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(Radiology. 2000;214:491-495.)
© RSNA, 2000

Gastrointestinal Imaging

Anatomy of the Right Anterosuperior Area (Segment 8) of the Liver: Evaluation with Helical CT during Arterial Portography1

Akihiro Cho, MD, Shinichi Okazumi, MD, Wataru Takayama, MD, Akihiko Takeda, MD, Koutaro Iwasaki, MD, Shinichi Sasagawa, MD, Toshiyuki Natsume, MD, Tuguaki Kono, MD, Satoru Kondo, MD, Takenori Ochiai, MD and Munemasa Ryu, MD

1 From the Second Department of Surgery, Chiba University School of Medicine, Japan (A.C., S.O., W.T., A.T., K.I., S.S., T.N., T.K., S.K., T.O.), and the Department of Surgery, National Cancer Center Hospital East, Chiba, Japan (M.R.). Received February 24, 1999; revision requested April 27; revision received June 4; accepted August 16. Address reprint requests to A.C., Department of Surgery, Sawara Prefectural Hospital, 2285 I Sawara, Chiba, 287-0003, Japan. (e-mail: cho@maple.ocn .ne.jp).


   Abstract
TOP
 Abstract
Introduction
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
PURPOSE: To evaluate the segmental anatomy of the right anterosuperior area (segment 8) of the liver by using helical computed tomography during arterial portography (CTAP).

MATERIALS AND METHODS: Twenty-seven patients without lesions at segment 8 underwent helical CTAP. Three-dimensional portograms were reconstructed to verify the course of the portal veins. The number of subsegmental branches, in addition to the branching point and the distribution in segment 8, was assessed.

RESULTS: In 25 (93%) patients, the dorsal branch of segment 8 gave rise to dorsally directed branches posterior to the right hepatic vein. In only four (25%) of 16 patients in whom the medial branch of segment 8 arose near the porta hepatis, the long paracaval portal branch of the caudate lobe extended upward above the interval between the middle and right hepatic veins.

CONCLUSION: In most of the patients, the dorsal branches of segment 8 supplied the dorsocranial area of the right lobe posterior to the right hepatic vein. The paracaval portion of the caudate lobe was limited to below the interval between the middle and right hepatic veins in the majority of patients who showed medial branches of segment 8 arising near the porta hepatis. Recognition of this vascular anatomy is clinically important for preoperative evaluation of hepatic tumors in segment 8 because it may contribute to a safer surgical approach.

Index terms: Computed tomography (CT), helical, 957.12915 • Computed tomography (CT), three-dimensional, 957.12917 • Liver, blood supply, 761.92 • Portal vein, anatomy, 957.92 • Portal vein, CT, 957.12915, 957.12916, 957.12917 • Portography, 761.1242, 957.1242


   Introduction
TOP
 Abstract
 Introduction
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
Patients with limited hepatic metastases from colorectal cancer who undergo surgical resection of the tumor have improved long-term survival rates compared with similar patients who do not undergo such resection (1–3). Most patients with small hepatocellular carcinomas have mild to severe cirrhosis. Thus, limited hepatic resection is indicated (4). Preoperative imaging must be performed to determine the number of hepatic lesions present and their segmental location and extent, as well as the relationship of these lesions to major venous structures. This information is vital both for determining which patients have resectable lesions and for planning the surgical approach (5).

Classifications proposed by Couinaud (6) and Bismuth (7) are widely accepted means of establishing the surgically relevant segmental anatomy of the liver. The liver is divided into eight segments, both longitudinally along the hepatic veins and transversely through the right and left portal pedicles. When a cross-sectional imaging technique is used, such as computed tomography (CT) or magnetic resonance (MR) imaging, lines drawn from the inferior vena cava straight through to the three hepatic veins coincide with the boundaries between segments—the longitudinal scissurae (8,9). Thus, it is believed that the longitudinal divisions can be clearly delineated on transverse images, since they run perpendicular to the axis of the scan (10).

However, we have often encountered a discrepancy between the findings for the longitudinal scissurae delineated on transverse scans and the avascular planes between the portal segments, especially in the right anterosuperior area (segment 8) of the liver (11,12). In addition, hepatocellular carcinoma has been found most frequently in segment 8 in patients who underwent systematic subsegmentectomies (4). Recent advances in helical CT have made visualization of the entire tiny vascular system possible, which allows for determination of the anatomy of small vessels. It has also become possible to easily reconstruct accurate and realistic three-dimensional images from arbitrary angles with helical CT (13,14). The purpose of the present study was to evaluate the segmental anatomy of segment 8 of the liver by using helical CT during arterial portography (CTAP).


   MATERIALS AND METHODS
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 References
 
Between April 1998 and January 1999, 51 consecutive patients with malignant hepatobiliary or pancreatic tumors underwent CTAP at our institution (Second Department of Surgery, Chiba University School of Medicine, Japan). Of these 51 patients, 27 patients (17 men, 10 women; age range, 28–72 years; mean age, 56.6 years) were enrolled in our study. All 27 patients met the following inclusion criteria: no lesions in segment 8 of the liver; no invasion of the hepatic hilum by cancer; no hepatic tumors, cirrhosis, or both that distorted the intrahepatic venous anatomy; and no previous hepatic surgery. In all 27 subjects, conventional CT, ultrasonographic (US), and MR images had been obtained for clinical reasons less than a week before CTAP and were used to determine if patients met the inclusion criteria.

Thirteen patients had metastatic hepatic tumor from colorectal cancer, seven had hepatocellular carcinoma, three had pancreatic cancer, two had gallbladder cancer, and the remaining two had bile duct cancer. The study protocol was approved by the institutional review board, and written informed consent was obtained from all patients.

All studies were performed with a commercially available helical CT scanner (Somatom Plus 4; Siemens, Erlangen, Germany). After a 5-F catheter was positioned in the superior mesenteric artery, the patient was transferred to the CT room to undergo CTAP. Helical CTAP was performed cephalocaudad with a single breath-hold helical technique and use of 5-mm collimation, 5 mm/sec table feed, 1-second scanning time per section, a pitch of 1, and contiguous 5-mm image reconstruction. For CTAP, 90 mL of iomeprol (Iomeron [300 mg of iodine per milliliter]; Eisai, Tokyo, Japan) diluted to one-half the concentration with saline solution was injected at a rate of 3 mL/sec during CT of the entire liver. The scanning delay after the start of the injection was 20 seconds.

Three-dimensional images of the portal system were displayed on a shaded surface display; they were created by using accessory software of the helical CT scanner, which depicted the shaded surface of the outer contour of the portal venous lumen. This method is based on an extraction of the contour from each of a consecutive series of CT sections, for which a threshold value is used to extract surface contours. For extraction of the portal venous contours, a threshold range of approximately 400–2,000 HU was chosen after evaluation of the models on the monitor.

In their study, Takayasu et al (15) divided the right anterosuperior portal branches into four subsegmental branches that were designated as (a) ventral, (b) dorsolateral, (c) dorsal, and (d) medial by using percutaneous transhepatic portograms. On the basis of the article by Takayasu et al (15), we divided the right anterosuperior portal branches into four subsegmental branches; P8a was defined on the basis of transverse CTAP images as the ventral branch, P8b as the dorsolateral branch, P8c as the dorsal branch, and P8d as the medial branch (Fig 1).



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  		Figure 1. Transverse diagram of the liver at the level of the confluence of the middle (M) and right (R) hepatic veins shows the four subsegmental branches of segment 8; P8a is defined as the ventral branch, P8b as the dorsolateral branch, P8c as the dorsal branch, and P8d as the medial branch.

 
P8d was further defined as the cranially directed portal branch that forked off the right anterior portal branches and was distributed over the interval between the entrance of the middle and right hepatic veins into the inferior vena cava. It was distinguished from the paracaval portal branches belonging to the paracaval portion of the caudate lobe, which branched off the left portal vein, the portal bifurcation, the portal trunk, the right portal vein, or the right posterior portal vein (16).

The original consecutive transverse CTAP images and three-dimensional portograms were interpreted in a separate blinded fashion by independent authors (A.C., T.N.) who are familiar with CT features and the anatomy of the liver. Any discrepancies that occured were resolved by consensus. We assessed the number of subsegmental portal branches of segment 8 and the branching point and pattern of distribution. Special attention was paid to the relationship between P8c and the right hepatic vein and the relationship between P8d and the paracaval portal branches. We did not investigate the right anteroinferior portal branches in the present study because the right anteroinferior area (segment 5) was supplied by multiple branches arising from the right anterior trunk directly, the right anterosuperior branches, or the first part of the right posterior trunk (11).


   RESULTS
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 References
 
In all 27 patients, the right anterosuperior portal vein bifurcated into P8a and P8c, which were approximately equal in size and were clearly visible on both transverse and three-dimensional images (Fig 2). In 15 (56%) patients, P8b branched off P8c. In nine (33%) patients, P8b branched off P8a. In three (11%) patients, P8b could not be detected (Table 1). In 25 (93%) patients, P8c was directed cranially and gave rise to dorsally directed branches that were distributed over the entire dorsocranial area of the right lobe posterior to the right hepatic vein (Fig 3).



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  		Figure 2a. Bile duct cancer in a 48-year-old man. (a) Transverse CTAP image shows both P8a (arrow) and P8c (arrowhead). (b) Transverse three-dimensional portogram shows a craniocaudal view of the portal system. The right anterosuperior portal vein bifurcates into P8a (arrow) and P8c (arrowhead), which are approximately equal in size.

 


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  		Figure 2b. Bile duct cancer in a 48-year-old man. (a) Transverse CTAP image shows both P8a (arrow) and P8c (arrowhead). (b) Transverse three-dimensional portogram shows a craniocaudal view of the portal system. The right anterosuperior portal vein bifurcates into P8a (arrow) and P8c (arrowhead), which are approximately equal in size.

 

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  		TABLE 1. Dorsolateral (P8b) Branching Points
 


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  		Figure 3a. (a) Transverse CTAP image obtained in a 68-year-old woman with pancreatic cancer shows P8c giving rise to dorsally directed branches (arrow) that are distributed over the entire dorsocranial area of the right lobe posterior to the right hepatic vein (arrowhead). (b) Transverse three-dimensional portogram obtained in a 51-year-old man with metastatic hepatic tumor from rectal cancer shows a left cranioventral-right caudodorsal view of the portal system. P8c is directed cranially and gives rise to dorsally directed branches (arrow).

 


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  		Figure 3b. (a) Transverse CTAP image obtained in a 68-year-old woman with pancreatic cancer shows P8c giving rise to dorsally directed branches (arrow) that are distributed over the entire dorsocranial area of the right lobe posterior to the right hepatic vein (arrowhead). (b) Transverse three-dimensional portogram obtained in a 51-year-old man with metastatic hepatic tumor from rectal cancer shows a left cranioventral-right caudodorsal view of the portal system. P8c is directed cranially and gives rise to dorsally directed branches (arrow).

 
On CTAP images, we observed three types of anatomic patterns of P8d. The type 1 pattern was characterized by a tiny portal branch that forked off the right anterior trunk or the first part of P8c (Fig 4). In the type 1 pattern, P8d branched off the proximal portion of the portal veins on the right side of the liver. The type 2 pattern was characterized by either a tiny portal branch that forked off P8a or the distal part of P8c, or no observed portal branch was identified as P8d (Fig 5). In the type 2 pattern, P8d was believed to branch off the distal portion of the portal veins on the right side of the liver. The type 3 pattern was characterized by multiple branches.



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  		Figure 4a. Pancreatic cancer in a 69-year-old man. (a) Transverse CTAP image shows P8d (arrow) between the entrance of the middle and right hepatic veins into the inferior vena cava. (b) Transverse three-dimensional portogram shows a left cranioventral-right caudodorsal view of the portal system. P8d (arrow) branches off the right anterior trunk.

 


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  		Figure 4b. Pancreatic cancer in a 69-year-old man. (a) Transverse CTAP image shows P8d (arrow) between the entrance of the middle and right hepatic veins into the inferior vena cava. (b) Transverse three-dimensional portogram shows a left cranioventral-right caudodorsal view of the portal system. P8d (arrow) branches off the right anterior trunk.

 


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  		Figure 5. Hepatocellular carcinoma in a 46-year-old man. Transverse CTAP image shows P8d (arrow) arising distally and being distributed over the interval between the entrance of the middle and right hepatic veins into the inferior vena cava.

 
Table 2 lists the frequency of the branching patterns observed in the study group. The type 1 pattern was seen in 16 (59%) patients. Types 2 and 3 were seen in eight (30%) and three (11%) patients, respectively.


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  		TABLE 2. Medial (P8d) Branching Patterns
 
Table 3 shows the relationship between the distribution of the three branching patterns of P8d and whether the long paracaval portal branch of the caudate lobe extended upward above the interval between the entrance of the middle and right hepatic veins into the inferior vena cava and could be detected on CTAP images. A long paracaval branch was detected in only four (25%) of 16 patients with the type 1 pattern. In contrast, a long paracaval branch was noted in six (75%) of eight patients with the type 2 pattern.


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  		TABLE 3. Correlation between the Branching Patterns of P8d and the Long Paracaval Branch of the Caudate Lobe
 

   DISCUSSION
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
References
 
Necessary preoperative imaging, which determines not only the number of lesions present but also the segmental location and extent of the lesions and their relationship to venous structures, is possible given recent advances in hepatic surgical oncology (4,17). Such information is vital for preoperative determination of the type of resection needed. CTAP images offer the advantage of clarifying the relationship between the hepatic parenchyma and the portal veins, thereby eliminating a large number of potentially confusing sectional images. In addition, three-dimensional images from arbitrary angles facilitate comprehension of the complex anatomic structures of the liver. In the anterior view, the ventral (P8a) and dorsal (P8c) branches are usually superimposed and cannot be distinguished (15). In contrast, craniocaudal views from three-dimensional shaded surface display images, which are not possible with use of conventional arterial or percutaneous transhepatic portograms, provide excellent resolution and thus make it easy to distinguish P8a from P8c.

In the present study, we found that the dorsal branches (P8c) of segment 8 gave rise to dorsally directed branches that were distributed over the entire dorsocranial area of the right lobe posterior to the right hepatic vein in 25 (93%) of the 27 patients examined. In a few previous studies (11,12), discrepancies between the right scissura and the plane that contains the right hepatic vein were reported.

van Leeuwen et al (11) reported that in most patients the area posterior to the right hepatic vein just below the diaphragm was supplied by posteriorly directed branches of the right anterior trunk. They found by using three-dimensional imaging that the mean angle of the right scissura was tilted 58.4° posteriorly relative to the coronal plane through the right hepatic vein in the cranial part of the liver. The posteriorly directed branches of the right anterior trunk described by van Leeuwen et al (11) were believed to be an equivalent of P8c. Ohashi et al (12) performed CT arteriography with selective catheterization of the right hepatic artery and concluded that the line that extended beyond the right hepatic vein from the inferior vena cava did not coincide with the right scissura on transverse images of the upper portion of the liver. These two descriptions are consistent with our results.

The boundary between segment 8 and the paracaval portion belonging to the caudate lobe (segment 1) is not clearly defined. Couinaud (18) determined by using injection-corrosion methods that the limit between segment 8 and the paracaval portion was an oblique plane extending from the posterior margin of the right portal pedicle up to the entrance of the middle and right hepatic veins into the inferior vena cava and that the long paracaval branches often extend upward above the fissure between segment 8 and the paracaval portion.

In the present study, a long paracaval branch was detected in only four (25%) of 16 patients in whom P8d branched off the proximal portion of the of the portal veins on the right side of the liver. In contrast, a long paracaval branch was detected in six (75%) of eight patients in whom P8d branched off the distal portion. We speculate that the paracaval portion of the caudate lobe is limited to below the interval between the middle and right hepatic veins in patients in whom P8d arises from the proximal portion of the portal veins on the right side of the liver.

As the portal, arterial, and biliary systems are grouped together in vasculobiliary sheaths (6), interruption of the elements within these sheaths will inevitably lead to depriving the region of its arterial and portal blood supply and also to the creation of bile stasis or leakage that result from a lack of intrahepatic anastomoses between the portal, arterial, and biliary structures of adjacent segments. Thus, the portal venous anatomy is a critical factor in candidates for systematic subsegmental hepatectomy.

Despite the fact that intraoperative US is presently used as a guide for hepatic resections to evaluate the portal venous anatomy and to determine the planes to be resected (4), knowledge of the exact anatomy prior to surgery is nonetheless required. In the present study of helical CTAP, a meticulous evaluation of the consecutive transverse images enabled an understanding of the individual portal branching and distribution pattern. However, three-dimensional reconstructions were often necessary, as the branching point of the portal veins could not be assessed by using transverse images alone. In addition, three-dimensional reconstructions provided images that were closer in appearance to surgically relevant hepatic segmental anatomy and enabled rational preoperative planning of surgical procedures.

Although CTAP provides precise anatomic information about the portal venous system, the procedure is relatively invasive. In our experience, helical CT with intravenously power-injected contrast material is a less invasive procedure that often provides valuable information with regard to anatomy of the portal veins. In a future study, we will attempt to compare both procedures for their relative usefulness in providing anatomic information.

In conclusion, although our study is limited in that only a small number of patients were examined, helical CTAP images showed that the dorsal branches (P8c) of segment 8 gave rise to dorsally directed branches that were distributed over the entire dorsocranial area of the right lobe posterior to the right hepatic vein in approximately 90% of the patients. In addition, the paracaval portion of the caudate lobe was limited to below the interval between the middle and right hepatic veins in the majority of patients in whom medial branches (P8d) of segment 8 arose from the proximal portion of the portal veins on the right side of the liver. We consider recognition of this vascular anatomy to be clinically important for a preoperative evaluation of hepatic tumors in segment 8 of the liver given that it may have implications for tumor resection and contribute to the development of a safer surgical approach.


   Acknowledgments
 
Special thanks to Eiji Ohishi, RT, Noriyuki Yanagawa, RT, Takashi Iimori, RT, and Mie Fukaya, RT, for processing the three-dimensional images.


   Footnotes
 
Abbreviation: CTAP = CT during arterial portography

Author contributions: Guarantors of integrity of entire study, S.O., T.O.; study concepts, A.C., M.R.; study design, A.C., T.N.; definition of intellectual content, A.C.; literature research, A.C.; clinical studies, A.C., W.T., K.I., S.S., T.K.; data acquisition, A.C., T.N., A.T., S.K.; data analysis, A.C., T.N.; manuscript preparation, editing, and review, A.C.


   References
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 

  1. Wagner JS, Adson MA, Van Heerden JA, Adson MH, Ilstrup DM. The natural history of hepatic metastases from colorectal cancer: a comparison with resective treatment. Ann Surg 1984; 197:502-508.
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  6. Couinaud C. Le foie In: Couinaud C, ed. Etudes anatomiques et chirurgicales. Paris: Masson, 1957.
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