Sinistroposition of the gallbladder and the common bile duct.

A left lateral bisegmentectomy was performed in a 29-year-old man presenting a primary lymphoma of the liver. Surgical exploration revealed a left-side gallbladder, located under the left lobe of the liver. During hepatic parenchyma dissection, performed strictly at the left of the round ligament and the umbilical portion of the left portal vein, common bile duct was injured.

The caudate lobe of the liver: implications of embryology and anatomy for surgery.

The anatomy of the caudate lobe has technical and possibly oncologic implications for surgeons. The complex anatomy of the lobe is clarified by embryologic and anatomic analysis. This posterior sector is embryonically and anatomically independent of the right and left liver and the main portal fissure.

[Errors in the topographic diagnosis of liver diseases].

To identify the portal pedicles in liver pathology is difficult: anatomical variations are ignored and only the modal disposition is retained, the obliquity of the liver in situ is ignored: strongly inclined to the right, posteriorly and inferiorly (the anterior sector is above and to the right of the posterior sector, their pedicles in an antero-posterior radiogram are superposed); and the sizes of segments IV and VI are quite variable (embryologic result). This study was made with a collection of 111 vasculo-biliary acrylic casts. The main portal fissure containing the middle hepatic vein follows the axis of the cystic fossa.

The dorsal sector of human liver: embryological, anatomical and clinical relevance.

The dorsal liver sector has been recognized as the parenchyma surrounding the vena cava and is quite independent of the remaining liver. It is that part of the organ in which the hepatic portion of the vena cava develops and its venous outflow remains strictly connected with the vena cava by means of multiple, not dissectable effluents as well as with the main hepatic veins. Therefore, this sector is a major shunt between the main hepatic veins and the inferior vena cava, which enlarges and ensures venous drainage for survival in cases of Budd-Chiari syndrome.

Liver anatomy: portal (and suprahepatic) or biliary segmentation.

Background/aims: In liver anatomy and surgery, is portal and hepatic vein segmentation (French segmentation) to be preferred over arteriobiliary segmentation (Healey and Schroy, North American segmentation)?

Methods: Several embryological arguments and an analysis of anatomical data from a personal collection of 110 vasculobiliary casts were made.

Results: Embryological arguments: Portal vein branching appears first, arteriobiliary branching secondly follows the portal vein distribution. Segment II (the left lateral sector) is the development of the right lateral embryological lobe.

[Dorsal sector of the liver].

The dorsal sector extends in front and to the sides of the inferior vena cava, separating the caval axis from the main liver (excepting superiorly the entrance of the main hepatic veins into the vena cava). The two elements, dorsal sector and retro-hepatic portion of the vena cava, actually make a single unit. It is made of two segments: left (segment I) larger than the Spieghel lobe, right (segment IX) incorporated in the posterior surface of the right liver.

[Intrahepatic anatomy. Application to liver transplantation].

In transplantation of the whole liver, the variable shape of the organ can exceptionally be the source of difficulties, as in the rare cases of situs inversus. Arterial variants may be the source of great difficulties. Among the biliary variants, the low junction of the right and left hepatic ducts in the main portal pedicle, and especially the cysto-hepatic ducts (entrance of a right duct into the gallbladder or the cystic duct) are particularly important, with a frequency ranging from 2 to 15% of the cases.

[A "scandal": segment IV and liver transplantation].

Partition right-left lobes keeps segment IV in continuity with the right liver, but interrupts its portal elements which arise from the left portal pedicle. A precise anatomical investigation shows that the venous inflow is totally interrupted. In 12.

[Absence of portal bifurcation].

Since the first description in 1957, absence of the portal bifurcation has been reported by four different teams, which makes a total of 5 cases and a frequency of 1.90%. Serious complications may occur postoperatively, and this anomaly should be systematically detected.

Controlled liver splitting for transplantation in two recipients: technique, results and perspectives.

A technique of controlled liver splitting for transplantation in two recipients is proposed, based on a full anatomical assessment of the graft including arteriography and cholangiography on the back-table. Using eight livers, 16 patients received a graft: right liver (eight patients), left lobe (four) or left liver (four). Twelve patients required urgent or very urgent transplantation.

[Variations of the right bile ducts. The futility of complete anatomical classifications].

Combination calculus shows that there is a considerable number of theoretical variations of the right ducts: [table: see text] Complete classification is therefore impossible, and the different frequencies of these variations in different series are easy to understand. Probably some of these theoretical distributions do not actually exist. A classification should be limited to a description of the mechanisms of variation (duplication and sliding on other ducts), to a list of the most frequent variations; dangerous distributions from the surgical point of view, even if they are exceptional, must be pointed out.

[Surgical approach to the dorsal section of the liver].

The dorsal sector of the liver is a deep and posterior territory which lies behind the hilum, close to the inferior vena cava, beneath a plane passing by the terminal portion of the main hepatic veins. Two segments may be distinguished. A left one, segment I, the prominent part of which is the caudate lobe, is united anteriorly with segment IV and lies to the left of the vena cava.

[Bisection of the liver for transplantation. Simplification of the method].

Blind bipartition of a whole liver to obtain two transplants is problematic, because of frequent vasculo-biliary duplications, especially arterial (mainly on the left) and biliary (mainly on the right) duplications. Arteriography and cholangiography on the back table are necessary to obtain a map of the arterial and biliary distributions without injuring the vessels of the biliary ducts enclosed in the vasculo-biliary sheaths. The surgeon may use three special maneuvers: resection of segment IV when the arterio-biliary duplication involves segment IV; attribution of the common hepatic artery on the side of the arterial duplication (frequent on the left); attribution of a short segment of the common hepatic duct on the side of a biliary duplication (frequent on the right).

Exposure of the left hepatic duct through the hilum or in the umbilical of the liver: anatomic limitations.

Anastomosis to the left hepatic duct approached by dissecting the hilar plate is the most reliable method of drainage of the left side of the liver in that longitudinal incision of the left hepatic duct allows a long cholangiojejunostomy. However, the anatomy is not satisfactory in 30% of cases for adequate drainage of the left side of the liver. To further clarify this surgically important area, 107 vasculobiliary casts were reviewed with regard to the anatomy and relationship between the left biliary ductal and left portal venous systems.

[An unknown syndrome: acute zinc deficiency in the elderly in a surgical milieu].

Old people often present a chronic depletion in zinc. Any stress increases zinc consumption and zinc loss through the kidneys; acute depletion then appears. Anorexia is usual, psycho-neurological troubles induce to a wrong diagnostic of sudden senility or psychiatric disorder.

The parabiliary venous system.

The parabiliary venous system originates from the pancreatico-duodenal and pyloro-duodenal veins, runs along the common bile-duct and the hepatic artery, and divides in the liver hilum into a venous network within the hilar plate. Embryologically, this system, apparently independent of the portal vein, develops together with the bile-ducts and the hepatic artery: these three structures are within the substance of the vasculo-biliary sheaths, and the whole complex invades the liver well after the distribution of the portal vein has been established. It should be pointed out that segments I and IV also appear rather late.