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Stepwise Evaluation of Liver Sectors and Liver Segments by Endoscopic Ultrasound

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Stepwise Evaluation of Liver Sectors and Liver Segments by Endoscopic Ultrasound Submit a Manuscript: http://www.f6publishing.com World J Gastrointest Endosc 2018 November 16; 10(11): 326-339 DOI: 10.4253/wjge.v10.i11.326 ISSN 1948-5190 (online) REVIEW Stepwise evaluation of liver sectors and liver segments by endoscopic ultrasound Malay Sharma, Piyush Somani, Chittapuram Srinivasan Rameshbabu, Tagore Sunkara, Praveer Rai Malay Sharma, Piyush Somani, Department of Gastro­ India. [email protected] enterology, Jaswant Rai Speciality Hospital, Meerut 25001, Uttar Telephone: +91­983­7031148 Pradesh, India Fax: +91­121­2657154 Piyush Somani, Department of Gastroenterology, Thumbay Received: May 25, 2018 Hospital, Dubai 415555, United Arab Emirates Peer-review started: May 25, 2018 First decision: June 14, 2018 Chittapuram Srinivasan Rameshbabu, Department of Anatomy, Revised: August 16, 2018 Muzaffarnagar Medical College, Muzaffarnagar 251001, Uttar Accepted: October 17, 2018 Pradesh, India Article in press: October 17, 2018 Published online: November 16, 2018 Tagore Sunkara, Department of Gastroenterology and Hepa­ tology, the Brooklyn Hospital Center, Clinical Affliate of The Mount Sinai Hospital, Brooklyn, NY 11201, United States Praveer Rai, Department of Gastroenterology, Sanjay Gandhi Abstract Post Graduate Institute, Lucknow 226014, Uttar Pradesh, India The liver has eight segments, which are referred to by numbers or by names. The numbering of the segments ORCID number: Malay Sharma (0000­0003­2478­9117); is done in a counterclockwise manner with the liver Piyush Somani (0000­0002­5473­7265); Chittapuram Srinivasan Rameshbabu (0000­0002­6505­2296); Tagore Sunkara (0000­00 being viewed from the inferior surface, starting from 01­9536­9027); Praveer Rai (0000­0002­5041­619X). Segment Ⅰ (the caudate lobe). Standard anatomi- cal description of the liver segments is available by Author contributions: Sharma M wrote the manuscript; Somani computed tomographic scan and ultrasonography. P, Rameshbabu CS, Sunkara T, and Rai P edited the manuscript; Endoscopic ultrasound (EUS) has been used for a Sharma M, Somani P, and Rameshbabu CS designed the study. detailed imaging of many intra-abdominal organs and for the assessment of intra-abdominal vasculature. A Conflict-of-interest statement: Authors declare no conflict of stepwise evaluation of the liver segments by EUS has interests for this article. not been described. In this article, we have described Open-Access: This article is an open­access article which was a stepwise evaluation of the liver segments by EUS. selected by an in­house editor and fully peer­reviewed by external This information can be useful for planning successful reviewers. It is distributed in accordance with the Creative radical surgeries, preparing for biopsy, portal vein Commons Attribution Non Commercial (CC BY­NC 4.0) license, embolization, transjugular intrahepatic portosystemic which permits others to distribute, remix, adapt, build upon this shunt, tumour resection or partial hepatectomy, and work non­commercially, and license their derivative works on for planning EUS guided diagnostic and therapeutic different terms, provided the original work is properly cited and procedures. the use is non­commercial. See: http://creativecommons.org/ licenses/by­nc/4.0/ Key words: Endoscopic ultrasound; Hepatic vein; Liver Manuscript source: Invited manuscript sectors; Portal vein; Liver segments; Caudate lobe; Cantlie’s line; Falciform ligament; Gallbladder Correspondence to: Malay Sharma, MD, Doctor, Department of Gastroenterology, Jaswant Rai Speciality Hospital, Saket, © The Author(s) 2018. Published by Baishideng Publishing Meerut 25001, Uttar Pradesh, Group Inc. All rights reserved. WJGE|www.wjgnet.com 326 November 16, 2018|Volume 10|Issue 11| Sharma M et al . EUS of liver segments and liver sectors Core tip: Standard anatomical description of the liver Table 1 The sectors and the segments of liver segments is available by computed tomographic scan and ultrasonography. A stepwise evaluation of the Four hepatic sectors Eight hepatic segments liver segments by endoscopic ultrasound (EUS) has Segment Ⅰ - the caudate lobe not been described. In this article, we have described Left lateral sector Segment Ⅱ - posterosuperior a stepwise evaluation of the liver segments by EUS. Segment Ⅲ - anteroinferior Left medial sector Ⅳa - superior segment This information can be useful for planning successful Ⅳb - inferior segment radical surgeries, preparing for biopsy, portal vein Right anterior sector Segment Ⅴ - inferior segment embolization, transjugular intrahepatic portosystemic Segment Ⅷ - superior segment shunt, tumour resection or partial hepatectomy, and Right posterior sector Segment Ⅵ - inferior segment for planning EUS guided diagnostic and therapeutic Segment Ⅶ - superior segment procedures. This table shows the relationship of hepatic sectors and hepatic seg- ments. The four segments of left liver are: Ⅰ (caudate); Ⅱ (left lateral superior); Ⅲ (left lateral inferior); and Ⅳ (left medial) [subdivided into Sharma M, Somani P, Rameshbabu CS, Sunkara T, Rai P. superior (Ⅳa) and inferior parts (Ⅳb) by Bismuth]. The four segments of Stepwise evaluation of liver sectors and liver segments by right liver are: Ⅴ (right anteroinferior); Ⅵ (right posteroinferior); Ⅶ (right endoscopic ultrasound. World J Gastrointest Endosc 2018; posterosuperior) and Ⅷ (right anterosuperior). The caudate lobe is often 10(11): 326­339 Available from: URL: http://www.wjgnet. called an independent segment. com/1948­5190/full/v10/i11/326.htm DOI: http://dx.doi. org/10.4253/wjge.v10.i11.326 Right lobe Left lobe Right posterior Right Left Left lateral anterior medial INTRODUCTION RHV MHV LHV The French surgeon and anatomist Claude Couinaud described “two lobes” (right and left), “two hemilivers” Ⅶ Ⅷ (right and left), “four sectors,” and “eight segments” Ⅱ of the liver. The two lobes are separated by the Ⅰ Ⅳa falciform ligament, the two hemilivers are separated by the Cantlie’s line, the four sectors are separated by LPV (U.S.) Ⅲ P A the planes of three hepatic veins (portal fissures or LPV (T.S.) RPV scissurae), and the eight segments are separated by Ⅳb an imaginary transverse plane passing by the portal Ⅵ [1] vein bifurcation (Figure 1 and Table 1) . Each of the Falciform segments is an independent segment and has its own Ⅴ ligament vascular inflow, outflow, and biliary drainage. The Gallbladder segments are referred to by number or by names[2,3]. The numbering of the segments is done in a counter­ Figure 1 Three vertical planes and a transverse plane divide the liver into clockwise manner starting from Segment Ⅰ (the caudate four sectors and eight segments. The vertical planes divide the liver into lobe). The segments Ⅱ to Ⅳ belong to the left and four sectors. The transverse plane divides the liver into superior and inferior segments Ⅴ to Ⅷ belong to the right hemiliver (Table segments. LHV: Left hepatic vein; MHV: Middle hepatic vein; RHV: Right hepatic 1)[2­4]. Standard anatomical description of the liver vein; LPV: Left branch of the portal vein; RPV: Right branch of the portal vein. segments is available by computed tomographic (CT) [5] scan . A stepwise evaluation of the liver segments divide the liver into four vertical sectors: right anterior, [6,7] is also described by ultrasonography . Endoscopic right posterior, left medial and left lateral (Figure 1). ultrasound (EUS) has been used for detailed imaging of The plane of portal vein bifurcation creates a transverse many intra­abdominal organs and for the assessment of plane that crosses the vertical planes and divides the [8­11] intra­abdominal vasculature . A stepwise evaluation four sectors into eight segments (Figures 1 and 2A, and of the liver segments by EUS has not been described. Table 1). The right hepatic vein lies in the right portal In this article, we describe a stepwise evaluation of the fissure and separates the right hemiliver into anterior liver segments by EUS. and posterior sectors. The left hepatic vein lies in the left portal fissure and separates the left hemiliver into APPLIED ANATOMY AND THE HOME medial and lateral sectors. The middle hepatic vein lies in the main portal fissure and separates the anterior BASES FOR IMAGING division of right liver from the medial division of the left The home bases of liver imaging are given in the figure liver. The main portal vein bifurcates into the right and and the table (Figure 2A and Table 2). The main key the left branches, which travel in an imaginary trans­ of the imaging is following the hepatic vein tributaries verse plane of the transverse fissure. The extrahepatic and the portal vein branches. The three hepatic veins part of the left branch of the portal vein is known as the WJGE|www.wjgnet.com 327 November 16, 2018|Volume 10|Issue 11| Sharma M et al . EUS of liver segments and liver sectors Table 2 The home bases of imaging for liver segments Home bases Defining of segments Hepatic veins LHV separates Ⅱ and Ⅲ from Ⅳ (a and b) MHV separates Ⅳa from Ⅷ and Ⅳb from Ⅴ RHV separates Ⅴ from Ⅵ and Ⅷ from Ⅶ Portal vein and its branches Superior segments lie above and inferior segments lie below the transverse fissure The LPV supplies segments Ⅱ to Ⅳ The RPV supplies segments Ⅴ to Ⅷ IVC IVC passes through the bare area of the liver and is related to superior segments in the upper part, segment Ⅰ for most of its course, and with segment Ⅵ close to the lower most part above the right kidney IVC suprahepatic part A transverse plane defines the upper limit of superior segments (Ⅱ, Ⅳ, Ⅷ, and Ⅶ) Ligamentum
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