Cholangiographic

Segmental Anatomy
of the Liver1
G. Scott Gazelle, MD
Michaelj Lee, MD
Peter R. Muelle, MD

The importance of understanding the Couinaud nomenclature describ-

ing hepatic segmental anatomy has been increasingly recognized by
practicing radiologists. The normal cholangiographic appearances of
the biliary ductal branches, as well as those of their common anatomic
variants, are less well known. As percutaneous biliary procedures in-
crease in frequency and complexity, a thorough understanding of this
anatomy is of utmost importance. In this article, we present cholan-
giograms, computed tomographic (CT) scans, and anatomic drawings to
illustrate cholangiographic segmental anatomy and its correlation with
segmental anatomy as depicted by CT. The significance of the anatomy
to percutaneous interventional procedures is discussed.

Abbreviations: (ill) = comnmn hepatic duct, LIII) = left hepatic duct. RASI) = right antcnor scctorl duct. RllI) = right
hepatic duct, RPSI) = right posterior sectoral duct

Index tenns: Bile ducts. anatomy. “6.92 #{149}Bile ducts. interventional prce(lurc. 6. 1 226. “6. 1 263 liver,
#{149} anatomy.
692 Liver.
#{149} interventional procedure. “61 . 1 263

RadioGraphlcs 1994; 14:i0()S-10l3

I 1mm the I)epartments of Radiology. Massachusetts Oencral hospital. 32 Fruit St. loston. MA 021 14 and llat-vard Medical
Schol. Boston. l’resented as a scientific exhibit at the l9)3 RSNA scientific assembly. Received March 23. l99i: revision re-
quested April 2’” and received May 9: accepted May Ii. Address reprint requests to (.S.G.

. RSNA, 1994

1005
 U INTRODUCTION
Modern hepatic surgery, especially hepatic re-
section, is based on the segmental anatomy as
described by Couinaud (Fig 1), which describes
eight distinct liver segments (1,2). Each of
these segments has its own portal venous sup-
ply and separate hepatic venous and biliary due-
tal drainage could therefore
and theoretically
be individually resected or survive on its own.
The Couinaud system of nomenclature is also
being used with increasing frequency by radiol-
ogists performing cross-sectional imaging stud-
ics of the liver (3-7). However, cholangiograph-
ic segmental anatomy is less well understood
and has received less attention in the literature
(8). Figure 1. I)rawing illustrates the hepatic segmen-
In this article, we illustrate the segmental no- tal anatomy as described by Couinaud. Each seg-
menclature of Couinaud and its relation to the ment with its portal venous supply (diagonally shad-
biliary drainage of individual hepatic segments ed vessels) and hepatic venous drainage (solid yes-
sels) is illustrated. Biliary drainage parallels portal
(Figs 1 , 2). There are eight distinct hepatic seg-
venous supply and is not shown in the drawing for
ments. Segment I is the caudate lobe. The re-
clarity.
mainder of the liver is divided into the “left liv-
er’ and the “right liver” by the middle hepatic
vein. Segments II, III, and IV are within the left
liver and are supplied by branches of the left or vena eava and the long axis of the gallblad-
portal vein; segments V-Vu! are within the der and contains the middle hepatie vein. The
right liver and are supplied by branches of the right liver is divided into the anterior sector
right portal vein. (which includes segments V and VIII) and the
The left liver is divided into two sectors by posterior sector (which contains segments VI
the left hepatic vein; segments III and IV (ante- and VII) by the right portal scissura-an off-
rior sector) are anterior to the vein, whereas coronal plane containing the right hepatic vein
segment II (posterior sector) is posterior to it. and the inferior vena cava. Finally, segments V
Within the anterior sector, segment III is sepa- and VI (inferior segments) are separated from
rated from segment IV by the umbilical fissure segments VII and VIII (superior segments) by
and falciform ligament. an axial plane containing the horizontal” por- “

The right liver is separated from the left liver tion of the right portal vein.
by the main portal scissura (Cantlie line)-a The Couinaud nomenclature differs from the
parasagittal plane that passes through the in.feri- “Anglo-Saxon” nomenclature (ie, lateral left,
medial left, anterior right, posterior right, eau-
date) in its division of the lateral segment of
the left lobe into anterior and posterior
subsegments (Couinaud segments) by the left

1006 U Scientific Exhibit Volume 14 Number 5

Figure 2. CT scans obtained during arterial porto)graphy of a patient with hiliary obstruction. I)iiated hiliary
ducts are identified adjacent to) contrast-enhanced portal venous branches. The presence of these dilated ducts
makes it easy to) distinguish l)ortal fron hepatic venous branches. (a) CT scan clearly shows the hepatic veins
(arrows) and segments II-IV, VII, and VIII. There is a lesion lo)cated within segment VIII. (b) CT scan obtained
16 mm caudad to a demonstrates the main l)r-anch of the left portal vein (open arrow) and the adjacent left he-
patic duct (I.HI)). The middle (short straight arrow) and right (curved arrow) hepatic veins are clearly seen,
without accompanying hiliary ducts. This image nicely illustrates the separation of segments II and III by the iat
eral aspect o)f the left hepatic vein (long straight arrow). (c) CT scan obtained 16 mm caudad to b demonstrates
the horizontal P0rti0)11 o)f the right portal vein (open arrow), dilated segment III and IV duets, middle hepatic
vein (solid straight arrow), and right hepatic vein (curved arrow). The middle hc.-patic vein separates the right
liver from the left liver, whereas the right hepatic vein separates the posterior and anterior sectors of the right
lobe. (d) CT scan obtained 24 mm caudad to) C shows the falciform ligament and umbilical fissure (small ar-
rows) separating segment III from IV. Several segment V and VI ducts, the middle hepatic vein (straight arrow),
right hepatic vein (curved arrow), and branches of the right portal vein are also) seen. Segmental branches of
the hiliary system have an intrasegmental course parallel to the portal vein branches. The paired hiliary ducts
and portal eiI1 branches can thus he easily distinguished from hepatic vein branches.

hepatic vein and in its division of the anterior ments of the right lobe does not also divide the
and posterior segments of the right lobe into) segments of the left lobe. As previously de-
superior and inferior subsegments (Couinaud scrihed, the left hcpatie segments are divided
segments) by the axial plane containing the by nonaxial landmarks, including the faleiform
right portal vein. In addition, one should no)tc ligament, umbilical fissure, and left hepatie
that, according to Couinaud (in co)ntradistine- vein.
tion to 5OfliC later authors on the subject), the
plane that divides the superior and inferior seg-

September 1994 Gazelle et al U RadioGraphics U 1007

 Figure 3. Normal hepatic ductal anatomy. Cholangio-
gram shows the three primary tributaries of the com-
mon hepatic duct-the RASI) (solid straight arrow),
RPSI) (open arrow), and LHI) (curved arrow)-in their
most common configuration. Note that the branches of
the RPSD pro)ject lateral to the branches of the RASI).

Figure 4. l)rawing ii-

lustrates the common
normal variants of the
confluence O)f hepatic

hiiiary tributaries, as
described by Couinaud,
shown with their fre-
qeny O)f o)ccurrence.

. NORMAL HEPATIC DUCTAL ANATO- main tributaries: the right posterior (or lateral)
MY seetoral duct (RPSI)) and the right anterior (or
Normal ductal anatomy is illustrated in Figure medial) sectoral duct (RASI)). The RPSD
3. The LHD drains the left liver and is formed drains segments VI and VII and has au almost
by individual segmental tributaries draining seg- horizontal course on projectional iniages. Its
ments II-IV. The right hepatie duet (RHD) branches project lateral to those of the RASD,
drains segments V-VIII and is formed by two which drain segments V atid VIII and tend to
have a iiire vertical course. The RPSD nor-
mali- l)asses Poster)r tO the RASI), joining it

1008 U Scientific Exhibit Volume 14 Number 5

a. b.
Figure 5. (a) T-tube cholangio)gram demonstrates a triple confluence of the RASD (solid straight arrow), RPSD
(open arrow), and LHI) (curved arro)w). Most o)f the smaller segmental ducts are also) clearly seen. This anatomic
variant is seen in appro)ximately 1 2% of patients (see Fig 4). (b) Transhepatic cholangiogram of the same anoma-
I) ill itiother i)itieflt with markedly dilated ducts shows the RASI), RPSI), and LHD joined in a triple confluence
to forni the CHI). ‘Fhis anomaly has no real significance in percutaneous hiliary drainage procedures.

from the left (medial) side to) form the RHD. I.HD to form the CHD. However, this left-right
The Ri-Il) is usually very short and joins the LHI) relationship of the RPSD and RASD can be re-
to form the COflifliOli hepatic duct (CHI)). versed so that the RPSD empties into the right
(lateral) aspect of the RASI). Alternatively, a tn-
plc confluence of the RPSI), RASD, and LHD
U COMMON ANATOMIC VARIANTS can be seen (Fig 5). The RPSD may also drain
Numerous normal uiatoniic variants in the ifltO either the LHD before its confluence with
eo)nfluence of the main hepatie hiliary branches the RASD (Figs 6-8) or the CHD after its forma-
have been described ( 1 ) and are illustrated in tio)n by the confluence of the RASD and LHD.
Figure 4. The most commonly seen variants in- Similarly, the RASD can drain into the LHD (Fig
volve die RPSI) and its junction with the RASI) 9). More complicated, and unusual, variants are
o)r the LHI). As described, the RISD normally also seen (Fig 10).
l)asses posterior to the RASI) to join its left as-
peet and form the RIII), which thcii joins the

September 1994 Gazelle Ct al U RadioGraphics #{149}

1009
 6.

8a. 8b.
Figures 6-8. (6) Left-sided transhepatic cholangiogram demonstrates drainage of the RPSI) (black arrow)
into the LHI). l’his is the rno)st co)mmon anatonhic variant of the hiliarv system. In this case. the LH1) and RPSI)
jo)in the RASI) (white arrow) to) form the CHI). If a left-sided percutaneous hiliary drainage were performed in
the patient, the majority of the liver (ie, the entire left liver as well as the posterio)r secto)r of the right liver)
wo)uld he drained. Conversely, a focal stricture or obstruction of the distal LHI) co)uld affect all hut the anterior
sector o)f the right liver, and a complete o)hstruction o)f the LI-il) might make it impossible to) pL55 a catheter ilito)
the duodenum with a right posterior approach. (7) Percutaneous biliary drainage perfornied with a right poste-
nor approach in another patient with ductal anatomy similar to) that seen in Figure 6. Cholangiogram shows the
course O)f the catheter from the segment VII ductal branches into) the RPSD-LHI)-CHI). In this case, the catheter
was successfully Placed across the stricture iii the distal common bile duct. pernhitting effective internal drain-
age. The aIlo)malous drainage of the RPSI) into the LHI) had no significant effect 0)11 the procedure. (8) Compli-
cated biiiarv drainage procedure in a patient with periportal metastatic disease and segmental ductal o)hstruc-
tio)ns. (a) i’ranshepatic cholangiogram obtained early in the procedure demonstrates a needle traversing a seg-
ment VIII duct, with opacification of only the RASI) and its branches. The RPSD is not opacified. and no ducts
are seen in a large central area of the right lobe. These findings were initially thought to indicate the presence
O)f a mass. A stricture of the distal RASD (arrow) is seen. (b) Choiangiograiii obtained after placement of a cath-
eter across the stricture clearly demonstrates the anatomy. The RPSI) (straight arro)w) empties into) the LHI)
(curved arrow), which joins the RASI) at or just distal to the stricture in the RASI). ‘Ihis stricture prevented
o)l)acificatio)n of the Li-ID and RPSI) earlier in the pro)cedure and explains the apparent mass” in the right lobe.
After the stricture was traversed with a drainage catheter, the LHD and RPSD were opacified and the anoma-
bus anatomy demonstrated. In this case, drainage might have been more difficult via a right l)o)sterio)r approach
or may have resulted in incomplete drainage of the liver (ie, the anterior sector may no)t have been adequately
drained). A left-sided appro)ach, however. wo)uld have drained the majo)ritv of the liver.

1010 #{149}
Scientific Exhibit Volume 14 Number 5
Figures 9, 10. (9) Percutaneous biiiary drainage in a patient with anatomy somewhat like that of the
l)atient in Figure 8. l)ut with the RASI), rather than the RPSI), draining into) the LHD. (a) Transhepatic
cl1o)langio)gran denlo)nstrates o)l)acifIcation o)f right- and left-sided biliary ducts, with an apparent ductal
stricture just distal to) the co)nfluence (arrow). However, on closer inspection, it is apparent that the
RASI) has l)eefl l)ullcttlred and that the RPSI) is not filled. In this case, the RASI) drains into) the LHI),
and the stricture is in the distal LHI) (arrow). (b) For the hiliary drainage, the needle was repositioned
more l)stcrio)rly, the RPSI) cannulated, and a catheter easily passed into the duodenum. Cholangio-
gram shows the RPS1) (arrow). l-io)wever, if the LHI) stricture had been a complete o)hstructio)n, the
current catheter (or a stent placed via the sanie approach) wo)uld not have drained either the RASI) or
the LHI). In retro)spect. either a left-sided or an anterior right-sided approach may have been a better
Pti0)1i for long-teriii drainage. (10) Perdutaneo)us hiliary drainage in a patient with unusual ductal anat-
o)my. Early in the I)ro)cedure, a guide wire was placed into) the segment VIII duct, 0)111)’ to) pass directly
into) tue LI-Il). rather than going down toward the CHD. (a) Cholangiogram shows the LHI) draining
itito the segment VIII duct (solid straight arrow), which joins, in a triple coiitluence, with the segment
V duct (oleli arro)w) and the RPSI) (curved arrow). (b) Cholangiograrn obtained after repositioning of
the wire shows it entering the RPSI) duct, near its triple confluence with the segment VIII duct-LHI)
and the segnwllt V duct. This led to) successful distal drainage.

September 1994 Gazelle et al #{149}

RadioGraphics 1011
 RASD

RPSD
LHD

a.
RASD
Figure 11. Drawings illustrate the
potential advantage of performing left-
sided biliary drainage in patients with
peniportal metastatic disease. (a) In a RPSD
hypothetical patient, periportal meta-
static disease has resulted in signifi- LHD
cant stenosis of all three duetal tribu-
taries. With progression of metastatie
disease, drainage via either the RPSD
or RASD may fail to drain other see-
tors. (b) In a hypothetical patient
with similar peniportal disease but
with the (most common) variant of
the RPSD emptying into the LHD, a
left-sided drainage would result in
draining the entire left liver as well as
the posterior sector of the right liver.

b.

U RELEVANCE TO PERCUTANEOUS BIL- that drain a specific hepatie segment. However,

IARY INTERVENTIONAL PROCEDURES because of the great variation in segmental due-
Percutaneous transhepatic biiary cholangiog- tal anatomy, a catheter placed via a right-sided
raphy and drainage procedures rely on external puncture can easily enter the CHD (via the
anatomic landmarks to guide puncture and RPSD through the LHD through the CHD),
cannulation of the biliary system. Unfortunate- whereas a catheter placed via a left-sided pune-
ly, the biliary ducts do not maintain a consistent tune can enter the RHD (via the LHD through
relationship to these external landmarks, and, the RASD or RPSD). If the contralateral duct
once cannulated, the pathway from a given seg- were obstructed or there were another reason
mental duct to the common bile duct is not al- to avoid draining it, these anatomic variants, if
ways predictable. This is further complicated not recognized early in the procedure, could
because, as the management of patients with have significant consequences.
biliary obstruction becomes more aggressive, For example, a posterior, right-sided pune-
one is often required to drain or avoid ducts ture in a patient with anomalous drainage of
the RPSD into the LHD (Figs &8) and a distal
LHD obstruction might result in catheter place-
ment into left lobe segmental duets, rather than

1012 U Scientific Exhibit Volume 14 Number 5

distally into) the duodenum. However, in such a Acknowledgments: The aUthlo)rs thank Pamela
patient, once drainage is obtained through ci- Taylor Sheppeck for preparing drawings for the
ther the RPSI) or LHI), niost of the liver would manuscript.

have been successfully drained. Furthermore,

given the relatively high frequency with which
. REFERENCES
I. Couinaud (;. Le foie. Paris, France: Ma.sson & Cie,
either the R1SD (23%) o)r the RASD (5%) drain
1957; 530.
anomalously into the LHI) (Fig 4), it may he
2. Bismuth H. Surgical anato)my and anato)mical stir-
that left-sided drainage is preferable in patients
gery of the liver. In: Biunigart L, ed. Surgery o)f
with pcriportal metastatic disease, who arc at the liver and hihiary tract. Edinburgh, Scotland:
increased risk of having multiple segmental Churchill & Livingstone, 1988; 3-9.
duetai obstructions. Left-sided drainage in these 3. Gazelle GS, Haaga JR. Hepatic neoplasms: surgi-
patients results in drainage of the left liver and a call)’ relevant segmental anatomy and imaging
techniques. AJR 1992; 158:1015-1018.
portion of the right liver (Fig I 1). An under-
standing of these issues is important to inter- 4. Gazelle GS, Boland C, I)awson SL, et al. Hepatic
ventional radiologists performing percutaneous segmental anato)my. Semin Intervent Radioi 1993;
10:162-168.
biliary procedures.
5. Lafortune M, Madore F, Patriquin H, et al. Seg-
mental anatomy of the liver: a so)nographic ap-
N SUMMARY
proach to) the Couinaud no)menclature. Radiology
In this article, we have discussed and illustrated
1991; 181:443-448.
the cholangiographie segmental anatomy as de- 6. Matsui 0, Takashima T, Kadova M. I)ynamic
scnihed by Couinaud. An understanding of this computed to)mography during arterial porto)g-
nomenclature is essential for radiologists per- raphy: the most sensitive examinatio)n for small
forming cross-sectional imaging studies of the hepatocellular careino)mas. J Coniput Assist
liver because of its increasing use by surgeons, Tomogr 1985; 9:19-24.
who often must know the exact segmental loca- 7. Sugarhaker P. Nelson R, Murray I), et al. A seg-
tion of tumors to plan effectively for hepatie re- mental approach to computerized portography for
hepatic resection. Surg Gynecol ()hstet 199();
sections. In addition, however, an understand-
17 1:189-195.
ing of both normal and anomalous biliary anato-
8. Smadja C, Blumgart LH. The hiliary tract and the
my is important for radiologists interpreting or
anato)my of hiliary exposure. In: Biumgart I., ed.
performing percutaneous hiliany cholangiog- Surgery O)f the liver and hihiary tract. Edinburgh,
raphy or drainage procedures. Anomalous drain- Scotland: Churchill & Livingstone, 1988: 145-162.
age of segmental or seetoral hiliary ducts can
lead to difficulties in opacifleation or drainage
of the entire ductai system. By understanding
the normal anatomy and conimon anatomic
variants, one can often plan a more successful
approach.

September 1994 Gazelle et al #{149}

RadioGraphics U 1013