1、1.iverSegmenta1.AnatomyRobinSmithu1.s1.iveranatomycanbedescribedusingtwodifferentaspects:morpho1.ogica1.anatomyandfunctiona1.anatomy.Thetraditiona1.morpho1.ogica1.anatomyisbasedontheexterna1.appearanceofthe1.iveranddoesnotshowtheinterna1.featuresofvesse1.sandbi1.iaryductsbranching,whichareofobviousi
2、mportanceinhepaticsurgery.C.Couinaud(1957)dividedthe1.iverintoeightfunctiona1.1.yindepedentsegments.Thisc1.assificationwi1.1.bepresentedherewithsevera1.i1.1.ustrations.Couinaudc1.assificationTheCouinaudc1.assificationof1.iveranatomydividesthe1.iverIntoeightfunctiona1.1.yindepedentsegments.Eachsegmen
3、thasitsownvascu1.arinf1.ow,outf1.owandbi1.iarydrainage.Inthecentreofeachsegmentthereisabranchoftheporta1.vein,hepaticarteryandbi1.educt.Intheperipheryofeachsegmentthereisvascu1.aroutf1.owthroughthehepaticveins.Righthepaticveindividestheright1.obeintoanteriorandposteriorsegments.Midd1.ehepaticveindiv
4、idesthe1.iverintorightand1.eft1.obes(orrightand1.efthemi1.iver).Thisp1.anerunsfromtheinferiorvenacavatothega1.1.b1.adderfossa.1.efthepaticveindividesthe1.eft1.obeintoamedia1.and1.atera1.part.Porta1.veindividesthe1.iverintoupperand1.owersegments.The1.eftandrightporta1.veinsbranchsuperior1.yandinferio
5、r1.ytoprojectintothecenterofeachsegment.Becauseofthisdivisionintose1.f-containedunits,eacsegmentcanberesectedwithoutdamagingthoseremaining.Forthe1.ivertoremainviab1.e,resectionsmustproceeda1.ongthevesse1.sthatdefinetheperipheriesofthesesegments.Thismeans,thatresecbo-1.inespara1.1.e1.thehepaticvans,T
6、hecentra1.1.y1.ocatedporta1.veins,bi1.educts,andhepaticarteriesarepreserved.根据Couinaud分段SegmentsnumberingThereareeight1.iversegments.Segment4issometimesdividedintosegment4aand4baccordingtoBismuth.Thenumberingofthesegmentsisinac1.ockwisemanner(figure).Segment1(caudate1.obe)is1.ocatedposterior1.y.Itis
7、notvisib1.eOnafronta1.view.娱时仲数字标记段Thei1.1.ustrationsaboveareschematicpresentationsofthe1.iversegments.Inrea1.ityhowevertheproportionsaredifferent.Onanorma1.fronta1.viewthesegments6and7arenotvisib1.ebecausetheyare1.ocatedmoreposterior1.y.Therightborderofthe1.iverisformedbysegment5and8.A1.thoughsegme
8、nt4ispartofteIefthemi1.iver,itissituatedmoretotheright.Couinauddividedthe1.iverintoafunctiona1.1.eftandright1.iver(inRench,gaucheetdroite(oie)byamainporta1.Scissuraecontainingthemidd1.ehepaticvein.ThisisknownasCant1.ies1.ine.Cant1.ies1.inerunsfromthemidd1.eofthega1.1.b1.adderfossaanterior1.ytotheinf
9、eriorvenacavaposterior1.y.Onthisi1.1.ustrationIt1.ooksasifthemedia1.partofthe1.eft1.obeisseparatedfromthe1.atera1.partbythefa1.ciform1.igament.Howeveritactua1.1.yisthe1.efthepaticvein,thatseparatesthemedia1.part(segment4)fromthe1.atera1.part(segments2and3).The1.efthepaticveinis1.ocateds1.ight1.ytoth
10、e1.eftofthefa1.ciform1.igament.从前方看.在不到六.七段TransverseanatomyThefar1.eftfigureisatransverseimagethroughthesuperior1.iversegments,thataredividedbythehepaticveins.Therightfigureshowsatransverseimageatthe1.eve1.ofthe1.eftporta1.vein.Atthis1.eve1.the1.eftporta1.veindividesthe1.eft1.obeofthe1.iverintothes
11、uperiorsegments(2and4A)andtheinferiorsegments(3and电.The1.eftporta1.veinisatahigher1.eve1.thantherightporta1.vein.左：在左门静射:以上水平右：在左门静脉水平Theimageonthefar1.eftisatthe1.eve1.oftherightporta1.vein.Atthis1.eve1.therightporta1.veindividestheright1.obeofthe1.iverintosuperiorsegments(7and8)andtheinferiorsegme
12、nts(5and6).The1.eve1.oftherightporta1.veinisinferiortothe1.eve1.ofthe1.eftporta1.vein.Atthe1.eve1.ofthesp1.enicvein,whichisbe1.owthe1.eve1.Oftherightporta1.vein,on1.ytheinferiorsegmentsareseen(rightimage).左：在右门静脉水平i在睥怖脉水平CaudateIobeThecaudate1.obeorsegment1is1.ocatedposterior1.y.Thecaudate1.obeisana
13、tomica1.1.ydifferentfromother1.obesinthatitoftenhasdirectconnectionstotheIVCthroughhepaticveins,thatareseparatefromthemainhepaticveins.Thecaudate1.obemaybesupp1.iedbybothrightand1.eftbranchesoftheporta1.vein.Onthe1.eftapatientwithcihosiswithextremeatrophyoftheright1.obe,norma1.vo1.umeofthe1.eft1.obe
14、andhypertrophyofthecaudate1.obe.Duetoadifferentb1.oodsupp1.ythecaudateIobeissparedfromthediseaseprocessandhypertrophiedtocompensateforthe1.ossofrxmaIiverparenchyma肝硬化尾叶增大注场右叶缩小OtherC1.assificationsandVariantsTherearemanyotheranatomica1.andfunctiona1.descriptionsofthe1.iveranatomy.Inthec1.assica1.des
15、criptiontheexterna1.appearanceofthe1.iverisusedtodescnbetheanatomy.Howevertherearemanydifferencesbetweenthisc1.assica1.mode1.andthefuctiona1.mode1.s,aspopu1.arizedbyCouinaudandBismuth.Amoredetai1.eddiscussionofthevariousmode1.sisgiveninreference4.C1.assica1.AnatomyThec1.assica1.desiptionofthe1.ivera
16、natomybasedontheexterna1.appearance.Onthediaphragmaticsurface,theIigamentumfa1.ciformedividesthe1.iverintotherightand1.eftanatomic1.obes,whichareverydifferentfromtefunctiona1.rightand1.eft1.obes(orrightand1.efthemi1.iver).Inthisc1.assica1.description,thequadrate1.obebe1.ongstotherightIObeofthe1.iver
17、butfunctiona1.1.ytispartof1.eft1.obe.Bismuthsc1.assificationThisc1.assificationisverysimi1.artotheCouinaudc1.assification,a1.thoughtherearesma1.1.differences.Itispopu1.arintheUnitedStates,vh1.eCouinaud1Sc1.assificationismorepopu1.arinAsiaandEurope.AcrdingtoBismuththreehepaticveinsdividethe1.iverint
18、ofoursectors,furtherdividedintosegments.Thesesectorsaretermedporta1.sectorsaseachissupp1.iedbyaporta1.pedic1.einthecentre.Theseparation1.inebetweensectorscontainahepaticvein.Thehepabcveinsandporta1.pedice1.sareintertwined,asarethefingersoftwohands.The1.eftporta1.sdssuradividesthe1.eft1.iverintotwose
19、ctors:anteriorandposterior.1.eftanteriorsectornsistsoftwosegments:segmentNwhichisthequadrate1.obeandsegmentIII,wkisanteriorpartofanatomica1.1.eftkbe.Thesetwosegmentsareseparatedbythe1.efthepaticfissureorumbi1.ica1.fissure.1.eftposteriorsectorconsistsOfon1.yonesegmentII.Itistheposteriorpartof1.eft1.o
20、be.VariationsIntheCouinaudc1.assification1.itt1.eattentionisgiventothehighpreva1.enceofanatomica1.variationswhichoccur;especia1.1.yintherighthemi1.iver.Usingvo1.umetricacquisitiontechniques,sputedtomographyscanning,detai1.edinsightintotheindividua1.segmenta1.anatomycannowbeobtainedinanon-invasiveman
21、ner(2,3)Thesignificanceofthisanatomica1.insight1.iesinthep1.anningofanatomica1.resections,wherebythere1.ationshipbetweentumourandindividua1.segmenta1.anatomycanbedepictedinathree-dimensiona1.formatThreedimensiona1.1.iverimagingisofmostpractica1.va1.ueifaresectionofoneormoresegmentsorsectorsisconside
22、red,especia1.1.yintherighthemi1.iver.Inthesecases,3D1.iverimagingcandemonstratetheprecise1.ocationofthescissrastothesurgeonpreoperative1.y.The8anatomica1.pointsofinterest:注意下面8个解剖标志theinferiorvenacava,therighthepaticvein,themedia1.hepaticvein,the1.efthepaticvein,thedeep1.igamentVenOSUm,thesuperficia1.1.igamentvenosumrthe1.eft1.obetipandtherightporta1.veinFigure1:Definitionof1.iverssegments(1.eft)andsamp1.eof1.iversurgeryptenifcatkn(right).国12.IH1.a的解剖如段A.前外表；B.后外表
