Anatomy Series: The Liver

by Brie Eteson, Medical Communications, Digital Surgery

In our anatomy series, Touch Surgery™ brings you the need-to-know anatomical knowledge for medical practitioners. A good foundation in anatomy is essential to surgical practice in all specialties. For the first in the series, we’re getting up close to the liver.

This simulation, which is available, for free, on the Touch Surgery™ app, uses the Brisbane 2000 classification of liver anatomy. Established by the International Hepato-Pancreato-Biliary Association (IHPBA), the classification is used globally to promote uniformity in the terminology of hepatic anatomy and surgery.

The Brisbane Classification

Our module visually takes you through the liver’s three orders of division:

1. The first order of division divides the liver into right and left hemilivers, externally marked by Cantlie’s line.

2. The second order of division divides the liver into four sections: the right anterior and posterior sections, and the left medial and lateral sections.

3. The third order of division divides the liver into eight sections, as defined by the Couinaud classification.

In the app, this simulation describes these divisions in more detail and how to identify them using anatomical landmarks.

First order of division

First order of division

Second order of division

Second order of division

Third order of division

Key Intrahepatic and Extrahepatic Structures

Each segment of the liver is drained by the hepatic vein and supplied by the portal vein, whilst the biliary tree drains bile from each liver segment. These structures have multiple variations, just to really keep you on your toes, with some structures having as many as 15 variations (like the left hepatic artery)! 

In the simulation, we have collated diagrams of the variations of intrahepatic structures. This is to demonstrate the possible variations surgeons should be aware of prior to surgery.

Common hepatic artery variations

Key Ligaments in Liver Surgeries

In this module, we focus on a few key ligaments that are important in surgery, namely:

  • Ligamentum venosum (Arantius’ ligament)
  • Falciform ligament
  • Round ligament
  • Right triangular ligament
  • Left triangular ligament
  • Coronary ligaments
  • Hepatocaval ligament (Makuuchi ligament)

The anatomical location of these ligaments and how they can be transected to effectively mobilize the liver is explained in the simulation on the Touch Surgery™ app.

Coronary ligaments

Interpretation of Liver Anatomy from Radiographic and Intraoperative Images

In radiographic images, internal landmarks are used to identify and demarcate the orders of division. For the first order of division, the middle hepatic vein is used. The middle, right, and left hepatic veins mark the fissures that identify the second order of division. In the coronal plane, the portal vein bifurcation is used to divide the liver into upper and lower segments.

Radiographic image in the coronal plane

To delve deeper into the anatomy of the liver and helpful classifications for surgical resection, find the full module on our  Touch Surgery™ app  and get started.

Launch in App

or scan the QR code below.

References

1. Terminology Committee of the IHPBA. Terminology of liver anatomy and resections. HPB Surgery. 2000;2:333–339.

2. Strasberg S. Nomenclature of hepatic anatomy and resections: a review of the Brisbane 2000 system. J Hepatobiliary Pancreat Surg. 2005;12:351–355.

3. Majno P, Mentha G, Toso C, Morel P, Peitgen HO and Fasel JH. Anatomy of the liver: An outline with three levels of complexity – A further step towards tailored territorial liver resections. J. Hepatol. 2014;60(3):654–662.

4. Lowe MC. and D’Angelica MI. Anatomy of Hepatic Resectional Surgery. Surg Clin N Amer. 2016;96(2):183–195.

5. Germain T, Favelier S, Cercueil JP, Denys A, Krausé D and Guiu B. Liver Segmentation: Practical tips. Diagn Interv Imaging. 2014;95:1003–1016.