Liver segments: an anatomical rationale for explaining inconsistencies with Couinaud's eight-segment concept. 2010

Jean H D Fasel, and Pietro E Majno, and Heinz-Otto Peitgen
Clinical Anatomy Research Group, Department of Cellular Physiology and Metabolism, University Medical Centre, Rue M. Servet 1, 1211 Geneva 4, Switzerland. jean.fasel@unige.ch

OBJECTIVE An increasing number of surgical and radiological observations call Couinaud's concept of eight liver segments into question and such inconsistencies are commonly explained with anatomical variations. This paper was intended to demonstrate that, beyond variability, another anatomical principle may allow to understand supposedly differing concepts on liver segmentation. METHODS The study was performed on 25 portal vein casts scanned by helical CT. The branches of the right and left portal vein and their corresponding territories were determined both anatomically and mathematically (MEVIS LiverAnalyzer, MEVISLab). RESULTS The number of branches coming-off the right and left portal vein was never 8, but many more (mean number 20, range 9-44). Different combinations of these branches and their respective territories, carried out in this study, yielded larger entities and supposedly contradictory subdivisions (including Couinaud's eight segments), without calling upon anatomical variability. CONCLUSIONS We suggest the human liver to be considered as corresponding to 1 portal venous territory at the level of the portal vein, to 2 territories at the level of the right and left branch of the portal vein, and to 20 at the level of the rami of the right and left branch. This "1-2-20-concept" is a rationale for reconciling apparent discrepancies with the eight-segment concept. On a pragmatic level, in cases in which imaging or surgical observations do not fit with Couinaud's scheme, we propose clinicians not to autonomically conclude to the presence of an anatomical variation, but to become aware of the presence of an average of 20 (and not 8) second-order portal venous territories within the human liver.

UI MeSH Term Description Entries
D008099 Liver A large lobed glandular organ in the abdomen of vertebrates that is responsible for detoxification, metabolism, synthesis and storage of various substances. Livers
D008297 Male Males
D008875 Middle Aged An adult aged 45 - 64 years. Middle Age
D011169 Portal Vein A short thick vein formed by union of the superior mesenteric vein and the splenic vein. Portal Veins,Vein, Portal,Veins, Portal
D005260 Female Females
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D000368 Aged A person 65 years of age or older. For a person older than 79 years, AGED, 80 AND OVER is available. Elderly
D000369 Aged, 80 and over Persons 80 years of age and older. Oldest Old

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