J Hepatobiliary Pancreat Surg (2005) 12:351–355

DOI 10.1007/s00534-005-0999-7

Topics: Systematic hepatectomy for liver cancer

Nomenclature of hepatic anatomy and resections: a review of

the Brisbane 2000 system
Steven M. Strasberg
Section of Hepatobiliary-Pancreatic Surgery, Department of Surgery, and the Siteman Cancer Center, Washington University School of
Medicine, BOX 8109, Suite 17308 West Pavilion Tower, 1 Barnes Hospital Plaza, St. Louis, MO 63110, USA

Abstract
The Brisbane 2000 system of nomenclature of hepatic
anatomy and resections was introduced to provide a universal
terminology in an area that was plagued by confusing and
inappropriate terminology. The article describes historical de-
velopments central to the emergence of the new terminology
and describes the terminology, its attributes, and rules of
application.
Key words Liver anatomy · Liver terminology · Liver surgery ·
Hepatectomy · Sectionectomy
Introduction
Anatomy is the science of the shape and structure of
organisms and their parts. Knowledge of hepatic
anatomy is the most important foundation of the prac-
tice of hepatic surgery. Terminology (or nomenclature)
is the vocabulary of technical terms used in a particular
field, subject, science, or art. The terminology of hepatic
anatomy and liver resections is the foundation for com-
munication among hepatic surgeons. Our understand-
ing of the major features of hepatic anatomy was
essentially complete by 1960, but only recently has a
universal terminology been adopted.1 In this article we
will describe how developments in anatomy have af-
fected terminology and how finally a coherent terminol-
ogy has emerged. This terminology is rapidly gaining
wide acceptance, as evidenced by its use in the latest
issue of Gray’s Anatomy.
A short history of hepatic terminology
Ancient and renaissance anatomists recognized the ob-
vious lobularity of the hepatic surface and named it on
Offprint requests to: S. M. Strasberg
Received: October 18, 2004 / Accepted: June 7, 2005
this basis. For instance, right and left lobes were defined
by the umbilical fissure and the attachment of the fal-
ciform ligament. Other surface features such as the
caudate lobe were also defined, but almost nothing was
known about the complex internal anatomy of the liver.
Apparently the ancient anatomists were good linguists,
since they recognized that the term “lobe” meant: a
portion of an organ demarcated by fissures, sulci, con-
nective tissue, or shape. Note that the key concept of
lobe is that it is a recognizably separate portion of an
organ when viewed from the surface of the organ. Thus,
“lobes” was a fitting term that selected the portions of
the organ separated by the umbilical fissure.
James Cantlie of Liverpool, in 1897, made a seminal
contribution to the science of hepatic anatomy when
he, following in the footsteps of Rex,2 used injection
of vessels to define the mysterious internal hepatic
anatomy.3 As is well known, Cantlie showed that the
principal division of the liver is based on a vascular
watershed, which lies in a plane intersecting the gall-
bladder fossa and the fossa for the inferior vena cava.
However, apparently Cantlie was not a good linguist.
He introduced terminologically incorrect terms,
which became the basis for confusion and dispute. Al-
though the vascular watershed which he defined is invis-
ible from the surface of the liver, he inappropriately
called the two parts of the liver defined by it the right
and left lobes. And although the watershed was obvi-
ously three-dimensional and therefore a plane, he called
it a line.
The twentieth century dawned and the science of
hepatic anatomy, enabled by corrosion casting,2 moved
forward slowly through the efforts of Mclndoe and
Counseller4 and Hjortsjo.5 However the seminal contri-
butions were made in a burst of activity by two mid-
century surgeon-anatomists, Couinaud6 and Healey.7,8
Working separately and apparently unknown to each
other, they used corrosion casting to define the intrahe-
patic divisions of blood vessels and bile ducts and to
352
establish the subdivisions of the liver. Their casts
showed them the same thing, but they chose to divide
the liver differently, because one (Couinaud) used the
ramifications of the portal veins as the basis of division6
and the other used the hepatic arteries and bile ducts.7,8
Each divided the liver into three orders or levels.
Couinaud6 called the three levels of division: (1), livers
or hemilivers (as in right and left livers); (2) sectors; and
(3) segments. Healey chose the terms: (1) lobes; (2)
segments; and (3) areas (or subsegments).7,8 Since the
portal vein hepatic artery and bile ducts have an identi-
cal branching pattern on the right, the right liver was
anatomically identical to the right lobe, the right ante-
rior and posterior sectors were identical to the right
anterior and posterior segments, and the numbered
Couinaud segments (5–8) corresponded to four of
Healeys areas. The difference between the two schemas
for division lay in the left side of the liver, and prin-
cipally in the difference between the second-order
divisions — the sectors of Couinaud and the segments
of Healey.
Couinaud described the left portal vein to divide into
an umbilical branch and a branch to segment 2. This
divided the left liver into two sectors, consisting of a
lateral sector (Couinaud segment 2) and a medial (or
paramedian median) sector (Couinaud segments 3 and
4).6 Healey described the left hepatic artery and bile
duct to divide into medial and lateral branches. The
former supplied the part of the left liver to the right side
of the umbilical fissure and the latter the part of the left
liver to the left of the umbilical fissure. This divided the
left liver into a medial segment (Couinaud segment 4)
and a lateral segment (Couinaud segments 2 and 3).7,8
Also, Couinaud referred to the watersheds as scissuras
(= fissures or clefts) because, in the corrosion casts, such
clefts are apparent.6
The studies of Couinaud and Healey were a great
advance for the science of hepatic anatomy but termino-
logically were less so. Hepatic terminology was left in a
state where there were two kinds of lobes. There were
lobes without surface markings to define them. There
were two kinds of segments. There were scissuras,
which existed in corrosion casts, but were invisible from
the surface of the organ. This is just as erroneous as
lobes without surface markings, since, if scissuras in
casts can be used as the basis of terminology of an organ
then these scissuras surely define lobes in those same
casts. There were two-dimensional terms such as areas
and lines defining three-dimensional structures. This
confusion in terminology also affected the terminology
of liver resection, where there were two kinds of lobec-
tomy and where some names for operations were based
on surface anatomy and others on vascular watersheds.
This sad state of affairs was pointed out by the author
in 1997.9 The biblical term “Babel” was used to indicate
S.M. Strasberg: Nomenclature of hepatic anatomy and resections
that surgeons were unable to understand each other.9
In 1998, the IHPBA established a Terminology
Committee to deal with the confusion in terminology
of hepatic anatomy and liver resections. The committee
consisted of eight hepatoparcreatobiliary (HPB) sur-
geons from around the world. The recommendations of
the committee were accepted by the IHPBA at the
biannual meeting of the IHPBA in Brisbane, Australia,
in 2000. This terminology, called The Brisbane 2000
terminology of liver anatomy and resections, is the first
universal terminology of hepatic anatomy and resec-
tions. A description of the new terminology, first pub-
lished in 2000,1 follows.
Attributes of the terminology
The attributes of the terminology are that: (1) it is ana-
tomically correct; (2) anatomical and surgical terms are
in agreement; (3) consistency; (4) self-explanatory; (5)
linguistically correct; (6) precise; (7) concise; and (8)
translatable.
Anatomically correct
This attribute means that the most common anatomical
pattern (i.e., the “prevailing pattern”) will be the basis
for naming anatomical structures.
Concordance of anatomical and surgical terms
This attribute means that the terminology for liver re-
sections will be based on the anatomical terminology.
For instance, if the anatomical terminology for each
side of the liver is “hemiliver”, then the correct name
for resection of one side of the liver would be
“hemihepatectomy”.
Consistent
This attribute means that the terminology is based on
one rather than more than one method of dividing the
liver. Surface markings and internal vascular (including
biliary) anatomy are different ways of subdividing the
liver. They should not be mixed in describing the several
levels of division of the liver. The terminology of the
anatomical divisions should be based completely on
the internal anatomy. Thus, the terms “liver” or
“hemiliver” are selected for the first-order division, the
term “section” is selected for the second-order division
to replace Healey’s segments, and the term “segment”,
meaning Couinaud segment, is selected for the third-
order division.
The watersheds of the hepatic artery, bile duct, and
portal vein are identical, except for the second-order
S.M. Strasberg: Nomenclature of hepatic anatomy and resections 353

division of these structures on the left side of the liver, Linguistically correct
as explained above. The IHPBA Terminology Commit-
This attribute means that the terminology is linguisti-
tee decided that the terminology be based on the arte-
cally correct and applicable to the organ itself, rather
rial and biliary anatomy, although, in an addendum, the
than organ models such as corrosion casts. Linguistic
correct terminology for discussing division based on
correctness means that the term will be true to its root
the portal vein was given. Readers interested in this
meaning and also to its use in common language. Thus,
are referred the original publication.1 The artery and
for these reasons, the terms “lobe”, “line”, and “scis-
biliary watersheds divide the left side of the liver
sura” would be excluded.
through the umbilical fissure. All anatomists, includ-
ing Couinaud and Healey, agree on this point.
There are several reasons for selecting the artery and Precise
the bile duct as the main basis for division. Hepatic
This attribute requires that a term has only one mean-
resections on the left side usually pass through the um-
ing. There were two terms in use which each had two
bilical fissure. Using terminology based on the artery
meanings — “lobe” and “segment”. “Lobe”, in one us-
and vein makes it much easier to describe these resec-
age, refers to a hemiliver and is linguistically incorrect
tions. Otherwise, one must resort to using surface
for the reasons given above. As a term of surface
anatomy to describe these particular resections and in-
anatomy it is not excluded, but it is excluded as a basis
ternal anatomy for other resections. Furthermore,
for naming liver resections. “Segment” is now restricted
Couinaud’s anatomical concepts in this area of the liver
to the third-order division, as in Couinaud segments 1–
have been challenged.10,11 There is good reason for con-
9. To name the second-order divisions, a new term,
cluding that the left portal vein is a unique structure
“section”, was introduced. It should be noted that the
derived from the fetal need to divert blood from the
terms “section” and “segment” are derived from the
placenta to the heart. The whole left portal vein, includ-
same Latin root meaning “to cut” and do not imply
ing transverse and umbilical portions, lies on the surface
the presence of a fissure. It is linguistically correct to
of the liver. It does not enter the liver. This is unique in
apply them to a division based on internal anatomy,
liver anatomy. The umbilical portion must be a straight
such as a vascular watershed, even when there are no
conduit in fetal life in order to conduct blood from the
surface markings indicative of that watershed. Note also
placenta to the ductus venosus. Since that is necessary,
that it is now proper to refer to segments without stipu-
it might be asked what would be expected when flow in
lating “Couinaud segments”, as the term has only one
the vein is reversed in order to supply the left liver after
meaning.
birth? It seems that the answer is a unique straight
structure, which emits branches from both sides to sup-
ply the liver. This is also unique and irregular, since Concise
elsewhere in the liver branching occurs in a bifid man-
This attribute requires that terms be brief and to the
ner. The arrangement of the portal vein on the right side
point.
of the liver is quite different. There the portal vein is an
internal structure showing bifid ramification as it runs in
tight conjunction with the arteries and bile ducts. It is Translatable
worth emphasizing that, on the right, the veins, arteries,
This attribute requires that it is desirable that the termi-
and ducts ramify in conjunction. Therefore, in attempt-
nology is translatable. The term, “section”, is apparently
ing to discover the segmentation on the left side of the
translated with difficulty into some languages, but there
liver in circumstances in which one of the internal
is a precedent for the adoption of new terms from the
guides (the portal vein) had been recruited to a unique
English language or into the English language, espe-
fetal purpose, it would seem most reasonable to look for
cially in technical specialities.
guidance to the bile duct and the arteries, which have
Also note that the third-order divisions into segments
not been modified for fetal needs.
are referred to in Arabic rather than Roman numerals,
i.e., segments 1–9, rather than segments I–IX.
Self-explanatory
This attribute means that the terminology will be inter-
nally evident. Eponymic terms e.g., “Cantlie’s line” fail The Brisbane 2000 terminology
this test, because they contain no intrinsic information.
In contrast, hemiliver or midplane of the liver contain The Brisbane 2000 terminology is presented in Figs. 1–
internalized information, which makes their meaning 4, which show the successive orders of division (Figs. 1–
clearer. 3) and the terminology for resections involving three
354
sections (Fig. 4). Each figure has four columns. The
anatomical term is described in the leftmost column of
each figure, the second column shows the segments re-
ferred to, the third column lists the surgical term and the
fourth column displays a diagram that illustrates the
part of the liver being described. Segments are indicated
in short form as “Sg1–9” (e.g., Sg6). “Sg” was chosen
rather than “S” to avoid the confusion of “segment”
with “section”. Arabic numerals are chosen rather than
Roman numerals because many non-Western nations
S.M. Strasberg: Nomenclature of hepatic anatomy and resections
Fig. 1. Nomenclature for first-order divi-
sion anatomy (hemilivers) and resections.
IVC, inferior vena cava
Fig. 2. Nomenclature for second-
order division anatomy (sections) and
resections
do not use Roman numerals. Note that the watersheds
of the three divisions are referred to as planes — the
midplane, the intersectional planes, and the interseg-
mental planes. When segment 1 is resected as part of a
procedure, it should be stated as in the following ex-
ample: “left hemihepatectomy with resection of seg-
ment 1” or “left hemihepatectomy extended to segment
1”. The terminology also allows the use of the term
caudate lobe”, as it is a true lobe. It also allows use of
“Sg1,9” as a description of the caudate lobe.
S.M. Strasberg: Nomenclature of hepatic anatomy and resections
The use of the Brisbane 2000 terminology is steadily
gaining acceptance around the world. It is hoped
that this will lead to better communication among
hepatic surgeons and easier comprehension of their
publications.
References
1. Terminology Committee of the IHPBA (authors). Terminology
of liver anatomy and resections. HPB Surg 2000;2:333–9.
2. Rex H. Beitrage zur Morphologie der Saugerleber. Morphol
Jahrb 1888;14:517–615.
3. Cantlie J. On a new arrangement of the right and left lobes of the
liver. Proc Anat Soc Great Britain and Ireland 1897;32:4–9.
4. Mclndoe AH, Counseller VS. The bilaterality of the liver. Arch
Surg 1927;15:589–612.
355
Fig. 3. Nomenclature for third-order divi-
sion anatomy (segments) and resections
Fig. 4. Nomenclature for resections of
there sections
5. Hjortsjo C-H. The topography of the intrahepatic duct systems.
Acta Anat 1951;11:599–615.
6. Couinaud C. Le Foie. Etudes anatomiques et chirugicales. Paris:
Masson & Cie; 1957.
7. Healey JE Jr, Schroy PC. Anatomy of the biliary ducts within the
human liver; Analysis of the prevailing pattern of branchings and
the major variations of the biliary ducts. Arch Surg 1953;66:599–
616.
8. Healey JE. Clinical anatomic aspects of radical hepatic surgery. J
Int Coll Surg 1954;22:542–50.
9. Strasberg SM. The terminology of liver anatomy and liver resec-
tions: coming to grips with hepatic Babel. J Am Coll Surg 1997;
184:413–34.
10. Masselot R, Leborgne J. Anatomical study of hepatic veins. Anat
Clin 1978;1:109–25.
11. Botero AC, Strasberg SM. Division of the left hemiliver in man —
segments, sectors or sections. Liver Transpl Surg 1998;4:226–
31.