Vascular

In 1954, the French famous human anatomy Coinaud C, Horst, Healey, Schroon and others on the basis of the study of the liver, based on the research of the bodies of the liver to Glisson system was put forward, on the basis of the distribution of hepatic vein for piecewise line segmentation method (Fig1) liver.Then with the further understanding of human on the liver, improve (Fig2, 3) several times, and gradually formed the modern liver surgery - Couinaud segments liver anatomical basis.
Counaud liver segment with 3 hepatic vein as vertical plane, longitudinal main crack (middle of crack, crack between the left lobe and right lobe cleft), by the portal vein, proper hepatic artery and bile duct system composed of Glisson contorts the system within the liver, mainly in the liver portal vein contorts primarily divided into two and a half, four area, 8 liver segmental (Fig4).One branch of liver paragraphs are Glisson system blood supply and drainage of bile, between paragraphs hepatic vein reflux, drainage of adjacent liver blood.Due to the particularity of caudate lobe, initially Couinaud define it as a separate Ⅰ section, with the deepening of the understanding of caudate lobe, Couinaud to be called back again in 1989 sectors.In 1994 and will be back sector is divided into Ⅰ, Ⅸ two segments.So ouinaud liver segment will appear in the different literature eight or nine paragraphs.The hepatic segment division method for clinical imaging diagnosis of liver, anatomical liver resection provides an important anatomical basis, has epoch-making significance in the development of liver surgery.
Withthe deepening of the research on liver anatomy physiology, found Couinaud liver segmentation is not completely in line with the actual distribution of intrahepatic duct, through a single plane to determine the boundary between portal vein simplification.Cho will therefore portal right front is divided into the ventral and dorsal, and put forward the right half liver is divided into the ventral segment, paragraph 3 and paragraph after dorsal segment and new ideas.This kind of the period of the new method is helpful for liver surgery on a more secure in the direction of development.Takasaki pointed out that the liver blood supply is derived from the three secondary branch of Glisson system, each secondary branch supply 1 liver segment, and the liver is divided into three main parts: the left, right and middle segment, each accounted for 30% of liver volume, and have been accepted level branch additional part of nutrition, known as the caudate lobe, accounted for 10% (Fig5).Despite the various new liver segmentation point of view, but with Glisson system branch blood supply and drainage of bile, in hepatic vein segment boundaries between adjacent liver blood and drainage of Couinaud hepatic segment division method is still the anatomical basis of modern liver segmentation research.Has not been the various segmentation methods to break through dividing principle, is essentially the Couinaud hepatic segments dividing method of modification and supplement.
Liver functional anatomy of the block is an ideal segmentation methods liver surgery.Divided according to the intrahepatic portal vein system blood flow distribution in the liver segment volume can reflect actual liver segment and the size of the volume, which can realize the functional section, avoid Couinaud segmented the uncertain factors of liver.But the segmentation method in practice is very difficult.Some scholars put forward the method of combined use of intraoperative ultrasound and Pringle has such as blood vessel blocking technology, although can achieve anatomical liver resection, but the technology for the liver anatomy and intraoperative ultrasound technology requirement is too high for the merger or partial liver cirrhosis atrophy when there are anatomical marks is difficult to identify faults.
Three-dimensional (3 d) imaging of the liver parenchyma, portal venous system and hepatic arterial system, biliary system, hepatic vein system, and the pathological changes in 3 d building, form a transparent, visualization, can be any combination of 3 d digital model, and then simulate the liver vascular supply situation, subsection (Fig6) on liver functional anatomy.Affiliated hospital of Qingdao university professor dong 蒨 led digital medical team with hisense medical cooperation, research and development of hisense hisense (CAS) computer assisted surgery system, hisense surgical intelligent display system (hisense SID), etc. Series of products, can achieve the newborn, child and adult liver patients of all ages 3 d building, liver segment, can be simulated liver resection, preoperative planning operation, etc., for the preoperative liver function evaluation and providing the basis of the exact operation scheme of the design, make liver segment of individualized, the accuracy of liver resection possible.At the same time, professor dong 蒨 joint baidu medical, hisense, a collection of different ages, different disease, disease of different stages of 3 d building digital liver model construction of "digital human liver database cooperation platform", achieve global sharing of human liver data, effective abandon rare rare mutations anatomy of the liver, liver diseases can't follow-up clinical data statistics, or incomplete, uncertain factors such as failure, in order to further improve the Couinaud liver segment for intuitive, adequate and effective clinical digital data, to break through the Couinaud liver segmentation principle, achieve real functional anatomy section provides research platform.
review:张刚,图片:朱呈瞻、吴莹

Fig1 Segmental organization of the liver (From: Blumgart LH, ed. Surgery of the Liver and Biliary Tract. 2nd ed. London: Churchill-Livingstone; 1994, with permission.)

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Fig2 Anatomy of the liver according to Couinaud[2]

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Fig3 Anatomy of the liver according to Couinaud, modified by the author[2]

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Fig4 Order division into numbered segments[3]

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Fig5 Takasaki’s concept of liver segmentation[2]

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Fig6 Calculation of the drainage area of the tributaries of the middle hepatic vein

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Reference

[1] Billingsley KG, Jarnagin WR, Fong Y, Blumgart LH. Segment-oriented hepatic resection in the management of malignant neoplasms of the liver. Journal of the American College of Surgeons 1998;187:471-81.
[2] Bismuth H. Revisiting Liver Anatomy and Terminology of Hepatectomies. Ann Surg 2013;257:383-6.
[3] Strasberg SM, Phillips C. Use and Dissemination of the Brisbane 2000 Nomenclature of Liver Anatomy and Resections. Ann Surg 2013;257:377-82.
[4] Mise Y, Tani K, Aoki T, Sakamoto Y, Hasegawa K, Sugawara Y, et al. Virtual liver resection: computer-assisted operation planning using a three-dimensional liver representation. Journal of hepato-biliary-pancreatic sciences 2013;20:157-64.