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Anatomy of the Right Anterior Sector of the Liver and Its Clinical Implications in Surgery

  • Review Article
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Background

Surgery remains the gold standard both for delimited hepatocellular carcinoma by selective anatomic liver segentectomy and for colorectal liver metastases by parenchymal sparing liver resection. Right anterior sector (RAS) (segments V–VIII; Couinaud) is the largest and most difficult sector to operate on. A better knowledge of its segmentation could prevent postoperative remnant liver ischemia and its impacts on patient’s survival.

Methods

A literature search was conducted in PubMed for papers on anatomy and surgery of the right anterior sector.

Results

Segmentation of the RAS depended of the anatomic variations of the third-order portal branches. Cranio-caudal segmentation was the most commonly found (50–53%), followed by ventro-dorsal (23–26%), trifurcation (13–20%), and quadrifurcation types (5–11%). Ventral and dorsal partial or total subsegmentectomy seemed accessible in 47 to 50% of patients, including bifurcation, trifurcation, and quadrifurcation types, and could spare up to 22% of the total liver volume. The RAS hepatic vein was present in 85–100% of the patients and could be used as a landmark between RAS dorsal and ventral part in 63% of patients. Reported overall morbidity rate of RAS subsegmentectomy ranged from 33 to 59% among studies with a postoperative major complication rate (Clavien-Dindo ≥ III) ranging around 18% and a biliary leakage rate from 16 to 21%. In-hospital reported mortality rate was low (0–3%), and results were comparable to “classic” liver resections. RAS subsegmentectomy remains a complex procedure; median operating time ranged from 253 to 520 min and median intraoperative blood loss reached 1255 ml.

Conclusion

Better knowledge of RAS anatomy could allow for parenchymal preservation by using subsegmentectomy of the RAS, selective or as a part of a major hepatectomy.

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Acknowledgements

The authors wish to express their gratitude to Dr. Philip Robinson (DRCI, Hospices Civils de Lyon) for his valuable contribution to the manuscript.

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Authors and Affiliations

  1. Hospices Civils de Lyon, Department of Surgical Oncology, Centre Hospitalier Lyon Sud, 165 Chemin du Grand Revoyet, 69310, Pierre Benite, France

    Jean-Baptiste Cazauran, Lucas Pâris, Frédéric Mercier, Vahan Kepenekian & Guillaume Passot

  2. Hospices Civils de Lyon, Department of Radiology, Centre Hospitalier Lyon Sud, 165 Chemin du Grand Revoyet, 69310, Pierre Benite, France

    Pascal Rousset

  3. EMR 3738, Claude Bernard University, Lyon 1, Lyon, France

    Pascal Rousset & Guillaume Passot

  4. Faculté de Médecine Lyon Sud-Charles Mérieux, Laboratoire d’Anatomie, Université de Lyon, Chemin du Petit Revoyet, 69600, Oullins, France

    Anthony Viste

  5. Department of Orthopaedic Surgery, Hospices Civils de Lyon, 165 Chemin du Grand Revoyet, 69310, Pierre Benite, France

    Anthony Viste

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  1. Jean-Baptiste Cazauran
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Contributions

Jean-Baptiste Cazauran: conception and design, literature review, cadaveric dissection, illustrations, drafting.

Lucas Pâris: conception and design, literature review, cadaveric dissection, drafting of manuscript.

Pascal Rousset: illustrations and medical imaging, critical revision of manuscript.

Frédéric Mercier: literature review, drafting of manuscript, critical revision of manuscript.

Vahan Kepenekian: literature review, drafting of manuscript, critical revision of manuscript.

Anthony Viste: cadaveric dissection, drafting of manuscript, critical revision of manuscript.

Guillaume Passot: conception and design, drafting of manuscript, cadaveric dissection, critical revision.

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Correspondence to Guillaume Passot.

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Cazauran, JB., Pâris, L., Rousset, P. et al. Anatomy of the Right Anterior Sector of the Liver and Its Clinical Implications in Surgery. J Gastrointest Surg 22, 1819–1831 (2018). https://doi.org/10.1007/s11605-018-3831-9

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