Hepatic surgical anatomy and approach based on the characteristics of hepatic inflow and outflow at subsegmental level

doi:10.3877/cma.j.issn.2095-3232.2025032

Abstract

Abstract:

The liver segmentation system described by Couinaud is the cornerstone of modern liver surgery.In recent years， with rapid standardization and maturation of laparoscopic anatomical hepatectomy， certain defects of Couinaud system have been gradually identified， and the concept of dynamic watershed theory has been proposed based on modern imaging technology.At the technical level， the scope of anatomical hepatectomy should include the watershed with complete portal vein blood supply and hepatic vein reflux.Therefore， the segmentation and naming of hepatic segments should not only clarify the supplying portal veins， but also emphasize the reflux path of hepatic veins.In this article， we suggest naming portal and hepatic veins at the subsegmental level， and recommend considering the blood supply of portal veins and the path of hepatic vein reflux to investigate the segmentation of hepatic lobes and segments， aiming to help achieve correct preoperative planning and facilitate the selection of surgical approach.

Key words: Liver segmentation, Surgical anatomy, Hepatic inflow and outflow pathways, Anatomical hepatectomy, Surgical approach

Di Zhou, Wei Sun, Jian Gong, Jiandong Wang, Zhiwei Quan, Jun Li. Hepatic surgical anatomy and approach based on the characteristics of hepatic inflow and outflow at subsegmental level[J]. Chinese Journal of Hepatic Surgery(Electronic Edition), 2025, 14(02): 209-216.

/ / Recommend

Add to citation manager EndNote|Ris|BibTeX

URL: https://zhgzwkssxdzzz.cma-cmc.com.cn/EN/10.3877/cma.j.issn.2095-3232.2025032

https://zhgzwkssxdzzz.cma-cmc.com.cn/EN/Y2025/V14/I02/209

Figures/Tables 7

References 34

［1］	Kaibori M， Matsui Y， Hijikawa T， et al.Comparison of limited and anatomic hepatic resection for hepatocellular carcinoma with hepatitis C［J］.Surgery， 2006， 139（3）： 385-394.DOI： 10.1016/j.surg.2005.08.035.
［2］	Kaibori M， Kon M， Kitawaki T， et al.Comparison of anatomic and non-anatomic hepatic resection for hepatocellular carcinoma［J］.J Hepatobiliary Pancreat Sci， 2017， 24（11）： 616-626.DOI： 10.1002/jhbp.502.
［3］	Monden K， Sadamori H， Iwasaki T， et al.Hepatic vein-guided approach in laparoscopic anatomic liver resection of the ventral and dorsal parts of segment 8［J］.J Pers Med， 2023， 13（6）： 1007.DOI：10.3390/jpm13061007.
［4］	Zhao Z， Lyu X， Lyu X， et al.Counterclockwise modular laparoscopic anatomical mesohepatectomy using combined glissonean pedicle（Takasaki approach） and hepatic vein-guided approaches［J］.Front Oncol， 2022， 12： 1046766.DOI： 10.3389/fonc.2022.1046766.
［5］	Lim JH， Choi GH， Choi SH， et al.Ventral segment-preserving right hepatectomy in patients with hepatocellular carcinoma［J］.World J Surg， 2015， 39（4）： 1034-1043.DOI： 10.1007/s00268-014-2894-3.
［6］	Zhang C， Ma J， Zhou Y.Laparoscopic dissection of the first and second Porta hepatis along Laennec’s capsule via “Hepatic Serosal Incision” approach： how I do it［J］.World J Surg， 2024， 48（8）： 1967-1972.DOI： 10.1002/wjs.12255.
［7］	Morimoto M， Matsuo Y， Nonoyama K， et al.Glissonean pedicle isolation focusing on the laennec’s capsule for minimally invasive anatomical liver resection［J］.J Pers Med， 2023， 13（7）： 1154.DOI：10.3390/jpm13071154.
［8］	Zhang Y， Shi N， Zou Y， et al.The characteristics of Laennec’s capsule around the hepatic veins： a histological study based on 71 liver surgical specimens［J］.Ann Gastroenterol Surg， 2022， 7（2）： 287-294.DOI： 10.1002/ags3.12618.
［9］	杨陈凤麟，李尧，王鑫，等.“门理论” 在微创解剖性肝切除术中的应用与展望［J］.中国实用外科杂志， 2024， 44（3）： 341-345.DOI：10.19538/j.cjps.issn1005-2208.2024.03.21.Yang-Chen FL， Li Y， Wang X， et al.Application and prospects of “gate theory” in minimally invasive anatomical hepatectomy［J］.Chin J Pract Surg， 2024， 44（3）： 341-345.DOI： 10.19538/j.cjps.issn1005-2208.2024.03.21.
［10］	张传海，周毅，王一帆，等.基于 “红/黄交界线” 胆囊板入路联合ICG荧光导航的腹腔镜解剖性肝切除（附视频）［J/OL］.中华肝脏外科手术学电子杂志， 2024， 13（1）： 62-67.DOI： 10.3877/cma.j.issn.2095-3232.2024.01.012.Zhang CH， Zhou Y， Wang YF， et al.Laparoscopic anatomical hepatectomy via cystic plate approach using “peritoneal reflection” combined with ICG fluorescence navigation （video attached）［J/OL］.Chin J Hepatic Surg （Electronic Edition）， 2024， 13（1）： 62-67.DOI： 10.3877/cma.j.issn.2095-3232.2024.01.012.
［11］	洪汉崟，陈志坚，池小斌，等.鞘外法和鞘内法Glisson蒂阻断在腹腔镜解剖性肝切除中应用的对比研究［J/OL］.中华肝脏外科手术学电子杂志， 2024， 13（1）： 21-26.DOI： 10.3877/cma.j.issn.2095-3232.2024.01.005.Hong HY， Chen ZJ， Chi XB， et al.Comparative study of extrathecal and intrathecal Glisson’s pedicle transection in laparoscopic anatomic hepatectomy［J/OL］.Chin J Hepatic Surg （Electronic Edition）， 2024，13（1）： 21-26.DOI： 10.3877/cma.j.issn.2095-3232.2024.01.005.
［12］	曾繁利，齐秩凯，杨贺庆.两种经Glisson蒂鞘解剖路径肝切除术治疗原发性肝癌的肿瘤学疗效及风险比对［J/OL］.中华普外科手术学杂志（电子版）， 2024， 18（5）： 525-527.DOI： 10.3877/cma.j.issn.1674-3946.2024.05.015.Zeng FL， Qi ZK， Yang HQ.Comparison of oncologic efficacy and risk of two kinds of hepatectomy via Glisson pedicle sheath anatomical route for primary liver cancer［J/OL］.Chin J Oper Proced Gen Surg（Electron Ed）， 2024， 18（5）： 525-527.DOI： 10.3877/cma.j.issn.1674-3946.2024.05.015.
［13］	唐啸，岳志强，蔡卫华，等.ICG荧光融合影像技术在肝癌腹腔镜解剖性肝切除术中的应用［J/OL］.中华肝脏外科手术学电子杂志，2023， 12（1）： 39-43.DOI： 10.3877/cma.j.issn.2095-3232.2023.01.008.Tang X， Yue ZQ， Cai WH， et al.Application of fusion ICG-fluorescence imaging in laparoscopic anatomical hepatectomy for primary liver cancer［J/OL］.Chin J Hepatic Surg （Electronic Edition）， 2023，12（1）： 39-43.DOI： 10.3877/cma.j.issn.2095-3232.2023.01.008.
［14］	《中华消化外科杂志》编辑委员会，中国研究型医院学会肝胆胰外科专业委员会.腹腔镜门静脉流域解剖性肝切除理论及技术标准中国专家共识（2023版）［J/OL］.中华消化外科杂志， 2023， 22（12）：1385-1397.DOI： 10.3760/cma.j.cn115610-20230925-00114.Editorial Board of Chinese Journal of Digestive Surgery， Society for Hepato-pancreato-biliary Surgery of Chinese Research Hospital Association.Chinese expert consensus on the theoretical and technical system of laparoscopic portal territory staining guided anatomic liver resection （2023 edition）［J/OL］.Chin J Dig Surg， 2023， 22（12）： 1385-1397.DOI： 10.3760/cma.j.cn115610-20230925-00114.
［15］	王鹏，荣维淇，张建，等.A-P-R三角解剖联合ICG荧光染色腹腔镜解剖性肝S5段切除术［J/OL］.中华肝脏外科手术学电子杂志， 2022，11（5）： 498-502.DOI： 10.3877/cma.j.issn.2095-3232.2022.05.014.Wang P， Rong WQ， Zhang J， et al.Application of A-P-R triangle dissection combined with ICG fluorescence staining in laparoscopic anatomical S5 segmentectomy［J/OL］.Chin J Hepatic Surg （Electronic Edition）， 2022， 11（5）： 498-502.DOI： 10.3877/cma.j.issn.2095-3232.2022.05.014.
［16］	Hjortsjo CH.The internal topography of the liver； X-ray and injection technique studies［J］.Nord Med， 1948， 38（15）： 745-748.
［17］	van Leeuwen MS， Fernandez MA， van Es HW， et al.Variations in venous and segmental anatomy of the liver： two- and three-dimensional MR imaging in healthy volunteers［J］.AJR Am J Roentgenol， 1994，162（6）： 1337-1345.DOI： 10.2214/ajr.162.6.8191995.
［18］	Minh TV， Galizia G.Segmentation of the liver and anatomical variants ［J］.Ann Chir， 1990，44（7）：561-569.
［19］	Kogure M， Hasui N， Kawaguchi S， et al.Vein-guided anatomical resection of liver segment III along the left hepatic vein： a feasible procedure？［J］.HPB， 2024， 26（8）： 1079-1081.DOI： 10.1016/j.hpb.2024.05.002.
［20］	Maurer R， Rivoire M， Basso V， et al.Portal supply of segment Ⅳ of the liver based on CT-scan［J］.Surg Radiol Anat， 2017， 39（5）： 471-476.DOI： 10.1007/s00276-016-1761-3.DOI： 10.3969/j.issn.1673-4254.2016.01.05.
［21］	谢于，蔡守望，董家鸿，等.基于肝内肝门静脉解剖的肝脏右前叶分段新概念［J］.中国临床解剖学杂志， 2010， 28（6）： 651-654.DOI：10.13418/j.issn.1001-165x.2010.06.017.Xie Y， Cai SW， Dong JH， et al.A reclassification of the right anterior lobe of liver based on the anatomy of portal vein［J］.Chin J Clin Anat，2010， 28（6）： 651-654.DOI： 10.13418/j.issn.1001-165x.2010.06.017.
［22］	竜崇正.肝臓の外科解剖第2版：門脈segmentationに基づく新たな肝区域の考え方［M］.医学書院， 2011.
［23］	范应方，向飞，蔡伟，等.基于三维可视化技术的右半肝门静脉3D分型及分段［J］.南方医科大学学报， 2016， 36（1）： 26-31.DOI： 10.3969/j.issn·1673- 4254.2016.01.05.Fan YF， Xiang F， Cai W， et al.Three-dimensional classification of the right portal vein and liver segmentation based on three-dimensional visualization technology［J］.J South Med Univ， 2016， 36（1）： 26-31.DOI： 10.3969/j.issn·1673-4254.2016.01.05.
［24］	Cho A， Okazumi S， Makino H， et al.Anterior fissure of the right liver：the third door of the liver［J］.J Hepatobiliary Pancreat Surg， 2004，11（6）： 390-396.DOI： 10.1007/s00534-004-0919-2.
［25］	Taniai N， Machida T， Yoshida H， et al.Role of the anterior fissure vein in ventral or dorsal resection at Segment 8 of liver［J］.Eur J Surg Oncol， 2018， 44（5）： 664-669.DOI： 10.1016/j.ejso.2018.01.607.
［26］	Kaneko T， Tomiyama T， Kiyuna H， et al.Identification of Ryu’s segmentation of the liver using MDCT analysis［J］.J Nippon Med Sch，2010， 77（5）： 244-249.DOI： 10.1272/jnms.77.244.
［27］	Hata F， Hirata K， Murakami G， et al.Identification of segments Ⅵ and VII of the liver based on the ramification patterns of the intrahepatic portal and hepatic veins［J］.Clin Anat， 1999， 12（4）： 229-244.DOI：10.1002/（SICI）1098-2353（1999）12： 4229： AID-CA1＞3.0.CO；2-0.
［28］	Hata F， Murakami G， Hirata K， et al.Configuration of hepatic veins in the right surgical lobe of the human liver with special reference to their complementary territorial relationships： morphometric analysis of controlled specimens with clearly defined portal segmentation［J］.Okajimas Folia Anat Jpn， 1999， 76（1）： 1-16.DOI： 10.2535/ofaj1936.76.1_1.
［29］	Kogure K， Kuwano H， Fujimaki N， et al.Reproposal for Hjortsjo’s segmental anatomy on the anterior segment in human liver［J］.Arch Surg， 2002， 137（10）： 1118-1124.DOI： 10.1001/archsurg.137.10.1118.
［30］	Ogiso S， Ikai I， Narita M， et al.Parenchyma-sparing anatomical liver resection based on Hjortsjo’s concept： a venous-drainage-guided approach to identify the ventral segment fissure［J］.Langenbecks Arch Surg， 2013， 398（5）： 751-758.DOI： 10.1007/s00423-013-1069-2.
［31］	Monden K， Sadamori H， Hioki M， et al.Laparoscopic anatomic segmentectomy 8 using the outer-Laennec approach［J］.Surg Oncol，2020， 35： 299-300.DOI： 10.1016/j.suronc.2020.08.029.
［32］	Honda G， Kurata M， Okuda Y， et al.Totally laparoscopic hepatectomy exposing the major vessels［J］.J Hepatobiliary Pancreat Sci，2013，20（4）：435-440.DOI： 10.1007/s00534-012-0586-7.
［33］	向飞.右半肝门静脉3D分型及基于门静脉流域的计算机肝脏分段研究［D］.广州：南方医科大学， 2016.Xiang F.The research of 3D classification of right portal vein and computer-assissted liver segmentation based on portal territory［D］.Guangzhou：Southern Medical University， 2016.
［34］	杜秋国，李凯，张日新，等.三维可视化、荧光影像联合术中超声在腹腔镜解剖性肝切除术中的应用［J］.腹部外科，2024，37（3）：190-194.DOI：10.3969/j.issn.1003-5591.2024.03.007.Du QG，Li K，Zhang RX，et al.Application efficacy of threedimensional visualization technology，fluorescent imaging system and intraoperative ultrasound for laparoscopic anatomical liver resection［J］.J Abdom Surg，2024，37（3）：190-194.DOI：10.3969/j.issn.1003-5591.2024.03.007.

[1]	Hongxia Song, Wancheng Wu. Research progress in the development of incision approaches for endoscopic thyroid surgery [J]. Chinese Journal of Operative Procedures of General Surgery(Electronic Edition), 2024, 18(04): 470-472.
[2]	Jianping Hu, Zhenqian Wang, Long Zhang, Renqi Yin, Han Chen, Ren Zhao, Qiang Lv. Comparison of caudal median combined approach and caudal approach in laparoscopic radical resection of right colon cancer [J]. Chinese Journal of Operative Procedures of General Surgery(Electronic Edition), 2024, 18(02): 196-199.
[3]	Xiaohui Du, Yang Yan. Selection and principles of laparoscopic surgery for low and ultra-low rectal cancer [J]. Chinese Journal of Operative Procedures of General Surgery(Electronic Edition), 2023, 17(05): 477-479.
[4]	Xintuan Wang, Bo Li, Dong Li, Ning Ma, Baoping Li, Shuping Liu. Comparative study of Laennec membrane approach and Glisson sheath approach in laparoscopic anaphylactic hepatectomy [J]. Chinese Journal of Operative Procedures of General Surgery(Electronic Edition), 2023, 17(04): 418-422.
[5]	Benlei Zhu, Fuheng Liu, Taicheng Zhou, Shuang Chen, Bing Zeng, Wenchang Gan, Shaoyong Peng, Yingru Li. Exploration of surgical approach for removing infected meshes after groin hernia surgery [J]. Chinese Journal of Hernia and Abdominal Wall Surgery(Electronic Edition), 2025, 19(01): 63-68.
[6]	Chaobo Chen, Decai Yu. Key points，lines，and planes for laparoscopic anatomical liver resection [J]. Chinese Journal of Laparoscopic Surgery(Electronic Edition), 2024, 17(06): 321-328.
[7]	Ke Su, Yajuan Cao, Jin Peng, Laizhu Zhang, Decai Yu. Conversion therapy combined with laparoscopic radical hepatectomy in patient with advanced biliary tract cancer: Laennec approach [J]. Chinese Journal of Laparoscopic Surgery(Electronic Edition), 2023, 16(01): 49-51.
[8]	Di Zhou, Zhiwei Quan. Standardization on diagnosis and treatment process of benign gallbladder diseases to reduce misdiagnosis and inappropriate treatment [J]. Chinese Journal of Hepatic Surgery(Electronic Edition), 2024, 13(06): 749-753.
[9]	Ziyao Wang, Nengwen Ke. Timing and selection of surgical treatments for chronic pancreatitis [J]. Chinese Journal of Hepatic Surgery(Electronic Edition), 2024, 13(04): 466-471.
[10]	Houping Zhou, Tingzheng Ou, Mingming Shang, Yuan Yuan, Beibei Li, Benneng Yao. Application of extrathecal transection of Glisson's pedicle via Laennec's capsule combined with ICG fluorescence imaging in anatomic hepatectomy (video attached) [J]. Chinese Journal of Hepatic Surgery(Electronic Edition), 2024, 13(01): 57-61.
[11]	Xiaomei Wang, Yu Liu, Jinlei Dong, Fanxiao Liu, Chenglong Wang, Lianxin Li. Curative effect analysis of open reduction and internal fixation via single anterior approach for proximal humerus fracture combined with posterior dislocation of humeral head [J]. Chinese Journal of Shoulder and Elbow(Electronic Edition), 2024, 12(04): 319-325.
[12]	Kunpeng Leng, Yutong Meng, Lei Shan, Yang Liu, Junlin Zhou. Clinical observation of different surgical approaches for the treatment of distal humerus coronal fracture [J]. Chinese Journal of Shoulder and Elbow(Electronic Edition), 2024, 12(02): 127-134.
[13]	Guangwei Sun, Changlong Hu, Tao Qiu. Evaluation of the efficacy of neuroendoscopic treatment of pituitary tumors in the elderly with different surgical approaches [J]. Chinese Journal of Brain Diseases and Rehabilitation(Electronic Edition), 2023, 13(03): 169-174.
[14]	Hongqing Ma, Miao Yu, Jianfeng Zhang, Xueliang Wu, Xvhua Hu, Guanglin Wang, Zesong Meng, Bin Yv, Guiying Wang. Efficacy of hybrid versus traditional central approach for laparoscopic radical resection of rectal cancer [J]. Chinese Journal of Clinicians(Electronic Edition), 2023, 17(05): 545-550.
[15]	Dehong Yang, Yuhui Wan, Kai Yang, Ailin Chen, Chungang Dai, Yanming Chen, Binglin Chen, Qing Zhu. Clinical effect of microsurgical clipping via supraorbital keyhole approach of non-dominant feeder for ruptured anterior communicating artery aneurysm [J]. Chinese Journal of Cerebrovascular Diseases(Electronic Edition), 2024, 18(02): 115-120.

Please choose a citation manager

Content to export