duct
• Medial bile duct
• Lateral bile duct
• Segments: 9 (not subsegments)
• Third-order division bile ducts (B1 ducts, B2, B3..)
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9. Nomenclature for first-order division
anatomy (hemilivers) and resections
thewatershedisthemidplaneoftheliver(Rex-Cantlie‘line’)
Anatomic term Couinaud
segments
Term for resection Diagram
Right hemiliver
OR
Right liver
Sg 5–8 (± Sg1) Right hepatectomy OR
Right hemihepatectomy
(± Sg1)
Resection 5–8
Left hemiliver
OR
Left liver
Sg 2–4 (± Sg1) Left hepatectomy OR
Left hemihepatectomy
(± Sg1)
Resection 2–4
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10. Nomenclature for second-order division
anatomy (sections) and resections
the watersheds: right and left (umbilical fissure – attachment of the falciform ligament) intersectional planes
Anatomic term Couinaud
segments
Term for resection Diagram
Right anterior
section
Sg 5,8 Right anterior
sectionectomy
Right posterior
section
Sg 6,7 Right posterior
sectionectomy
Left medial section Sg 4 Left medial
sectionectomy
OR
Resection segment 4
OR
Segmentectomy 4
Left lateral section Sg 2,3 Left lateral sectionectomy
OR
Segmentectomy 2,3
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11. Emphasis on
Main bile duct
(CHD + CBD)
2nd-order
division bile
duct anatomy
Divisions of
gallbladder:
Gn (includes Hp)
Gb
Gf
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12. Subsegmental, ie 4th order-division, bile ducts:
17 subsegments or more as 4D and 8D have been later described (S1 excluded)
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13. Illustration of the running course of Right Posterior Bile Duct:
two patterns and five (A – E) types
Biliary anatomy: sectional ducts: 4 (ref from Japan)
More
common
Less
common
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14. Biliary anatomy: Rouviere’s sulcus
4 types: Opened, closed, split, scar
What bile duct/artery/vein (portal triad) are there?
Singh, Prasad. J Minim Access Surg,
2017;13:89-95
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15. What bile duct/artery/vein is in the bottom of
Rouviere’s sulcus?
S6A triad
4rd order-division portal triad
Rarely: protruding (extrahepatic) from open Rouviere’s sulcus
not RHD (not right hepatic duct)
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16. Subsegmental, ie 4th order-division, bile ducts:
17 subsegments or more as 4D and 8D have been later described (S1 excluded)
6A
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17. Subvesical bile duct (Lushka): 4%
The mean diameter 2mm (range 1 – 18mm)
DEFINITION: bile duct which traverses in close contact with GB’s fossa (within cystic plate)
CATEGORIES:
Type 1: segmental/sectional:
common
Type 2: accessory: most
common (SUBSEGMENTAL)
Type 3: hepaticocholecystic:
very rare
Type 4: aberrant, ie within
cystic plate, no connection with
gallbladder: rare Schnelldorfer, J Gastroint Surg 2012
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18. Subvesical bile duct (Lushka): 4%
The mean diameter 2mm
• What to do?
• Clip it if bile leaks
• More harm, if you would decide to insert T tube
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19. Cystic duct anatomy
• Identical CDs do not exist
• Evaluate every image before to LC
• Ex: tubogram after OPEN sub-total cholecystectomy
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20. Cystic duct (tubogram)
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21. Cystic duct
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22. Cystic duct
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23. Cystic duct:
Calculus in CBD & Calculi in LONG CD; ERCP on 28th Sep 2012
(No. 26)
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24. Cystic duct: anteroductal (more likely) or
postero(retro-)ductal
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25. Unlikely biliary anatomy but possible (online image)
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Thank you