Surgical anatomy of the left lateral segment as applied to living-donor and split-liver transplantation: a clinicopathologic study

OBJECTIVE: To evaluate intrahepatic vascular and biliary anatomy of the left lateral segment (LLS) as applied to living-donor and split-liver transplantation. SUMMARY BACKGROUND DATA: Living-donor and split-liver transplantation are innovative surgical techniques that have expanded the donor pool. Fundamental to the application of these techniques is an understanding of intrahepatic vascular and biliary anatomy. METHODS: Pathologic data obtained from cadaveric liver corrosion casts and liver dissections were clinically correlated with the anatomical findings obtained during split-liver, living-donor, and reduced-liver transplants. RESULTS: The anatomical relation of the left bile duct system with respect to the left portal venous system was constant, with the left bile duct superior to the extrahepatic transverse portion of the left portal vein. Four specific patterns of left biliary anatomy and three patterns of left hepatic venous drainage were identified and described. CONCLUSIONS: Although highly variable, the biliary and hepatic venous anatomy of the LLS can be broadly categorized into distinct patterns. The identification of the LLS duct origin lateral to the umbilical fissure in segment 4 in 50% of cast specimens is significant in the performance of split-liver and living-donor transplantation, because dissection of the graft pedicle at the level of the round ligament will result in separate ducts from segments 2 and 3 in most patients, with the further possibility of an anterior segment 4 duct. A connective tissue bile duct plate, which can be clinically identified, is described to guide dissection of the segment 2 and 3 biliary radicles.     

Extended liver resection for hilar cholangiocarcinoma

Liver resection for hilar cholangiocarcinoma should be designed for individual patients, based on both precise diagnosis of cancer extent and accurate evaluation of hepatic functional reserve. Therefore we have developed various types of hepatic segmentectomy. Combined caudate lobectomy is essential in every patient with separated hepatic confluence. So-called extensive hepatectomy, resection of 50% or more of the hepatic mass, includes right lobectomy and right or left trisegmentectomy. Right lobectomy with caudate lobectomy is indicated when the progression of cancer is predominant in the right anterior and posterior segmental bile ducts. The plane of liver transection is along the Cantlie line, and the left hepatic duct is divided just at the right side of the umbilical portion of the left portal vein. Right trisegmentectomy with caudate lobectomy is performed in carcinoma which involves the right hepatic ducts in continuity with the left medial segmental bile duct. The umbilical portion of the left portal vein is freed from the umbilical plate by dividing the small portal branches arising from the cranial side of the umbilical portion. Then the left lateral segmental bile ducts are exposed and divided at the left side of the umbilical portion of the left portal vein. Left trisegmentectomy with caudate lobectomy is suitable for carcinoma which involves the left intrahepatic bile duct in continuity with the right anterior segmental bile duct. Liver transection is advanced along the right portal fissure. The right posterior segmental bile duct is usually divided distal to the confluence of the inferior and superior branches.     

Is cholangiography required for ex situ splitting of cadaveric livers?

Anomalous biliary anatomy is encountered frequently and, if not considered at the time of ex situ splitting of a cadaveric liver into left lateral segment and right lobe grafts, right-sided second-order ducts that enter the left system, or the segment IV duct, may be damaged, leading to biliary complications in the recipients. Bench cholangiography facilitates delineation of these anomalies, but if one considers the commonly encountered variations in biliary anatomy, in relation to the correct plane of division of the left hepatic duct (away from the hilum, close to the umbilical fissure), it is possible to avoid inadvertent injury to right-sided sectoral ducts. This approach, combined with careful probing of the ducts and absolute identification of the segment IV duct negates the contribution of cholangiography.     

Hepatectomy for cholangiocarcinoma complicated with right umbilical portion: anomalous configuration of the intrahepatic biliary tree

The right umbilical portion (right-sided round ligament) has been discussed as an intrahepatic portal venous anomaly associated with "left-sided gallbladder" in several reports. We treated two patients with right umbilical portion (RUP) associated with cholangiocarcinoma. Left hepatectomies were performed, preserving the residual hepatic blood flow and biliary continuity. From our experience in these patients we propose the presence of anomalous configuration of the intrahepatic biliary tree in RUP, because both patients showed medial segmental bile ducts ramified from the right and left hepatic ducts. In general, although the medial segmental bile duct ramified from the left, we surmised that this abnormal bilateral drainage pattern may not be a rare phenomenon in RUP. Special attention may be required to focus on the anatomy of the portal tributaries and biliary ramifications in RUP. Received for publication on July 7, 1999; accepted on Nov. 11, 1999     

Successful Duct-to-duct Biliary Reconstruction after Right Hemihepatectomy. Operative Planning Using Virtual 3D Reconstructed Images

Accurate knowledge of partial anatomy is essential in hepatic surgery but is difficult to acquire. We describe the potential impact of a new technique for constructing three-dimensional virtual images of the portal vein, hepatic artery, and bile ducts and present a representative case. An 80-year-old man was suspected of having papillary cholangiocarcinoma arising in S8 of the liver and extending to the hepatic hilum intraluminaly. Right hemihepatectomy with bile duct resection was planned. However, it was uncertain whether duct-to-duct biliary reconstruction would be possible based on the appearance of the confluence of the right and left hepatic ducts on cholangiogram and conventional computed tomograph. Virtual three-dimensional images of the liver were constructed and revealed vascular and biliary anatomy. They showed that the upper margin of bile duct excision would be 19 mm from the umbilical point of the left portal vein, and that the site of the left branch of the caudate lobe bile duct could be preserved. Based on this information, we performed a sphincter-preserving biliary operation safely without complications. Planning complex biliary surgery may be improved by the use of virtual three-dimensional images of the liver. This approach is especially useful in candidates for postoperative regional chemotherapy.     

Intrahepatic vascular division in the pig: basis for partial hepatectomies.

Transplantation of resected hepatic fragments, with the attendant vascular and biliary tract reconstruction, presents difficulties. We have studied the intraparenchymal vascular division in the pig with a view to performing partial hepatectomies with the greastest possible anatomical support. Forty-six molds of the various vascular territories were obtained from the 31 porcine livers. Each segment of the median lobe is dependent on the adjacent lateral lobe. Its intersegmental fissure is the obligatory site for parenchymal section to be continued through horizontal portion of portal vein, hepatic artery, and left hepatic duct. A right hemihepatectomy unfailingly results in the devitalization of the left side of the liver. If the goal of a hepatectomy is the transplantation of the resected fragment, it is recommended that the right side of the liver be utilized, as its more convenient extrahepatic vascular and biliary calibre will permit pedicular conservation and anastomosis.     

Infraportal bile duct of the caudate lobe: a troublesome anatomic variation in right-sided hepatectomy for perihilar cholangiocarcinoma

OBJECTIVE: We present our experiences with infraportal bile duct of the caudate lobe (B1) and discuss surgical implications of this rare variation. SUMMARY BACKGROUND DATA: Although various authors have investigated biliary anatomy at the hepatic hilum, an infraportal B1 (joining the hepatic duct caudally to the transverse portion of the left portal vein) has not been reported. METHODS: Between January 1981 and December 2005, 334 patients underwent hepatectomy combined with caudate lobectomy for perihilar cholangiocarcinoma. Four of them (1.2%) had infraportal B1 and were investigated clinicoanatomically. RESULTS: All infraportal B1 were B1l, draining Spiegel's lobe; no infraportal B1r (draining the paracaval portion) or B1c ducts (draining the caudate process) were found. The infraportal B1l joined the common hepatic duct or the left hepatic duct. Three patients underwent right trisectionectomy with caudate lobectomy; for one, in whom preoperative diagnosis was possible, combined portal vein resection and reconstruction were performed before caudate lobectomy to resect the caudate lobe en bloc without division of infraportal B1. For the other 2 patients, the infraportal B1 was divided to preserve the portal vein, and then the caudate lobe was resected en bloc. The fourth patient underwent right hepatectomy with right caudate lobectomy; the cut end of the infraportal B1 showed no cancer by frozen section, so the bile duct was ligated and divided to preserve the left caudate lobe. CONCLUSION: Infraportal B1 can cause difficulties in performing right-sided hepatectomy with caudate lobectomy or harvesting the left side of the liver with the left caudate lobe for transplantation. Hepatobiliary and transplant surgeons should carefully evaluate biliary anatomy at the hepatic hilum, keeping this variation in mind.     

Studies on the radiographic anatomy of the biliary tree of the caudate lobe

The cholangiograms obtained through percutaneous transhepatic cholangioscopy (PTCS) were studied for the purpose of clarifying radiographic anatomy of confluence of the bile ducts of the caudate lobe and the main trunks at the hepatic hilum. PTCS was performed on a total of 112 patients at our department, January, 1979 through December, 1984. Among them 60 cases without lesions in the hepatic hilum were used for this study. Four types of the bile duct of the caudate lobe were distinguished by cholangiography in the 60 cases: 1) A duct ran from the cranial portion of the right caudate lobe along the inferior vena cava to the hepatic hilum in 53 (Blr); 2) A duct ran from the cranial portion of the left caudate lobe to the hepatic hilum in 50 (Blls); 3) A duct ran from the left lateral part of the left caudate lobe to the hepatic hilum in 59 (Blli) and 4) A duct from the caudate process to the hepatic hilum in 42 (Blc). We found that cholangiogram following percutaneous transhepatic biliary drainage or selective cholangiogram using the PTCS make an accurate identification of the bile duct of the caudate lobe possible.     

Rare Portal Venous Anomaly in a Living Liver Donor: A Case Report

Knowledge of the anatomy of the portal system is essential for safe liver resection. We report a very rare anatomic anomaly of the portal system in a living liver donor. A 24-year-old female living liver donor was found to have anomalies of the portal system on preoperative contrast-enhanced computed tomography. The ventral branch of the right anterior segment arose from the transverse portion of the left portal vein. The gallbladder and round ligament were positioned normally. Intraoperative cholangiography for evaluation of biliary anatomy revealed very low confluence of the right and left hepatic ducts. All the bile ducts from the right lobe merged into the right hepatic duct. A right lobe graft was performed, including the ventral area of the right anterior segment. The portal branch of the ventral area of the right anterior segment could be transected extrahepatically. In the recipient operation, each of the right main portal branches, including the right posterior segment branch and the dorsal branch of the right anterior segment, and the ventral branch of the right anterior segment, were anastomosed to the right and left branches of the portal vein, respectively, of the recipient. The transected right hepatic duct of the graft was anastomosed with the recipient's common hepatic duct. Sixteen years after the liver transplant, the recipient continues to do well and has good portal flow.     

Preliminary study of the anatomy of the venous drainage of the intrahepatic and extrahepatic bile ducts and its relevance to the practice of hepatobiliary surgery

Background : Although there have been many studies of the arterial supply of the biliary system, attempts to study the corresponding venous drainage have been few and all have been incomplete. The purpose of the present investigation is to describe the anatomy of the venous drainage of both the intrahepatic and extrahepatic bile ducts and to determine its relevance to hepatobiliary surgery. Methods : The intrahepatic and extrahepatic venous drainage of the bile ducts was investigated in seven specimens by injecting a solution of 10% gelatin coloured with Alcian blue into the portal vein or the superior mesenteric vein to outline the venous drainage. The specimens were dissected under loop magnification and representative drawings were obtained. Results : The surface of the intrahepatic and extrahepatic bile ducts was covered by a fine venous plexus. On the surface of the supraduodenal common hepatic duct and common bile duct the venous plexus drained laterally into marginal veins, usually two in number and known as the 3 o’clock and 9 o’clock marginal veins. Inferiorly the marginal veins and the venous plexus communicated with the pancreaticoduodenal venous plexus, which in its turn drained into the posterosuperior pancreaticoduodenal vein, a branch of the superior mesenteric vein. Superiorly the marginal veins divided into a number of branches. Some branches followed the left and right hepatic ducts into the liver, communicating with the venous plexus and the adjacent branches of the portal vein. Other branches of variable size entered either segment IV or the caudate lobe or process via the hilar venous plexus. A most important finding was that even after dividing the bile duct and all communicating veins at the upper border of the duodenum, the venous plexus and the marginal veins filled normally to the level of transection. This occurred almost certainly by retrograde filling from above. Conclusion : The satisfactory results of end‐to‐end anastomosis in whole liver transplantation depends partly on the presence of adequate venous drainage. This has been amply demonstrated by the injection studies. This would indicate that the poor results of end‐to‐end repair of the bile duct after surgical trauma results from other factors such as poor technique, devascularization of the cut ends due to trauma, and carrying out the anastomosis under tension. After resection of the hilum for cholangiocarcinoma the venous drainage of the left and right hepatic ducts and their branches depends mainly on the communications between the venous plexus on the ducts and the adjacent branches of the portal vein, even at a lobular or sinusoidal level. The satisfactory results obtained after anastomosis of the left and right hepatic ducts or their branches to a Roux loop of jejunum attest to this. This applies also to the transplantation of segments II and III in paediatric patients from related adult donors and in patients receiving split liver transplants. Finally, the venous drainage at the bifurcation of the common hepatic duct has been shown to enter the caudate lobe and segment IV directly. This suggests that a hilar cholangiocarcinoma may metastasize to these segments, and perhaps partly explain the significantly better long‐term results when the caudate lobe and segment IV are resected en bloc with the cholangiocarcinoma as part of modern radical surgery for this condition.     

Two tapes to control the main fissure of the liver

Herein we report a technique that allows a rapid and selective clamping of the left and right glissonian sheats and that secures the opening of the main fissure. The posterior face of segment IV capsula is opened immediately above the hilum on the left side of the gallbladder fossa. The tip of a right angled dissector is gently pushed in the liver substance from front to back while maintained against the hilar plate, until it arises in the caudate process just below the pedicle. A tape is used to encircle the Glisson sheath. Its inferior extremity can be picked up either on the right or the left side of the liver pedicle in order to clamp the right or the left portal pedicle, respectively. Both clamping precisely mark the anterior limit of the main fissure. Using a Kelly forceps, a second tape is introduced in the Couinaud space, between the inferior vena cava and segment one. The inferior extremity of this tape is then picked up above the Glisson sheat and allows to hang the posterior limit of the main fissure which can be securely approached. The two tapes technique cannot be applied when liver is fibrotic or when biliary ducts are dilated.     

The blood supply of the hilar bile duct and its relationship to the communicating arcade located between the right and left hepatic arteries

BACKGROUND: There is an increasing demand for living donor liver transplants. However, the biliary complication rates are still high. METHODS: The anatomy of the communicating arcade (CA) between the right and left livers and its relevance to the blood supply of the hilar bile duct was evaluated using adult cadaveric livers and cast specimens. RESULTS: In all specimens that were of sufficient quality for evaluation, the CA was found to be located extrahepatically in the hilar plate with thin tributaries branching to the hilar bile duct. On the left side, 55% of the CA originated from a segment IV artery. On the right side, 73% of the CA originated from the right anterior hepatic artery. CONCLUSIONS: To maintain an adequate blood supply for the hilar bile duct of the donor graft during living donor liver transplantation, the branching point of the CA should be preserved.     

Resection of metastatic liver cancer in a patient with a left-sided gallbladder and intrahepatic portal vein and bile duct anomalies: A case report

INTRODUCTIONThe presence of left-sided gallbladder is closely associated with multiple combined anomalies of the portal vein, hepatic vein, hepatic artery, and bile duct. This requires special attention for preoperative evaluation for the purpose of preventing postoperative complications.PRESENTATION OF CASEA 70-year-old woman with metastatic liver cancer and intrahepatic portal vein, biliary system and hepatic artery anomalies with left-sided gallbladder is reported. On computed tomography (CT), a solitary low density mass occupied from the right anterior to the posterior segment of the liver. The gallbladder bed was on the left of the hepatic fissure. On drip-infusion-cholangiography (DIC) CT three-dimensional (3D) reconstruction, the left medial bile duct arose from the right umbilical portion after arising from the left lateral bile duct. Following a right hepatectomy and lymph node dissection of the hepatoduodenal ligament, hepaticojejunostomy was conducted separately to the left medial and left lateral bile duct.DISCUSSIONThe left-sided gallbladder accompanies with several anomalies of hepatic vascular and bile duct anomalies in a frequent manner. A safe hepatectomy needs accurate operative plans to ascertain the range of hepatectomy, because it often has the diversity of a combined anomaly.CONCLUSIONPreoperative DIC-CT 3D reconstruction was extremely useful because it provided an important information that could not be obtained with 2D-DIC-CT. 3D imaging has the ability to demonstrate complex anatomical relationships, this devise is a effective new tool for making appropriate preoperative strategy.     

肝动脉栓塞术后的肝内外胆道损毁性病变

目的 探讨经导管肝动态栓塞术后对胆道损伤的病因、治疗及预防。方法 总结５例因肝动脉栓塞引起的胆道损伤患者,其中４例为肝血管瘤经导管动脉栓塞术后,１例为手术时结扎肝动脉注射ＴＨ胶后。动物实验观察向大鼠肝动脉内注射乙醇复制血管栓塞剂对肝脏的损伤。结果 ５例患者均有胆道毁坏性病变,甚至造成胆汁性肝硬化,４例进行胆管空肠吻合及胆道支撑。实验结果证实肝动脉注射血管硬化剂无水乙醇后可以引起邻近汇管区肝脏局部坏     

Errors in the topographic diagnosis of liver diseases

To identify the portal pedicles in liver pathology is difficult: anatomical variations are ignored and only the modal disposition is retained, the obliquity of the liver in situ is ignored: strongly inclined to the right, posteriorly and inferiorly (the anterior sector is above and to the right of the posterior sector, their pedicles in an antero-posterior radiogram are superposed); and the sizes of segments IV and VI are quite variable (embryologic result). This study was made with a collection of 111 vasculo-biliary acrylic casts. The main portal fissure containing the middle hepatic vein follows the axis of the cystic fossa. Actually the position of this axis varies from 18 degrees to the right of the vein (gall-bladder under segment V) and 14 degrees to the left (gall-bladder under segment IV); the fissure reaches the inferior vena cava only at the limit of the upper surface of the liver, the vena cava is separated from the right and left livers by the dorsal sector. The anterior half of the right portal fissure is quite variable, it can reach the anterior liver from the main portal fissure up to the anterior portion of the right margin of the liver (segment VI variation); in 41% of the livers (n = 100), the right hepatic vein is in the right portal fissure; occlusion of the anterior or the posterior right arteries indicates the fissure. The left portal fissure is often confused with the left hepatic fissure (limit between academic left and right lobes). Segments breadths are measured in the upper surface of the liver. The largest segments are VIII, V, III and II; their transversal breadth is also the largest (simple to double). In difficult cases, a tri-dimensional reconstruction of the pedicles should be made from an helico?dal tomodensitometry.     

Liver anatomy: portal (and suprahepatic) or biliary segmentation

BACKGROUND/AIMS: In liver anatomy and surgery, is portal and hepatic vein segmentation (French segmentation) to be preferred over arteriobiliary segmentation (Healey and Schroy, North American segmentation)? METHODS: Several embryological arguments and an analysis of anatomical data from a personal collection of 110 vasculobiliary casts were made. RESULTS: Embryological arguments: Portal vein branching appears first, arteriobiliary branching secondly follows the portal vein distribution. Segment II (the left lateral sector) is the development of the right lateral embryological lobe. The umbilical vein enters the left portion of the middle embryological lobe, forming segment IV on the right and segment III on the left: this is the left paramedian sector. So the left portal fissure (between left and middle lobes) transversally crosses the classical left lobe, which is not a portal unit. Segment VI is a late secondary prominence of segment VII, reaching the anterior margin of the liver only in man. Anatomical arguments: hepatic vein segmentation must be added to portal segmentation; the academic left lobe is the left hepatic vein sector, and the left hepatic fissure separates the classical right and left lobes. Portal vein segmentation must be preferred: portal vein duplication of branches of first order occurs only in 23.5% of the cases, while arteriobiliary duplication of first-order branches is noted in 50% of the livers, portal segmentation being much simpler. CONCLUSIONS: Portal and hepatic vein segmentation seems to be much more accurate.     

Left-Sided gallbladder with intrahepatic portal venous anomalies

The congenital anomaly in which the gallbladder is found on the left of the round and falciform ligaments (left-sided gallbladder) is rare. We report two patients with left-sided gallbladder in whom intrahepatic portal venous anomalies were identified. Computed tomography and intraoperative ultrasonography were used to define the portal venous anomaly. A long straight left main portal vein was demonstrated, which did not have the typical umbilical portion. The right anterior segmental portal branch (case 1), or the right main portal vein (case 2) were shown to course in a ventral direction and terminate as a cul de sac. The round ligament (right round ligament) was attached to this venous termination, forming the right umbilical portion. The left medial segmental portal venous branches originated from the right umbilical portion, and coursed to the left. In contrast, cholangiography disclosed that the left medial segmental bile duct coursed to the right after arising from the left hepatic duct (case 1), or the common hepatic duct (case 2). The essence of this anomalous condition is not a left-sided gallbladder, but a right round ligament, which is an embryologic abnormality of the umbilical vein. A review of the English language literature revealed no reports of left-sided gallbladder with intrahepatic portal venous anomalies.     

Extended right hepatectomy with total caudate lobe resection and biliary tree resection for a large colorectal liver metastasis involving both the right and left hepatic lobes and the umbilical fissure: a case report

Very large right-sided liver tumors may grow up to the base of the umbilical fissure and involve the left hepatic duct and can occasionally reach the bile duct confluence. This kind of involvement has often been considered a contraindication to resection. We report a patient who presented with a large hepatic metastasis from colorectal cancer that reached the umbilical fissure and involved the left hepatic duct just above the bile duct confluence. An extended right hepatectomy including complete resection of caudate lobe was performed. We resected the left and common hepatic ducts, as well as both the entire hepatic and the proximal third of common bile duct. A long jejunal limb Roux-en-Y (45 cm) single-layer left intrahepatic hepaticojejunostomy was constructed. She is still well 14 months postoperatively. To the best of our knowledge, this is the first report of such a procedure employed for the treatment of a liver metastasis from colorectal cancer. Extended right hepatectomy including complete caudate lobe resection can be feasible even when the majority of the extrahepatic biliary system needs to be resected. Our approach probably offers the only chance to prevent early death from liver failure in these patients.     

Surgical anatomy of the hepatic hilar area

It is important to understand the main variations of the biliary and vascular elements inside the plate system for hilar bile duct carcinoma because all variations of these elements occur in this plate system. The plate system consists of the hilar plate, cystic plate, and umbilical plate which cover the extrahepatic vascular system and are fused with the hepatoduodenal ligament. The bile duct and vascular system that penetrate the plate system form Glisson's capsule in the liver, but the caudate branch and the medial segmental branch are exceptions. The bile duct and hepatic artery accompanying the plate system can be exfoliated from the portal vein with numerous lymph ducts and nerves. The bile ducts in the right hepatic lobe are classified into 4 types, and the standard type is present in 53-72% of cases. In the left bile duct, the medial segmental bile duct is connected in the vicinity of the hilar area in 35.5% of cases, and these cases should be treated the same as the caudate lobe in hilar bile duct carcinoma. Generally, there is little main variation of the portal vein (16-26%), but more variation in the hepatic artery (31-33%). During surgery for hilar bile duct carcinoma, it is important to observe the plate system and the many variations of the bile duct and vascular system.     

Clinicoanatomical study on the infraportal bile ducts of segment 3

In some patients, bile ducts of segments 2 and 3 (B2 and B3) run caudally to the umbilical portion of the left portal vein (UP)--an infraportal course. We aimed to evaluate the frequency and clinical implications of this variation. Between January 1992 and October 2000, 108 patients underwent resection for hilar cholangiocarcinoma. The records of the 6 patients with infraportal left hepatic ducts were evaluated. An infraportal B3 was diagnosed in 6 patients (6%). No patient had an infraportal B2. An infraportal B3 could be demonstrated by computed tomography (CT) before biliary drainage, percutaneous transhepatic or endoscopic cholangiography, portography after percutaneous transhepatic biliary drainage (PTBD) via B3 and CT after PTBD via B3. Four patients (4/6) had a liver bridge covering Rex's recess (B3 not in the bridge). The incidence of the bridge in 75 comparable patients was 9/75. In conclusion, common radiologic methods are sufficient for diagnosis of abnormal biliary anatomy. The presence of a liver bridge over Rex's recess is suggestive of this variation. Separate biliary reconstruction for an infraportal branch is mandatory in an extended right hepatectomy for biliary tract cancer and may be necessary in liver transplantation with segments 2+3 grafting.