Dr Amit Dangi, profile picture
Uploaded byDr Amit Dangi
PPT, PDF3,854 views

Surgical liver anatomy

The liver has significant anatomic variability. It develops from the foregut and is divided into lobes based on vascular and biliary anatomy. The caudate lobe is located posteriorly between the IVC and other lobes. It has complex vascular and biliary drainage patterns. The liver is commonly divided into segments based on Couinaud's or Brisbane's classifications to describe resection types. The caudate lobe specifically can be further divided into the Spiegel lobe, caudate process, and paracaval portion.

Embed presentation

Downloaded 120 times
SURGICAL ANATOMY OF LIVER MODERATOR : Dr PRADEEP JOSHI
Anatomic variability is the rule rather than the exception in liver surgery • Embryology • Peritoneal attachments • Classifications • Caudate lobe • Bile duct anatomy • Hepatic artery anatomy • Hepatic venous anatomy • Portal vein anatomy • Plate system
Embryology • Biliary system and liver originate from the embryonic foregut as a diverticulum at four weeks • Liver diverticulum initially separates into a caudal and cranial portion. The caudal portion gives rise to the cystic duct and gallbladder and the cranial portion gives rise to the intrahepatic and hilar bile ducts. • The cranial endodermal diverticulum extends into the septum transversum mesenchyme promoting formation of endothelium and blood cells. The extrahepatic biliary system is initially occluded with epithelial cells but later it canalizes as cells degenerate
Segmental anatomy • 8 functionally indepedent segments with its own vascular inflow, outflow and biliary drainage • Middle hepatic vein divides the liver into right and left hemiliver. This plane runs from the inferior vena cava to the gallbladder fossa. • Right hepatic vein divides the right lobe into anterior and posterior segments. • Left hepatic vein divides the left lobe into a medial and lateral part. • Portal vein divides the liver into upper and lower segments
Cantlie’s line • 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
Peritoneal attachments of Liver • Include falciform ligament, the left triangular ligament , and the coronary ligament with the right triangular ligament •There are no right and left coronary ligaments, only the left triangular and the complex of coronary and rt triangular ligaments • They represent the remnants of liver’s development in the septum transversum •Falciform ligament carries the obliterated left umbilical vein & the round ligament. The coronary ligament carries the hepatic veins and the retroperitoneal IVC . The left triangular ligament may also contain large blood vessels •Falciform ligament – main blood supply arises from left inferior phrenic and middle hepatic arteries. Veins converge into 2 branches and ultimately drain in to left inferior phrenic vein 7
Peritoneal attachments of Liver •Liver is suspended mostly by the fibrous attachments in the bare area and by the attachment of the hepatic veins to the IVC •Double layer of parietal peritoneum – continues to form falciform ligament sagitally– surrounds all except bare area •left layer of falciform lig forms the ant layer of left triangular lig •Coronary lig has sup and inf layers rather than anterior and posterior layers which are united laterally at angular extensions forming the left and right triangular ligaments. On the right the two layers are widely separated and they are named coronary ligaments. 8
Bismuth's classification • 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 3 hepatic veins divide the liver into 4 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 pedicles are intertwined. • 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.
• Traditionally referred to as segment 1, the caudate lobe has been divided into 2 segments: 1 and 9. • Segment 1 refers to the Spiegel lobe, and segment 9 refers to the paracaval portion and caudate process • Reidel lobe refers to a ‘‘tongue-like projection of the anterior border of the right lobe of the liver to the right of the gallbladder’’ below the costal margin. It is not a true anatomic lobe, but is a normal variant of segments 5 and 6
Brisbane 2000 • Liver anatomy is described in first-, second-and third-order divisions. • The third order divisions, or segments (Sg), are referred to by Arabic numerals, not Roman numerals.
Brisbane - I order • First-order division divides the liver into the left and right hemiliver, or left and right liver. The term lobe is not used because the division between the right and left hemiliver is not an externally apparent structure. • The border, also referred to as a watershed, of the first-order division is referred to as the midplane of the liver ( plane between the IVCand the gallbladder fossa) • Cantlie line is a misnomer, because the division between the hemilivers is a three dimensional space, and therefore technically a plane. • The caudate lobe, also referred to as segment 1 is not included in the first-order division. • The terminology for surgical resection at the first-order division is right or left hepatectomy or hemihepatectomy. To correctly classify the resection, whether or not segment 1 was included in the resection must be stipulated
I order division
Brisbane - II order • Second-order division divides the liver into 4 sections based on the biliary and hepatic artery anatomy. • The right liver is divided into the right anterior section (Sg 5,8) and the right posterior section (Sg 6,7). • The left liver is divided into the left medial section (Sg 4) and the left lateral section (Sg 2,3). The terminology for resection is obtained by adding -ectomy to the anatomic term (ie, left lateral sectionectomy)
II order division
Addendum for alternate second order division • Based on portal vein anatomy rather than biliary and arterial anatomy. • Uses the term sector rather than section. • The right lobe is divided as in the addendum system, but given different names; segments 5 and 8 are referred to as the right anterior sector or the right paramedian sector, and segments 6 and 7 are referred to as the right posterior sector or right lateral sector. • Segments 3 and 4 are referred to as the left medial sector or the left paramedian sector and segment 2 is referred to as the left lateral sector or the left posterior sector.
Brisbane – III order • Third-order division refers to the individual segments of the liver. The segments are referred to as segment 1 to segment 9. • Resection of a single segment is referred to as a segmentectomy and resection of any 2 contiguous segments is referred to as a bisegmentectomy
III order
• Resection of segments 4 to 8 ( Sg 1) is referred to as a right trisectionectomy (preferred term) or extended right hepatectomy or extended right hemihepatectomy. • Resection of segments 2 to 5 and 8 ( Sg 1) is referred to as a left trisectionectomy (preferred term) or extended left hepatectomy or extended left hemihepatectomy.
Problems with Brisbane • Does not address the nomenclature of resections that do not encompass a complete segment, sometimes referred to as wedge resections or partial segmentectomies. • Does not define gray zones between resections; that is, is a right hepatectomy that includes only a portion of segment 4 classified as a right hepatectomy or a right trisectionectomy?
Caudate Lobe:Anatomic Location • Space below hilum • Proximity to confluences • Anterior to IVC • From the level of HV as they enter IVC • Inferior edge of liver
Caudate Lobe
Caudate • Caudate lobe itself can be divided into right, left, and caudate process. • Caudate lobe proper is located between the inferior vena cava and the umbilical fissure • Caudate process connects the caudate lobe to the right hepatic lobe • In 44%, 3 separate ducts drain each part. In 26% of cases, the caudate process duct and the duct from the right portion of the caudate form a common duct. • In most cases, the caudate process duct drains into the RHD (85%) and the left part of the caudate lobe drains into the LHD (93%).
• The caudate lobe receives portal blood flow from both the left and, to a lesser extent, the right portal systems • Venous drainage occurs along its posterior aspect directly into the IVC through multiple small branches of variable size and location. • Biliary drainage includes small tributaries to the right, but is predominantly through the left hepatic duct. • Isolated resection of segment 1 is technically demanding because of its anatomical position posterior to the liver, between the hepatic hilum and the inferior caval vein, in close proximity to the middle and left hepatic vein • Selective caudate segmentectomy can be done via an anterior transhepatic approach or high dorsal resection
Anatomic Subclassification • Papillary process or Spiegel lobe proper – Protuberant portion to the left of IVC – Seen through the hepatogastric ligament, • Caudate Process – Portion to the right of IVC – Right border blends into the right hemiliver • Paracaval portion – Intimate contact with IVC – Connects the Spiegel lobe to the caudate process
Anatomic subclassification
Segment IX ? Couinaud 1994 used the term seg IX for an area on the dorsal sector of the liver (caudate lobe) close to the IVC (paracaval portion) The anatomy of the paracaval portion is the liver parenchyma ventral to the hepatic IVC, between the Spiegel lobe and the right lobe, adjacent to the middle hepatic vein ventrally. This portion was classified by Couinaud as segment IX •However in 2002 Couinaud and co-workers abandoned the concept of seg IX as according to them no separate arteries, veins or ducts can be identified for the right paracaval portion of the posterior liver and because pedicles cross the proposed division between the right and left caudate lobe 28
ANATOMY OF BILE DUCT BRANCHES IN THE HILAR AREA Junction of anterior seg duct and post seg duct to form the RHD which in turn joins the LHD at the hilar confluence 53-72% Post seg duct joining the LHD 9-27% Ant seg duct joins the hilar conf forming 3 br type hilar conf 7-14% Ant seg duct joins the LHD 6-9% 29
CONFLUENCE VARIANTS Smadja C, Blumgart
Anomalies of IHBR
• The classic biliary anatomy appears in about 58% of the population and consists of the right hepatic duct and left hepatic duct draining the right and left lobes of the liver, respectively (Fig 6). • The right duct branches into the right posterior hepatic duct, draining posterior segments VI and VII, and the right anterior hepatic duct, draining anterior segments V and VIII. • The right posterior duct, which has a horizontal course, usually runs posterior to the right anterior duct, which is more vertically oriented, and fuses with it from a medial approach to constitute a short right hepatic duct. • Segmental tributaries draining segments II–IV form the left hepatic duct. • The fusion of the right and left hepatic ducts gives rise to the common hepatic duct. The caudate lobe usually drains to the origin of the left hepatic duct, or to the right hepatic duct. • The cystic duct usually drains into the lateral aspect of the common hepatic duct below its origin
RHD • Right posterior sectoral duct is generally oriented in a horizontal direction as opposed to the right anterior sectoral duct, which runs in a vertical direction. • The posterior sectoral duct is typically more superior and longer than the anterior duct. • In most cases, the anterior sectoral duct drains segments 8 and 5; however, in 20% of cases, segment 8 joins the right posterior sectoral duct
LHD • Compared with the RHD, less anatomic variation of the LHD. • Significant variation in bile ducts draining the left medial section • Usually the sectoral branches from the lateral and medial sections join each other within the umbilical fissure to form the LHD. • Orientation of the LHD and left portal vein are typically horizontal at the hilum before entering the umbilical recess where they lie in a more vertical direction. The LHD courses horizontally at the base of segment 4 superior to the left portal vein. It then joins the RHD anterior to the portal vein bifurcation to form the CHD
Confluence pattern of RHD
RHD • Supraportal pattern – Right posterior sectional bile duct ran dorsally and cranially to the right or the right anterior portal vein and joined with the distal bile duct at its cranial side • Infraportal pattern – Right posterior sectional bile duct ran ventrally and caudally to the right or the right anterior portal vein and drained into the distal bile duct at its caudal side • Combined pattern – Some parts of the right posterior sectional bile duct entered the distal bile duct supraportally and the remaining parts of the right posterior sectional bile duct joined with the distal bile duct infraportally.
Supraportal pattern • Type A – Right posterior sectional bile duct joined with the right anterior sectional bile duct, forming the right hepatic duct • Type B – Right posterior sectional bile duct entered the confluence of the right anterior sectional bile duct and the left hepatic duct • Type C – Right posterior sectional bile duct drained into the left hepatic duct
Infraportal pattern • Type D – Right posterior sectional bile duct joined with the right anterior sectional bile duct, forming the right hepatic duct • Type E – Right posterior sectional bile duct entered the common hepatic duct
Combined pattern • Type F – A portion of the right posterior sectional bile duct joined with the right anterior sectional bile duct infraportally, becoming the right hepatic duct, and the remaining parts of the right posterior sectional bile duct entered the right hepatic duct supraportally • Type G – portion of the right posterior sectional bile duct joined with the common hepatic duct infraportally and the remaining parts entered the left hepatic duct supraportally
Summary - RHD
Confluence Patterns of the LHD • Type H – Left medial sectional bile duct drained into the left lateral sectional bile duct • Type I – Left medial sectional bile duct entered the confluence of the left lateral anterior and posterior segmental bile ducts • Type J – Left medial sectional bile duct joined with the left lateral anterior segmental bile duct • Type K – Left medial sectional bile duct entered the hepatic confluence
LHD
Clinical implication – Ductal anatomy • Right hepatic duct was absent in 26%. • When harvesting a donor without a right hepatic duct, two or more orifices of the bile ducts will be present in plane of transection of the graft. Biliary reconstruction of these variants is complicated and technically difficult. It is essential that both stumps must be reconstructed when they are present • Particular care must be taken in harvesting the left liver from a donor with a type C or G variant. As the right posterior sectional bile duct will be divided from the left hepatic duct in these cases, oversight or ligation of the stump of the right posterior sectional bile duct will lead to biliary leakage or obstruction in the donor.
Surgical Anatomy of the Left Lateral Segment as Applied to Living-Donor and Split-Liver Transplantation Four specific patterns of left biliary anatomy: •segment 2 and 3 bile ducts unite close to the umbilical fissure to form a single LLS duct that receives a single segment 4 duct medially (55%) • segment 2 and 3 bile ducts unite medial to the umbilical fissure with two parallel segment 4 ducts joining the single LLS duct to form the left hepatic duct (30%) • segment 3 duct that receives the duct from segment 4 and joins segment 2 close to the hepatic hilum (10%) • and segments 2 and 3 ducts unite lateral to the umbilical fissure to form a short LLS duct that immediately receives the segment 4 duct forming the left hepatic duct (5%) 44
Summary • In LDLT, the biliary anatomy of the donor usually is evaluated using intraoperative cholangiography • The surgeon must make a snap decision as to the biliary anatomy and its relationship to the line of transection. • When the right posterior sectional bile duct drains into the left hepatic duct, it runs supraportally; and when the right posterior sectional bile duct enters the common hepatic duct, it runs infraportally. • Familiarity with the variations of the hepatic confluence, especially types B, C, E, G, J’, and K, will decrease the likelihood of surgical misadventure. Masayuki Ohkubo,Masato Nagino,Junichi Kamiya, Surgical Anatomy of the Bile Ducts at the Hepatic Hilum as Applied to Living Donor Liver Transplantation. Ann Surg 2004;239: 82–86
Vascular anatomy
CBD arterial supply • Two major axial vessels along the lateral borders of the supraduodenal CBD – 3 o’clock and 9 o’clock arteries • 8 small arteries with a diameter of 0.3 mm supplying the supraduodenal CBD. These arteries arise from-  Below – 60%  posterior or anterior superior pancreaticoduodenal artery  gastroduodenal artery  retroportal artery  Above – 38%  right hepatic artery  cystic artery  left hepatic artery  Rarely – 2%  nonaxial supply from the common hepatic artery
• Hilar ducts – Arterial branches from the right and left hepatic arteries; form a rich network around the ducts and are in continuity with the plexus around the CBD • Retropancreatic CBD – multiple small branches from the posterior superior pancreaticoduodenal artery
Surgical implications
Hepatic Venous anatomy
MHV • Hepatic venous outflow of the median sector(corresponding to Couinaud segments 5, 8 and 4) is drained mainly into the middle hepatic vein • As a result, preservation of MHV outflow drainage plays an important role in LDLT with the right lobe. • However, inclusion of the MHV in the right lobe graft and the necessity of MHV tributaries reconstruction are still controversial
Right lobe graft - methods • Two harvesting methods for right lobe grafts have been proposed: an extended right lobe graft, in which the MHV trunk is included in the grafts, and a modified right lobe graft, in which only the MHV tributaries are included. • Leaving the MHV with the remnant liver will place the anterior segment (corresponding to segments 5 and 8) at risk for congestion and this drainage problem can lead to severe graft dysfunction and septic complications. • In such cases, the reconstruction of MHV tributaries have been recommended.
Deciding on MHV • Kyoto group, using the three-dimensional reconstructed images of the hepatic vascular anatomy, divided the right lobe graft morphologically into two types: one is a right hepatic vein dominant graft in which the territory draining into the MHV is less than 40% of the right lobe graft, and the other is a MHV dominant graft. • Their indication for a right lobe graft with or without the MHV is based on dominancy of the hepatic vein, graft-to- recipient weight ratio, and remnant liver volume Kaneko T, Kaneko K, Sugimoto H et al. Intrahepatic anastomosis formation between the hepatic veins in the graft liver of the living related liver transplantation: observation by Doppler ultrasonography. Transplantation 2000;70:982-985.
MHV ? • Sano et al reported that venous congestion in the right liver graft can be assessed by temporary arterial clamping and intraoperative Doppler ultrasonography. They suggested the reconstruction of the hepatic vein or its tributaries if the graft volume excluding the discolored area under arterial clamping was estimated to be insufficient for postoperative metabolic demand (the remaining liver volume was less than 40% of the standard liver volume). • Kubota et al proposed if the congestive area of the liver surface appeared after clamping of MHV tributaries and the hepatic artery is larger than half of the surface of the anterior segment, the vein should be reconstructed.
Preservation of MHV during left hepatectomy The key step is the accurate identification of the intrahepatic origin of the MHV, by IOUS detection of the venous branches originating from segments 4 (4b) and 5 •It’s origin usually lies 2.5 to 3 cm deep into the liver parenchyma. •The parenchymal transection is continued by following the orientation of the main trunk of the MHV up to the IVC, on the left side of the vein securing and cutting only the left branches, which drain subsegments 4a and 4b. 56
Few techniques aiming to preserve the MHV during left hepatectomy Classically, dissection of the parenchyma is performed at about 2 to3 mm to the left of the main portal fissure, dividing the left branches of the MHV, which is kept unseen. The major drawback of this technique is the risk of accidental injury of the MHV. Parenchymal dissection along the MHV under visual control reduces this risk and also allows a better oncological margin whenever needed 57
Vessel diameter • Other institutions concerned mainly about vessel diameter. • Gyu Lee et al indicated that when larger than 5 mm diameter, the reconstruction of MHV drainage from the anterior segment is recommended • Mizuno et al suggested 7 mm as the demarcation for reconstruction of MHV tributaries.
IRHV • Before transplantation, the size of the vein must be determined as well as the distance between the main right hepatic vein (at the confluence of the hepatic vein with the inferior vena cava) and the drainage site of the inferior right hepatic vein into the inferior vena cava. • The size of the accessory inferior right hepatic vein is important because it can affect the surgical approach. If the cross-sectional diameter is greater than 5 mm, the vessel has to be preserved and reanastomosed in the recipient’s inferior vena cava; otherwise, it can result in a congested graft and lead to organ rejection
IRHV • The IRHVs are divided into superior, medial and inferior groups, separately named the superior, medial and inferior right hepatic veins according to the position of the IRHV entering the inferior vena cava. The superior right hepatic vein mainly drains the superior part of segment Ⅶ, and the medial right hepatic vein drains the middle part of segment Ⅶ •The smaller the diameter of the right hepatic vein, the larger the diameter of the IRHV, and vice versa •It is possible to perform anatomical resections removing the entire right hepatic vein but sparing the right postero-inferior area. The postero-inferior area of the right lobe can be preserved along with the hypertrophic IRHV even if the entire major hepatic vein (MHV) is resected •The posteroinferior area of the right lobe can be preserved along with the hypertrophic IRHV even if the entire main right hepatic vein is resected during segmentectomy of Ⅶ and Ⅷ with right hepatic 60
Portal Venous anatomy
Portal vein br in the hilar area Because the portal vein develops during the very earliest part of the gestational period, few variations are found in the portal vein branches, and variations in the anterior segmental branches of the portal vein (P5,P8) are very rare. Three principal portal vein branching patterns found in the hilar area → common type – anterior segmental br joining the posterior seg br to form the RPV 74-84% → the 3 br type in which the anterior seg br joins the PV conf 8-12% → Left br type in which anterior seg br joins the LPV 9- 17% 62
PV VARIANTS
• Failure to recognize PV trifurcation lead to loss of supply to right anterior or right posterior segment. It needs division on right side of trifurcation. • Non division of main portal trunk with absence of separate main left PV is absolute C/I to right lobe LDLT.
Biliary-Vascular Sheaths (PLATE) • Fusion of the Glisson capsule with the connective tissue sheaths surrounding the biliary and vascular elements.
HILAR PLATE • Is bounded above by S4a, on the right by the Rouviere sulcus (a landmark demarcating the division between S6 and S5) and the cystic plate, and on the left it is continuous with the umbilical plate. • The anterior Glisson’s sheath generally runs behind the junction between the cystic plate and the hilar plate, and the posterior-inferior Glisson’s sheath runs behind the Rouviere sulcus.
CYSTIC PLATE • The cystic plate is located in the gallbladder bed and is continuous with the capsule of S5, S4a, and the Glisson’s sheath of the anterior segment of the liver.
UMBILICAL PLATE • The umbilical plate is located along the inferior edge of the ventral surface of the umbilical fissure. • It contains the ducts and blood vessels of S2, S3, and S4, and is continuous with the round ligament inferiorly.
LEFT DUCT EXPOSURE • Its also called HEPP COUINAUD approach.(1st to describe transfissural (intrahepatic) approach through main fissure) • For high biliary stricture in BDI and cholangiocarcinoma. (dense adhesions) • Length of left hepatic duct is reflected by the length of the base of the quadrate lobe. • It may be hazardous in case of atrophy- hypertrophy liver lobes and deep hilus which displaced upwards.
Cont… • This approach is difficult if quadrate lobe is large or carcinoma involving of left duct. • it is ideal for repair of type El to E3 injuries. (confluence is patent) • Resection of segment 4 is very useful when the liver is overhanging the upper ducts, as has recently been advocated by Mercado et al. (type E3)- confluence intact.
LIGAMENTUM TERES APPROACH
LEFT DUCT EXPOSURE
LOWERING HILAR PLATE • Biliary confluence and left hepatic duct exposed by lifting segment IV upward after incision of the Glisson capsule at its base.
• The hilar plate is detached from the liver parenchyma by dissecting in between the left portal pedicle and liver tissue. • The umbilical fissure and plate is the site of origin of segmental and sectoral pedicles to the left liver. Its anatomic landmarks are the falciform ligament and the left longitudinal sulcus. • The sulcus of Rouvière is an irregular fissure in continuity with the right hilum. Following this structure leads to the pedicles of segments V and VI and further deeply and posteriorly to the pedicles of segments VII and VIII.
EXPOSURE OF RIGHT DUCT • Indicated in some cases of hilar cholangiocarcinoma, the planned surgical procedure—partial hepatectomy or segment III duct bypass —seems impossible much more hazardous and imprecise than that of the left.
Hepatectomy: the posterior intrahepatic approach (launious)- RIGHT DUCT • reliant upon early division of the hepatic pedicle extrahepatically. • This allows delineation of the line of resection for hepatectomy and segmentectomy. • approach is through the dorsal fissure between segments IV and I, and segment VIII and the new segment IX described by Couinauds.
• The main hepatic pedicle is clamped en masse and incisions made into the liver capsule in two regions, the first posterior to and the second anterior to the hilus. • anterior incision is made in front of the hilum and through the liver capsule from the gallbladder bed to the umbilical fissure. • An identical incision is made posterior to the hilum, the surgeon’s index finger is insinuated through this incision, and liver tissue is blindly pushed away until the superior surface of the confluence is reached.
EXPOSURE OF ISOLATED RIGHT DUCT IN BDI • Right and left duct are in same coronal plane.(the key to the dissection is to stay in the coronal plane of the left hepatic duct.) • To find the bile duct within the sheath of the right portal pedicle, which also contains the portal vein and hepatic artery, the cystic plate must be detached from the anterior surface of the sheath of the right portal pedicle. • Base of segment 5 must be cored out to expose right portal pedicle.
Thank you..

More Related Content

PPTX
Surgical anatomy of liver
byAshish Tripathi
 
PPT
Surgical Anatomy of the Liver : Ηepatectomies - Dimitris P. Korkolis
byDimitris P. Korkolis
 
PPTX
Basic principle of liver resection
byAnupshrestha27
 
PPTX
Surgical anatomy of Liver, Concept of liver.pptx
byPushpa Lal Bhadel
 
PPTX
Caudate lobe resection by Dr Harsh Shah(www.gastroclinix.com)
byDr Harsh Shah
 
PPTX
Surgical anatomy of liver
byKarthik Krishna
 
PPTX
Hepatectomy
bySana Sali
 
PPTX
Recent advances in liver resections
byDr Harsh Shah
 
Surgical anatomy of liver
byAshish Tripathi
 
Surgical Anatomy of the Liver : Ηepatectomies - Dimitris P. Korkolis
byDimitris P. Korkolis
 
Basic principle of liver resection
byAnupshrestha27
 
Surgical anatomy of Liver, Concept of liver.pptx
byPushpa Lal Bhadel
 
Caudate lobe resection by Dr Harsh Shah(www.gastroclinix.com)
byDr Harsh Shah
 
Surgical anatomy of liver
byKarthik Krishna
 
Hepatectomy
bySana Sali
 
Recent advances in liver resections
byDr Harsh Shah
 

What's hot

PPTX
Segemental anatomy of liver
byBe Akash Sah
 
PDF
Liver segmental anatomy
byHisham Khatib
 
PPTX
Bile duct injury
byRobal Lacoul
 
PPTX
LAP RIGHT HEMICOLECTOMY-STEP BY STEP Operative Surgery.pptx
bySelvaraj Balasubramani
 
PPTX
Ivor lewis esophagectomy
byrajat1906
 
PPT
TEP
byGeorge S. Ferzli
 
PPTX
Management of duodenal trauma
byUday Sankar Reddy
 
PPTX
SAFE LAPAROSCOPIC CHOLECYSTECTOMY
byDrAnandUjjwalSingh
 
PPTX
Hilar Cholangiocarcinoma
byDr Harsh Shah
 
PPTX
Liver and billiary anatomy
bymaroofkhanjabasaria
 
PPT
Surgical rectal anatomy
byBilal Mansoor
 
PPTX
Bile duct injuries
byAnkur Kajal
 
PPT
Internal hernia
byAsif Ansari
 
PPTX
Liver resection indications & methods
byDr Harsh Shah
 
PDF
Lt hemicolectomy - Surgical Approach, Complications.
byVikas V
 
PPTX
ENDOSCOPIC ULTRASOUND
bykims1990
 
PPTX
Rectal Prolapse
byPrashantSharma962
 
PPTX
Traumatic Injuries of Diaphragm
byFatima Hashmi
 
PPTX
MANAGEMENT OF CA COLON
byIsha Jaiswal
 
PPTX
Segmental Anatomy of Liver and its Radiological Correlation
byTarun Goyal
 
Segemental anatomy of liver
byBe Akash Sah
 
Liver segmental anatomy
byHisham Khatib
 
Bile duct injury
byRobal Lacoul
 
LAP RIGHT HEMICOLECTOMY-STEP BY STEP Operative Surgery.pptx
bySelvaraj Balasubramani
 
Ivor lewis esophagectomy
byrajat1906
 
TEP
byGeorge S. Ferzli
 
Management of duodenal trauma
byUday Sankar Reddy
 
SAFE LAPAROSCOPIC CHOLECYSTECTOMY
byDrAnandUjjwalSingh
 
Hilar Cholangiocarcinoma
byDr Harsh Shah
 
Liver and billiary anatomy
bymaroofkhanjabasaria
 
Surgical rectal anatomy
byBilal Mansoor
 
Bile duct injuries
byAnkur Kajal
 
Internal hernia
byAsif Ansari
 
Liver resection indications & methods
byDr Harsh Shah
 
Lt hemicolectomy - Surgical Approach, Complications.
byVikas V
 
ENDOSCOPIC ULTRASOUND
bykims1990
 
Rectal Prolapse
byPrashantSharma962
 
Traumatic Injuries of Diaphragm
byFatima Hashmi
 
MANAGEMENT OF CA COLON
byIsha Jaiswal
 
Segmental Anatomy of Liver and its Radiological Correlation
byTarun Goyal
 

Similar to Surgical liver anatomy

PPTX
DOC-20250923-WA0000..pptx...............
byRaviMeena81892
 
PPTX
surgical anatomy of liver.pptx....... mmm
byRaviMeena81892
 
PPTX
Ajay liver ppt
byajay0722
 
PPTX
1.Antomy and physiology of liver by worku.pptx
byGoldGetnet
 
PPTX
799045419-LIVER-ANATOMY-PPT(1).ppt.pdfthyrtew y que te lo que no te gusta que...
byphilippanduquia
 
PDF
Anatomia hepática normal (2013)
byLeonardo Vincent
 
PPTX
The Normal Liver anatomy and histology.pptx
byDhivyaElango3
 
PPTX
HEPATIC SEGMENTS detailed evaluation HV.pptx
byHarshitchaudhary76
 
PPTX
Anatomical division of liver
byMohsin Khan
 
PPTX
Liver ct anatomy 2.pptx
byVishnuDutt40
 
PPT
Liver, biliary system, pancreas and spleen
byess_online
 
PPTX
Radiological anatomy of hepatobiliary system
byKamalAdhikari13
 
PPTX
Liver ct anatomy(1).pptx
byVishnuDutt40
 
PPTX
LIVER INJURY manahement in low resoueces
byDeogratiasGeorge1
 
PPTX
Liver segments
bymohamed alhashmi
 
PPTX
Liver anatomy
byUdayamoorthy Kasirajan
 
PDF
2.Segemental Anatomy of the liver.pdf
byEyasuKibret
 
PPTX
Anatomy of liver
byPratap Tiwari
 
PPTX
Radiological anatomy of liver segments
byTarun Goyal
 
PPTX
Liver anatomy - history, lobes, segments (by Armata manus)
byDmitriy Shamrai
 
DOC-20250923-WA0000..pptx...............
byRaviMeena81892
 
surgical anatomy of liver.pptx....... mmm
byRaviMeena81892
 
Ajay liver ppt
byajay0722
 
1.Antomy and physiology of liver by worku.pptx
byGoldGetnet
 
799045419-LIVER-ANATOMY-PPT(1).ppt.pdfthyrtew y que te lo que no te gusta que...
byphilippanduquia
 
Anatomia hepática normal (2013)
byLeonardo Vincent
 
The Normal Liver anatomy and histology.pptx
byDhivyaElango3
 
HEPATIC SEGMENTS detailed evaluation HV.pptx
byHarshitchaudhary76
 
Anatomical division of liver
byMohsin Khan
 
Liver ct anatomy 2.pptx
byVishnuDutt40
 
Liver, biliary system, pancreas and spleen
byess_online
 
Radiological anatomy of hepatobiliary system
byKamalAdhikari13
 
Liver ct anatomy(1).pptx
byVishnuDutt40
 
LIVER INJURY manahement in low resoueces
byDeogratiasGeorge1
 
Liver segments
bymohamed alhashmi
 
Liver anatomy
byUdayamoorthy Kasirajan
 
2.Segemental Anatomy of the liver.pdf
byEyasuKibret
 
Anatomy of liver
byPratap Tiwari
 
Radiological anatomy of liver segments
byTarun Goyal
 
Liver anatomy - history, lobes, segments (by Armata manus)
byDmitriy Shamrai
 

More from Dr Amit Dangi

PPTX
Management of Gall Bladder Polyps
byDr Amit Dangi
 
PPTX
Esophagectomy
byDr Amit Dangi
 
PPT
Topic Benign liver tumor
byDr Amit Dangi
 
PPTX
Role of laparoscopic surgery in colorectal cancer
byDr Amit Dangi
 
PPT
D2 distal gastrectomy final
byDr Amit Dangi
 
PPTX
Rectal prolapse: Do we really have a perfect surgical solution? pptx copy
byDr Amit Dangi
 
PPTX
ILEAL POUCH ANAL ANASTOMOSIS
byDr Amit Dangi
 
PPTX
COMPOSITE GRAFT: ANTROPYLORUS TRANSPOSITION AND GLUTEUS MAXIMUS WRAP
byDr Amit Dangi
 
PPTX
PREOPERATIVE DONOR WORKUP FOR LDLT
byDr Amit Dangi
 
PPTX
ACHALASIA CARDIA: ENDOSCOPIC THERAPY (POEM)
byDr Amit Dangi
 
PPTX
Recent Update on Management of Ulcerative Colitis
byDr Amit Dangi
 
PPTX
Esophagectomy : APPROACHES, CONTROVERSIES AND CURRENT EVIDENCE
byDr Amit Dangi
 
PPTX
Metabolic surgery
byDr Amit Dangi
 
PPTX
Timing of repair in Bile Duct Injury
byDr Amit Dangi
 
PPTX
Peritoneal Carcinomatosis : Dr Amit Dangi
byDr Amit Dangi
 
PPTX
Perioperative Care in surgical patients
byDr Amit Dangi
 
PPTX
Biological therapy for Ulcerative colitis
byDr Amit Dangi
 
PPTX
Budd chiari syndrome. ppt
byDr Amit Dangi
 
Management of Gall Bladder Polyps
byDr Amit Dangi
 
Esophagectomy
byDr Amit Dangi
 
Topic Benign liver tumor
byDr Amit Dangi
 
Role of laparoscopic surgery in colorectal cancer
byDr Amit Dangi
 
D2 distal gastrectomy final
byDr Amit Dangi
 
Rectal prolapse: Do we really have a perfect surgical solution? pptx copy
byDr Amit Dangi
 
ILEAL POUCH ANAL ANASTOMOSIS
byDr Amit Dangi
 
COMPOSITE GRAFT: ANTROPYLORUS TRANSPOSITION AND GLUTEUS MAXIMUS WRAP
byDr Amit Dangi
 
PREOPERATIVE DONOR WORKUP FOR LDLT
byDr Amit Dangi
 
ACHALASIA CARDIA: ENDOSCOPIC THERAPY (POEM)
byDr Amit Dangi
 
Recent Update on Management of Ulcerative Colitis
byDr Amit Dangi
 
Esophagectomy : APPROACHES, CONTROVERSIES AND CURRENT EVIDENCE
byDr Amit Dangi
 
Metabolic surgery
byDr Amit Dangi
 
Timing of repair in Bile Duct Injury
byDr Amit Dangi
 
Peritoneal Carcinomatosis : Dr Amit Dangi
byDr Amit Dangi
 
Perioperative Care in surgical patients
byDr Amit Dangi
 
Biological therapy for Ulcerative colitis
byDr Amit Dangi
 
Budd chiari syndrome. ppt
byDr Amit Dangi
 

Recently uploaded

PPTX
Cardio-Respiratory-System-to-Physical-Education.pptx
byedralinkalix
 
PPTX
Diabetic retinopathy- Investigation and Management
byDr. Sambandha Khati
 
PPTX
India’s Top 10 Neurologist. Their Specialities and Expertise
bydavesthrone54
 
PPTX
anatomy and physiology of brain and its parts
byAsian Institute of medical and management science
 
PPTX
BRAIN TUMORS- final.pptx diagnosis, management
bydorcascherop63
 
PDF
Pediatric neurodegenerative disorders and anesthesia considerations. Dalamagk...
bycatlist1
 
PDF
X-Ray in Emergency Trauma Care – By Durjay Laha.pdf ATLS Based Imaging for Ra...
byDurjay Laha
 
PDF
Understanding Olaparib Therapy for Cancer Treatment
byLetsMeds
 
PDF
Scholar.postdoc - Anaesthesia: Dalamagka, Maria
bycatlist1
 
PDF
Abdominal Muscles (Ant. & Post).pdf anatomy
bynehalhelmy2005
 
PPTX
Castration-Sensitive Prostate Cancer.pptx
bySumitKumar452
 
PDF
Autoimmune diseases in children and anesthesia. Dalamagka, Maria
bycatlist1
 
PPTX
Biotransformation and Excretion
byBadrinathSelvakumar
 
PDF
4_5857478915135641976.pdf physiology of menstruation
bykdabhdhkryat94
 
PDF
Top 9 Websites for Purchasing Google Voice Accounts Online.pdf
bymarketing
 
PPTX
PCOS ,PCOS MANAGEMENT, WEIGHT LOSS,INFERTILITY IN PCOS
bymukeshkumar559904
 
PPTX
Back Pain Evaluation: Red Flags, Neurological Examination & Special Tests | S...
byDaradia: The Pain Clinic
 
PPTX
SGLT-2 inhibitors for MD Geriatrics/Internal Medicne.pptx
byRameshKandel5
 
PPTX
COVID -19 or SARS-CoV-2(2019-nCoV) disease
byNandiniM72
 
PPTX
From Planning to Delivery: Precision Workflows That Reduce Errors, Toxicity, ...
bySubrata Roy
 
Cardio-Respiratory-System-to-Physical-Education.pptx
byedralinkalix
 
Diabetic retinopathy- Investigation and Management
byDr. Sambandha Khati
 
India’s Top 10 Neurologist. Their Specialities and Expertise
bydavesthrone54
 
anatomy and physiology of brain and its parts
byAsian Institute of medical and management science
 
BRAIN TUMORS- final.pptx diagnosis, management
bydorcascherop63
 
Pediatric neurodegenerative disorders and anesthesia considerations. Dalamagk...
bycatlist1
 
X-Ray in Emergency Trauma Care – By Durjay Laha.pdf ATLS Based Imaging for Ra...
byDurjay Laha
 
Understanding Olaparib Therapy for Cancer Treatment
byLetsMeds
 
Scholar.postdoc - Anaesthesia: Dalamagka, Maria
bycatlist1
 
Abdominal Muscles (Ant. & Post).pdf anatomy
bynehalhelmy2005
 
Castration-Sensitive Prostate Cancer.pptx
bySumitKumar452
 
Autoimmune diseases in children and anesthesia. Dalamagka, Maria
bycatlist1
 
Biotransformation and Excretion
byBadrinathSelvakumar
 
4_5857478915135641976.pdf physiology of menstruation
bykdabhdhkryat94
 
Top 9 Websites for Purchasing Google Voice Accounts Online.pdf
bymarketing
 
PCOS ,PCOS MANAGEMENT, WEIGHT LOSS,INFERTILITY IN PCOS
bymukeshkumar559904
 
Back Pain Evaluation: Red Flags, Neurological Examination & Special Tests | S...
byDaradia: The Pain Clinic
 
SGLT-2 inhibitors for MD Geriatrics/Internal Medicne.pptx
byRameshKandel5
 
COVID -19 or SARS-CoV-2(2019-nCoV) disease
byNandiniM72
 
From Planning to Delivery: Precision Workflows That Reduce Errors, Toxicity, ...
bySubrata Roy
 

Surgical liver anatomy

  • 1.
    SURGICAL ANATOMY OFLIVER MODERATOR : Dr PRADEEP JOSHI
  • 2.
    Anatomic variability isthe rule rather than the exception in liver surgery • Embryology • Peritoneal attachments • Classifications • Caudate lobe • Bile duct anatomy • Hepatic artery anatomy • Hepatic venous anatomy • Portal vein anatomy • Plate system
  • 3.
    Embryology • Biliary systemand liver originate from the embryonic foregut as a diverticulum at four weeks • Liver diverticulum initially separates into a caudal and cranial portion. The caudal portion gives rise to the cystic duct and gallbladder and the cranial portion gives rise to the intrahepatic and hilar bile ducts. • The cranial endodermal diverticulum extends into the septum transversum mesenchyme promoting formation of endothelium and blood cells. The extrahepatic biliary system is initially occluded with epithelial cells but later it canalizes as cells degenerate
  • 5.
    Segmental anatomy • 8functionally indepedent segments with its own vascular inflow, outflow and biliary drainage • Middle hepatic vein divides the liver into right and left hemiliver. This plane runs from the inferior vena cava to the gallbladder fossa. • Right hepatic vein divides the right lobe into anterior and posterior segments. • Left hepatic vein divides the left lobe into a medial and lateral part. • Portal vein divides the liver into upper and lower segments
  • 6.
    Cantlie’s line • Couinauddivided 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
  • 7.
    Peritoneal attachments ofLiver • Include falciform ligament, the left triangular ligament , and the coronary ligament with the right triangular ligament •There are no right and left coronary ligaments, only the left triangular and the complex of coronary and rt triangular ligaments • They represent the remnants of liver’s development in the septum transversum •Falciform ligament carries the obliterated left umbilical vein & the round ligament. The coronary ligament carries the hepatic veins and the retroperitoneal IVC . The left triangular ligament may also contain large blood vessels •Falciform ligament – main blood supply arises from left inferior phrenic and middle hepatic arteries. Veins converge into 2 branches and ultimately drain in to left inferior phrenic vein 7
  • 8.
    Peritoneal attachments of Liver •Liveris suspended mostly by the fibrous attachments in the bare area and by the attachment of the hepatic veins to the IVC •Double layer of parietal peritoneum – continues to form falciform ligament sagitally– surrounds all except bare area •left layer of falciform lig forms the ant layer of left triangular lig •Coronary lig has sup and inf layers rather than anterior and posterior layers which are united laterally at angular extensions forming the left and right triangular ligaments. On the right the two layers are widely separated and they are named coronary ligaments. 8
  • 9.
    Bismuth's classification • Similarto 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 3 hepatic veins divide the liver into 4 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 pedicles are intertwined. • 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.
  • 11.
    • Traditionally referredto as segment 1, the caudate lobe has been divided into 2 segments: 1 and 9. • Segment 1 refers to the Spiegel lobe, and segment 9 refers to the paracaval portion and caudate process • Reidel lobe refers to a ‘‘tongue-like projection of the anterior border of the right lobe of the liver to the right of the gallbladder’’ below the costal margin. It is not a true anatomic lobe, but is a normal variant of segments 5 and 6
  • 12.
    Brisbane 2000 • Liveranatomy is described in first-, second-and third-order divisions. • The third order divisions, or segments (Sg), are referred to by Arabic numerals, not Roman numerals.
  • 13.
    Brisbane - Iorder • First-order division divides the liver into the left and right hemiliver, or left and right liver. The term lobe is not used because the division between the right and left hemiliver is not an externally apparent structure. • The border, also referred to as a watershed, of the first-order division is referred to as the midplane of the liver ( plane between the IVCand the gallbladder fossa) • Cantlie line is a misnomer, because the division between the hemilivers is a three dimensional space, and therefore technically a plane. • The caudate lobe, also referred to as segment 1 is not included in the first-order division. • The terminology for surgical resection at the first-order division is right or left hepatectomy or hemihepatectomy. To correctly classify the resection, whether or not segment 1 was included in the resection must be stipulated
  • 14.
  • 15.
    Brisbane - IIorder • Second-order division divides the liver into 4 sections based on the biliary and hepatic artery anatomy. • The right liver is divided into the right anterior section (Sg 5,8) and the right posterior section (Sg 6,7). • The left liver is divided into the left medial section (Sg 4) and the left lateral section (Sg 2,3). The terminology for resection is obtained by adding -ectomy to the anatomic term (ie, left lateral sectionectomy)
  • 16.
  • 17.
    Addendum for alternate secondorder division • Based on portal vein anatomy rather than biliary and arterial anatomy. • Uses the term sector rather than section. • The right lobe is divided as in the addendum system, but given different names; segments 5 and 8 are referred to as the right anterior sector or the right paramedian sector, and segments 6 and 7 are referred to as the right posterior sector or right lateral sector. • Segments 3 and 4 are referred to as the left medial sector or the left paramedian sector and segment 2 is referred to as the left lateral sector or the left posterior sector.
  • 18.
    Brisbane – IIIorder • Third-order division refers to the individual segments of the liver. The segments are referred to as segment 1 to segment 9. • Resection of a single segment is referred to as a segmentectomy and resection of any 2 contiguous segments is referred to as a bisegmentectomy
  • 19.
  • 20.
    • Resection ofsegments 4 to 8 ( Sg 1) is referred to as a right trisectionectomy (preferred term) or extended right hepatectomy or extended right hemihepatectomy. • Resection of segments 2 to 5 and 8 ( Sg 1) is referred to as a left trisectionectomy (preferred term) or extended left hepatectomy or extended left hemihepatectomy.
  • 21.
    Problems with Brisbane •Does not address the nomenclature of resections that do not encompass a complete segment, sometimes referred to as wedge resections or partial segmentectomies. • Does not define gray zones between resections; that is, is a right hepatectomy that includes only a portion of segment 4 classified as a right hepatectomy or a right trisectionectomy?
  • 22.
    Caudate Lobe:Anatomic Location •Space below hilum • Proximity to confluences • Anterior to IVC • From the level of HV as they enter IVC • Inferior edge of liver
  • 23.
  • 24.
    Caudate • Caudate lobeitself can be divided into right, left, and caudate process. • Caudate lobe proper is located between the inferior vena cava and the umbilical fissure • Caudate process connects the caudate lobe to the right hepatic lobe • In 44%, 3 separate ducts drain each part. In 26% of cases, the caudate process duct and the duct from the right portion of the caudate form a common duct. • In most cases, the caudate process duct drains into the RHD (85%) and the left part of the caudate lobe drains into the LHD (93%).
  • 25.
    • The caudatelobe receives portal blood flow from both the left and, to a lesser extent, the right portal systems • Venous drainage occurs along its posterior aspect directly into the IVC through multiple small branches of variable size and location. • Biliary drainage includes small tributaries to the right, but is predominantly through the left hepatic duct. • Isolated resection of segment 1 is technically demanding because of its anatomical position posterior to the liver, between the hepatic hilum and the inferior caval vein, in close proximity to the middle and left hepatic vein • Selective caudate segmentectomy can be done via an anterior transhepatic approach or high dorsal resection
  • 26.
    Anatomic Subclassification • Papillaryprocess or Spiegel lobe proper – Protuberant portion to the left of IVC – Seen through the hepatogastric ligament, • Caudate Process – Portion to the right of IVC – Right border blends into the right hemiliver • Paracaval portion – Intimate contact with IVC – Connects the Spiegel lobe to the caudate process
  • 27.
  • 28.
    Segment IX ? Couinaud1994 used the term seg IX for an area on the dorsal sector of the liver (caudate lobe) close to the IVC (paracaval portion) The anatomy of the paracaval portion is the liver parenchyma ventral to the hepatic IVC, between the Spiegel lobe and the right lobe, adjacent to the middle hepatic vein ventrally. This portion was classified by Couinaud as segment IX •However in 2002 Couinaud and co-workers abandoned the concept of seg IX as according to them no separate arteries, veins or ducts can be identified for the right paracaval portion of the posterior liver and because pedicles cross the proposed division between the right and left caudate lobe 28
  • 29.
    ANATOMY OF BILEDUCT BRANCHES IN THE HILAR AREA Junction of anterior seg duct and post seg duct to form the RHD which in turn joins the LHD at the hilar confluence 53-72% Post seg duct joining the LHD 9-27% Ant seg duct joins the hilar conf forming 3 br type hilar conf 7-14% Ant seg duct joins the LHD 6-9% 29
  • 30.
  • 31.
  • 32.
    • The classicbiliary anatomy appears in about 58% of the population and consists of the right hepatic duct and left hepatic duct draining the right and left lobes of the liver, respectively (Fig 6). • The right duct branches into the right posterior hepatic duct, draining posterior segments VI and VII, and the right anterior hepatic duct, draining anterior segments V and VIII. • The right posterior duct, which has a horizontal course, usually runs posterior to the right anterior duct, which is more vertically oriented, and fuses with it from a medial approach to constitute a short right hepatic duct. • Segmental tributaries draining segments II–IV form the left hepatic duct. • The fusion of the right and left hepatic ducts gives rise to the common hepatic duct. The caudate lobe usually drains to the origin of the left hepatic duct, or to the right hepatic duct. • The cystic duct usually drains into the lateral aspect of the common hepatic duct below its origin
  • 33.
    RHD • Right posteriorsectoral duct is generally oriented in a horizontal direction as opposed to the right anterior sectoral duct, which runs in a vertical direction. • The posterior sectoral duct is typically more superior and longer than the anterior duct. • In most cases, the anterior sectoral duct drains segments 8 and 5; however, in 20% of cases, segment 8 joins the right posterior sectoral duct
  • 34.
    LHD • Compared withthe RHD, less anatomic variation of the LHD. • Significant variation in bile ducts draining the left medial section • Usually the sectoral branches from the lateral and medial sections join each other within the umbilical fissure to form the LHD. • Orientation of the LHD and left portal vein are typically horizontal at the hilum before entering the umbilical recess where they lie in a more vertical direction. The LHD courses horizontally at the base of segment 4 superior to the left portal vein. It then joins the RHD anterior to the portal vein bifurcation to form the CHD
  • 35.
  • 36.
    RHD • Supraportal pattern –Right posterior sectional bile duct ran dorsally and cranially to the right or the right anterior portal vein and joined with the distal bile duct at its cranial side • Infraportal pattern – Right posterior sectional bile duct ran ventrally and caudally to the right or the right anterior portal vein and drained into the distal bile duct at its caudal side • Combined pattern – Some parts of the right posterior sectional bile duct entered the distal bile duct supraportally and the remaining parts of the right posterior sectional bile duct joined with the distal bile duct infraportally.
  • 37.
    Supraportal pattern • TypeA – Right posterior sectional bile duct joined with the right anterior sectional bile duct, forming the right hepatic duct • Type B – Right posterior sectional bile duct entered the confluence of the right anterior sectional bile duct and the left hepatic duct • Type C – Right posterior sectional bile duct drained into the left hepatic duct
  • 38.
    Infraportal pattern • TypeD – Right posterior sectional bile duct joined with the right anterior sectional bile duct, forming the right hepatic duct • Type E – Right posterior sectional bile duct entered the common hepatic duct
  • 39.
    Combined pattern • TypeF – A portion of the right posterior sectional bile duct joined with the right anterior sectional bile duct infraportally, becoming the right hepatic duct, and the remaining parts of the right posterior sectional bile duct entered the right hepatic duct supraportally • Type G – portion of the right posterior sectional bile duct joined with the common hepatic duct infraportally and the remaining parts entered the left hepatic duct supraportally
  • 40.
  • 41.
    Confluence Patterns ofthe LHD • Type H – Left medial sectional bile duct drained into the left lateral sectional bile duct • Type I – Left medial sectional bile duct entered the confluence of the left lateral anterior and posterior segmental bile ducts • Type J – Left medial sectional bile duct joined with the left lateral anterior segmental bile duct • Type K – Left medial sectional bile duct entered the hepatic confluence
  • 42.
  • 43.
    Clinical implication –Ductal anatomy • Right hepatic duct was absent in 26%. • When harvesting a donor without a right hepatic duct, two or more orifices of the bile ducts will be present in plane of transection of the graft. Biliary reconstruction of these variants is complicated and technically difficult. It is essential that both stumps must be reconstructed when they are present • Particular care must be taken in harvesting the left liver from a donor with a type C or G variant. As the right posterior sectional bile duct will be divided from the left hepatic duct in these cases, oversight or ligation of the stump of the right posterior sectional bile duct will lead to biliary leakage or obstruction in the donor.
  • 44.
    Surgical Anatomy ofthe Left Lateral Segment as Applied to Living-Donor and Split-Liver Transplantation Four specific patterns of left biliary anatomy: •segment 2 and 3 bile ducts unite close to the umbilical fissure to form a single LLS duct that receives a single segment 4 duct medially (55%) • segment 2 and 3 bile ducts unite medial to the umbilical fissure with two parallel segment 4 ducts joining the single LLS duct to form the left hepatic duct (30%) • segment 3 duct that receives the duct from segment 4 and joins segment 2 close to the hepatic hilum (10%) • and segments 2 and 3 ducts unite lateral to the umbilical fissure to form a short LLS duct that immediately receives the segment 4 duct forming the left hepatic duct (5%) 44
  • 45.
    Summary • In LDLT,the biliary anatomy of the donor usually is evaluated using intraoperative cholangiography • The surgeon must make a snap decision as to the biliary anatomy and its relationship to the line of transection. • When the right posterior sectional bile duct drains into the left hepatic duct, it runs supraportally; and when the right posterior sectional bile duct enters the common hepatic duct, it runs infraportally. • Familiarity with the variations of the hepatic confluence, especially types B, C, E, G, J’, and K, will decrease the likelihood of surgical misadventure. Masayuki Ohkubo,Masato Nagino,Junichi Kamiya, Surgical Anatomy of the Bile Ducts at the Hepatic Hilum as Applied to Living Donor Liver Transplantation. Ann Surg 2004;239: 82–86
  • 46.
  • 47.
    CBD arterial supply •Two major axial vessels along the lateral borders of the supraduodenal CBD – 3 o’clock and 9 o’clock arteries • 8 small arteries with a diameter of 0.3 mm supplying the supraduodenal CBD. These arteries arise from-  Below – 60%  posterior or anterior superior pancreaticoduodenal artery  gastroduodenal artery  retroportal artery  Above – 38%  right hepatic artery  cystic artery  left hepatic artery  Rarely – 2%  nonaxial supply from the common hepatic artery
  • 48.
    • Hilar ducts –Arterial branches from the right and left hepatic arteries; form a rich network around the ducts and are in continuity with the plexus around the CBD • Retropancreatic CBD – multiple small branches from the posterior superior pancreaticoduodenal artery
  • 50.
  • 51.
  • 52.
    MHV • Hepatic venousoutflow of the median sector(corresponding to Couinaud segments 5, 8 and 4) is drained mainly into the middle hepatic vein • As a result, preservation of MHV outflow drainage plays an important role in LDLT with the right lobe. • However, inclusion of the MHV in the right lobe graft and the necessity of MHV tributaries reconstruction are still controversial
  • 53.
    Right lobe graft- methods • Two harvesting methods for right lobe grafts have been proposed: an extended right lobe graft, in which the MHV trunk is included in the grafts, and a modified right lobe graft, in which only the MHV tributaries are included. • Leaving the MHV with the remnant liver will place the anterior segment (corresponding to segments 5 and 8) at risk for congestion and this drainage problem can lead to severe graft dysfunction and septic complications. • In such cases, the reconstruction of MHV tributaries have been recommended.
  • 54.
    Deciding on MHV •Kyoto group, using the three-dimensional reconstructed images of the hepatic vascular anatomy, divided the right lobe graft morphologically into two types: one is a right hepatic vein dominant graft in which the territory draining into the MHV is less than 40% of the right lobe graft, and the other is a MHV dominant graft. • Their indication for a right lobe graft with or without the MHV is based on dominancy of the hepatic vein, graft-to- recipient weight ratio, and remnant liver volume Kaneko T, Kaneko K, Sugimoto H et al. Intrahepatic anastomosis formation between the hepatic veins in the graft liver of the living related liver transplantation: observation by Doppler ultrasonography. Transplantation 2000;70:982-985.
  • 55.
    MHV ? • Sanoet al reported that venous congestion in the right liver graft can be assessed by temporary arterial clamping and intraoperative Doppler ultrasonography. They suggested the reconstruction of the hepatic vein or its tributaries if the graft volume excluding the discolored area under arterial clamping was estimated to be insufficient for postoperative metabolic demand (the remaining liver volume was less than 40% of the standard liver volume). • Kubota et al proposed if the congestive area of the liver surface appeared after clamping of MHV tributaries and the hepatic artery is larger than half of the surface of the anterior segment, the vein should be reconstructed.
  • 56.
    Preservation of MHVduring left hepatectomy The key step is the accurate identification of the intrahepatic origin of the MHV, by IOUS detection of the venous branches originating from segments 4 (4b) and 5 •It’s origin usually lies 2.5 to 3 cm deep into the liver parenchyma. •The parenchymal transection is continued by following the orientation of the main trunk of the MHV up to the IVC, on the left side of the vein securing and cutting only the left branches, which drain subsegments 4a and 4b. 56
  • 57.
    Few techniques aimingto preserve the MHV during left hepatectomy Classically, dissection of the parenchyma is performed at about 2 to3 mm to the left of the main portal fissure, dividing the left branches of the MHV, which is kept unseen. The major drawback of this technique is the risk of accidental injury of the MHV. Parenchymal dissection along the MHV under visual control reduces this risk and also allows a better oncological margin whenever needed 57
  • 58.
    Vessel diameter • Otherinstitutions concerned mainly about vessel diameter. • Gyu Lee et al indicated that when larger than 5 mm diameter, the reconstruction of MHV drainage from the anterior segment is recommended • Mizuno et al suggested 7 mm as the demarcation for reconstruction of MHV tributaries.
  • 59.
    IRHV • Before transplantation,the size of the vein must be determined as well as the distance between the main right hepatic vein (at the confluence of the hepatic vein with the inferior vena cava) and the drainage site of the inferior right hepatic vein into the inferior vena cava. • The size of the accessory inferior right hepatic vein is important because it can affect the surgical approach. If the cross-sectional diameter is greater than 5 mm, the vessel has to be preserved and reanastomosed in the recipient’s inferior vena cava; otherwise, it can result in a congested graft and lead to organ rejection
  • 60.
    IRHV • The IRHVsare divided into superior, medial and inferior groups, separately named the superior, medial and inferior right hepatic veins according to the position of the IRHV entering the inferior vena cava. The superior right hepatic vein mainly drains the superior part of segment Ⅶ, and the medial right hepatic vein drains the middle part of segment Ⅶ •The smaller the diameter of the right hepatic vein, the larger the diameter of the IRHV, and vice versa •It is possible to perform anatomical resections removing the entire right hepatic vein but sparing the right postero-inferior area. The postero-inferior area of the right lobe can be preserved along with the hypertrophic IRHV even if the entire major hepatic vein (MHV) is resected •The posteroinferior area of the right lobe can be preserved along with the hypertrophic IRHV even if the entire main right hepatic vein is resected during segmentectomy of Ⅶ and Ⅷ with right hepatic 60
  • 61.
  • 62.
    Portal vein brin the hilar area Because the portal vein develops during the very earliest part of the gestational period, few variations are found in the portal vein branches, and variations in the anterior segmental branches of the portal vein (P5,P8) are very rare. Three principal portal vein branching patterns found in the hilar area → common type – anterior segmental br joining the posterior seg br to form the RPV 74-84% → the 3 br type in which the anterior seg br joins the PV conf 8-12% → Left br type in which anterior seg br joins the LPV 9- 17% 62
  • 63.
  • 64.
    • Failure torecognize PV trifurcation lead to loss of supply to right anterior or right posterior segment. It needs division on right side of trifurcation. • Non division of main portal trunk with absence of separate main left PV is absolute C/I to right lobe LDLT.
  • 65.
    Biliary-Vascular Sheaths (PLATE) •Fusion of the Glisson capsule with the connective tissue sheaths surrounding the biliary and vascular elements.
  • 68.
    HILAR PLATE • Isbounded above by S4a, on the right by the Rouviere sulcus (a landmark demarcating the division between S6 and S5) and the cystic plate, and on the left it is continuous with the umbilical plate. • The anterior Glisson’s sheath generally runs behind the junction between the cystic plate and the hilar plate, and the posterior-inferior Glisson’s sheath runs behind the Rouviere sulcus.
  • 69.
    CYSTIC PLATE • Thecystic plate is located in the gallbladder bed and is continuous with the capsule of S5, S4a, and the Glisson’s sheath of the anterior segment of the liver.
  • 70.
    UMBILICAL PLATE • Theumbilical plate is located along the inferior edge of the ventral surface of the umbilical fissure. • It contains the ducts and blood vessels of S2, S3, and S4, and is continuous with the round ligament inferiorly.
  • 71.
    LEFT DUCT EXPOSURE •Its also called HEPP COUINAUD approach.(1st to describe transfissural (intrahepatic) approach through main fissure) • For high biliary stricture in BDI and cholangiocarcinoma. (dense adhesions) • Length of left hepatic duct is reflected by the length of the base of the quadrate lobe. • It may be hazardous in case of atrophy- hypertrophy liver lobes and deep hilus which displaced upwards.
  • 72.
    Cont… • This approachis difficult if quadrate lobe is large or carcinoma involving of left duct. • it is ideal for repair of type El to E3 injuries. (confluence is patent) • Resection of segment 4 is very useful when the liver is overhanging the upper ducts, as has recently been advocated by Mercado et al. (type E3)- confluence intact.
  • 73.
  • 74.
  • 75.
    LOWERING HILAR PLATE • Biliaryconfluence and left hepatic duct exposed by lifting segment IV upward after incision of the Glisson capsule at its base.
  • 76.
    • The hilarplate is detached from the liver parenchyma by dissecting in between the left portal pedicle and liver tissue. • The umbilical fissure and plate is the site of origin of segmental and sectoral pedicles to the left liver. Its anatomic landmarks are the falciform ligament and the left longitudinal sulcus. • The sulcus of Rouvière is an irregular fissure in continuity with the right hilum. Following this structure leads to the pedicles of segments V and VI and further deeply and posteriorly to the pedicles of segments VII and VIII.
  • 77.
    EXPOSURE OF RIGHTDUCT • Indicated in some cases of hilar cholangiocarcinoma, the planned surgical procedure—partial hepatectomy or segment III duct bypass —seems impossible much more hazardous and imprecise than that of the left.
  • 78.
    Hepatectomy: the posteriorintrahepatic approach (launious)- RIGHT DUCT • reliant upon early division of the hepatic pedicle extrahepatically. • This allows delineation of the line of resection for hepatectomy and segmentectomy. • approach is through the dorsal fissure between segments IV and I, and segment VIII and the new segment IX described by Couinauds.
  • 79.
    • The mainhepatic pedicle is clamped en masse and incisions made into the liver capsule in two regions, the first posterior to and the second anterior to the hilus. • anterior incision is made in front of the hilum and through the liver capsule from the gallbladder bed to the umbilical fissure. • An identical incision is made posterior to the hilum, the surgeon’s index finger is insinuated through this incision, and liver tissue is blindly pushed away until the superior surface of the confluence is reached.
  • 81.
    EXPOSURE OF ISOLATEDRIGHT DUCT IN BDI • Right and left duct are in same coronal plane.(the key to the dissection is to stay in the coronal plane of the left hepatic duct.) • To find the bile duct within the sheath of the right portal pedicle, which also contains the portal vein and hepatic artery, the cystic plate must be detached from the anterior surface of the sheath of the right portal pedicle. • Base of segment 5 must be cored out to expose right portal pedicle.
  • 84.