FEATURE

Revisiting Liver Anatomy and Terminology of Hepatectomies

Henri Bismuth, MD, FACS (Hon)

Background: Since the development of liver surgery, several descriptions of
liver anatomical division and hepatectomies have been made, causing some
confusion among surgeons.
Methods: The initial anatomical description according to Couinaud is re-
viewed and corrected taking into account the descriptions made in the follow-
ing decades.
Results: It seems that by reviewing the description of the different authors,
a precise anatomical division of the liver may be achieved and a simple
terminology of hepatectomies may be proposed.
Conclusions: It is hoped that the proposal of this anatomical description
and this terminology of hepatectomies may find a consensus among the liver
surgical community from America, Asia, and Europe.
Keywords: liver anatomy, liver surgery, liver transplantation, living donor,
terminology of hepatectomies
(Ann Surg 2013;257: 383–386)
T he detailed anatomy of the liver described by Couinaud in his
original article in 19541 and his book in 1957,2 Le foie; études
anatomiques et chirurgicales, has been the basis for major advances
both in surgical techniques and in diagnostic and interventional radi-
ology. Since the introduction of this anatomical model, several mod-
ifications have been made and the list of terms used to describe the
anatomy of the liver has been complicated. Advances in surgical and
radiologic techniques in recent years, including reduced-size liver for
pediatric and adult transplants, split liver, and living donor in liver
transplantation, make the reexamination and further the international
consensus on hepatic anatomy and terminology of hepatectomies a
current priority.
The goal of this article was to focus on aspects of the hepatic
anatomy that have prompted the greatest confusion. It is important to
provide a concise vocabulary that accurately describes the anatomy of
the liver and draws on previous important works. At the same time, a
unified nomenclature for hepatic anatomy must dispel confusing mis-
nomers that have become commonplace in anatomical descriptions
of the liver.
COUINAUD’S DESCRIPTION OF SEGMENTAL LIVER
ANATOMY
Couinaud’s description of the anatomy of the liver is based
on the portal vein distribution into the liver. There are 2 livers (or
hemilivers), right and left, already known since Rex3 in 1888 de-
scribed the midline division of the liver. Both livers are divided into
sectors according to the secondary division of the branches of the por-
tal vein: 2 sectors for the right and 2 sectors for the left. Goldsmith,4
in the same year as Couinaud’s book in 1957, also did a division
of the right and left livers (in a different way for the left liver) and
From the Institut Hépato-Biliaire, Hôpital Paul Brousse, Villejuif, France.
Disclosure: The author declares that there is nothing to disclose.
Reprints: Henri Bismuth, MD, FACS (Hon), Institut Hépato-Biliaire, Hôpital Paul
Brousse, 12 Ave Paul Vaillant-Couturier, 94800 Villejuif, France. E-mail:
henri.bismuth@pbr.aphp.fr.
Copyright C 2013 by Lippincott Williams & Wilkins
ISSN: 0003-4932/13/25703-0383
DOI: 10.1097/SLA.0b013e31827f171f
called them segments. This started the confusion between the sectors
of Couinaud and the segments of Goldsmith.
Couinaud—and this was the main originality of his work—
divided the sector in segments. On the right liver, the 2 sectors are each
divided into 2 segments—superior segment and inferior segment,
which give 4 segments. On the left liver, the median sector is divided
in 2 segments separated by the falciform ligament and the round
ligament. The lateral sector is not divided and becomes 1 segment.
Therefore, there are 4 segments in the right liver and 3 segments in
the left liver, plus 1 segment for the small central and posterior part
of the liver between the portal vein bifurcation and the vena cava. It
has independent hepatic veins and portal branches. It may be called
posterior liver or central sector or, as called by Couinaud, segment 1.
In total, there are 8 segments. In 1994, Couinaud5 added a segment
that he called segment 9. It was the posterior and lateral part of the
right liver along the right side of the inferior vena cava. Indeed, this
territory belongs to segment 1, and Couinaud, when he gave his initial
description, forgot it. This small territory must be added to segment 1.
Couinaud later on recognized this fact. Segment 9 has to be forgotten.
Couinaud gave numbers to the segments in a clockwise manner
from 1 to 8. Couinaud’s classification of the liver anatomy is illustrated
in Figure 1: 2 livers, 4 sectors, and 8 segments.
In the early 1980s, ultrasonography of the liver—which was
really the first preoperative investigation of the liver—allowed to find
small tumors of the liver (<3 cm) that were the size of a segment.
And the segmental anatomical surgery of the liver started.
In 1982, the author published an article titled “Surgical
Anatomy and Anatomical Surgery of the Liver,”6 based on the
anatomy described by Couinaud and showing the ways of perform-
ing anatomical liver resection, which means following the lines of
division of the liver. In this article, some abnormalities of anatomy
described by Couinaud were pointed out and some corrections were
made.
The first one was a topographic correction: Couinaud, as an
anatomist, worked on cadaveric liver. This means that the liver was
put on the table for dissection and, as Couinaud did, for cast injection:
it was a kind of flat liver. The 2 sectors of the right liver were called
by Couinaud as anteromedial and posterolateral sectors. In reality, in
the patient body, the anteromedial sector lies totally in front of the
posterolateral sector (Fig. 2). The 2 right sectors are actually anterior
and posterior sectors (Fig. 3).
The second correction that was made to the anatomy described
by Couinaud is more important. On the left liver, Couinaud described
2 sectors: one sector, the lateral one, is the only segment that is un-
usual. And the other sector, the medial one, is divided into 2 segments
by the left portal branch in continuity with the round ligament. This
is not in accordance with Couinaud’s division, for, normally, the por-
tal branch lies inside the segment. What happens in this part of the
liver is that the umbilical vein—coming from the left branch of the
portal vein—is pulling out the portal branch and creates an additional
division of this part of the liver, which is, in fact, if we put inside
the portal branch, a single segment. Left medial sector becomes 1
segment, and segments 3 and 4 are indeed half-segments. Left lateral
sector, only with segment 2, has to be united to the left medial sector
which becomes 1 segment and together they constitute 1 sector: 1
sector with 2 segments (Fig. 4); this is in accordance with the usual
description of Couinaud. In order not to change the numbers put by

Annals of Surgery r Volume 257, Number 3, March 2013 www.annalsofsurgery.com | 383

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Bismuth
FIGURE 1. Anatomy of the liver according to Couinaud.2
FIGURE 2. The direction of the main and middle scissurae:
ex vivo in the flat liver according to the initial description of
Couinaud (top) and in situ in the body (bottom).
Couinaud, it is better to keep the numbers 3 and 4, knowing that these
segments are in fact half-segments.
We arrive at the following description of the liver anatomy
(Fig. 5):
• 2 hemilivers (right and left);
• 3 sectors (the right posterior, the right anterior, and the left);
• 7 segments:
• 6 segments (each sector divided in 2 segments):
◦ right posterior sector: segments 6 and 7,
◦ right anterior sector: segments 5 and 8,
◦ left sector: half segments 3–4 (as 1 segment) and segment 2;
• Plus segment 1.
THE OTHER DESCRIPTIONS OF LIVER ANATOMY
Takasaki, a Japanese surgeon, in 1986,7 provided a different
anatomy from his predecessors Couinaud and Goldsmith. The main
differences are as follows: (1) The portal vein divides into 2 branches:
the right, the middle, and the left. (2) There are 2 hepatic veins: the
right and the middle, the left hepatic vein of Couinaud being a branch
of the middle hepatic vein (Fig. 6). Therefore, the liver is divided
into 3 parts, almost of equal volume, called segments according to
384 | www.annalsofsurgery.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 257, Number 3, March 2013
FIGURE 3. A, The umbilical fissure that divides the anterior
sector of the left lobe into 2 segments is, in fact, an artificial
scissura. B, When it is suppressed, the anterior sector appears as
a single segment. With permission from Bismuth.10 Copyright
1982 Springer.
FIGURE 4. Anatomy of the liver according to Couinaud,6 mod-
ified by the author.
the 3 portal branches and the 2 hepatic veins. The anatomy described
by Takasaki avoids the mistakes of Couinaud. Apart from the terms,
Takasaki’s description is similar to the modified anatomy described
by Couinaud as described earlier: the liver is made up of 3 territories
and not 4, with 3 portal branches and 2 hepatic veins. This unifies
the Western and Asian liver anatomy. The criticism of the anatomy
described by Takasaki is that it does not take into account the divi-
sion of the left liver by the round ligament, which is an important
anatomical and surgical landmark of the liver. The advantage is the
individualization of the middle segment, which facilitates the central
hepatectomy.
The Brisbane terminology of liver anatomy8,9 is based on the
anatomy described by Couinaud but changes the terminology. The
term “sector” is replaced by the term “section” (Fig. 7). The right
liver has 2 sections (replacing exactly Couinaud’s sectors: right an-
terior and right posterior sections). On the left, segment 4 becomes
1 section: the left medial section. Segments 2 and 3 of Couinaud
become the left lateral section. This terminology aimed to define the
usual liver resections. However, for the left liver, the boundaries of the
sections do not follow the real anatomical division. One section, the
left medial section, is 1 segment and the left lateral section is between
2 Couinaud’s sectors. Indeed, the change of sector to section aimed
mainly to introduce a simple term for both segments 2 and 3. Since
its introduction in 2000, this terminology does not find the consensus
among liver surgeons.

C 2013 Lippincott Williams & Wilkins
Annals of Surgery r Volume 257, Number 3, March 2013 Revisiting Liver Anatomy

FIGURE 5. Surgical anatomy of the liver with definition of the

sectors, the hemilivers, and the lobes.

FIGURE 7. The Brisbane terminology of liver anatomy: the

sections.

FIGURE 6. Takasaki’s concept of liver segmentation.7

One of the difficulties that meet the anatomical descriptions of

the liver is the lateral part of the left liver, which is neither a segment
nor a sector. It is difficult to individualize it if we follow the distribu-
tion of the portal branches: for as described by Couinaud, the limits
of the liver territories are the hepatic veins and the portal branches are
inside. Indeed, this lateral part of the left liver is well individualized
by the round ligament and the falciform ligament. Resection of this
part of the liver was the first anatomical liver resection performed, and
it is one of the most common hepatectomies. It is called left lateral
segmentectomy according to Goldsmith’s description, bisegmentec-
tomy 2–3 by Couinaud, left lateral sectionectomy by Strasberg, and
equivalent to resection of a half segment by Takasaki.
Indeed, if we refer to the classical anatomy—the morphologic
one—this part of the liver is well defined and rightly called the left
lobe (Fig. 8). This term, “lobe,” is anatomically correct, for “a lobe is a
part of an organ defined by a fissure seen at the surface of the organ.”
And for the liver, the falciform ligament and the round ligament
FIGURE 8. The morphologic anatomy of the liver. With per-
mission from Bismuth. Copyright 1982 Springer.6
create a real fissure. This term, “left lobe,” was banned since the 1950s
because of the confusion between lobectomy and hepatectomy. At the
start of liver surgery, most of the surgeons performing liver resection
spoke about right lobectomy and left lobectomy when performing
what is now called right hepatectomy and left hepatectomy. Today,
the word “lobectomy” is no longer used. Indeed the best way to call
the resection of the left lateral part of the liver is to come back to the
classical anatomy and say left lobectomy, which is removal of the true
left lobe of the liver.


C 2013 Lippincott Williams & Wilkins www.annalsofsurgery.com | 385

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Bismuth
FIGURE 9. Anatomical surgery of the liver with defini-
tion of segmentectomies, sectorectomies, hepatectomies, and
lobectomies.
Figure 9 illustrates the terminology of the hepatectomies ac-
cording to what was said earlier, returning to Couinaud’s classifica-
tion. All hepatectomies may be defined by the number and identifi-
cation of the resected segments. For 1 segment removed, segmentec-
tomy + number: 1 to 8. Resection of 2 segments: bisegmentectomy +
numbers. For 3 segments: trisegmentectomy + numbers (for instance:
trisegmentectomy 8-5-1). Central hepatectomy (better to avoid saying
middle hepatectomy) has to be defined by the segments removed: usu-
ally they are the segments 5-8-4, but it may also include segment 1.
Resection only of segment 4 is segmentectomy 4. As segment 4 is
divided in 2 subsegments–4a, the upper one, and 4b, the lower one—
each may be removed independently: subsegmentectomy 4a or 4b.
386 | www.annalsofsurgery.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 257, Number 3, March 2013
Right or left hepatectomies are well defined. For the lobec-
tomies, left lobectomy may also be called bisegmentectomy 2-3. Right
lobectomy includes 5 segments (segments 4-5-6-7-8). Because this
extension of the right hepatectomy may remove segment 1 instead
of segment 4, it is better to say right extended hepatectomy, which
allows precisely to which segment the right hepatectomy is extended:
segment 4 or 1. Extension may involve 2 segments: 4 and 1, which
is the 6-segmentectomy on the right, also called right hepatectomy
extended to segments 1 and 4. The left extended hepatectomy to seg-
ments 1, 5, and 8 is the same resection en miroir on the left: left
hepatectomy extended to segments 1, 5, and 8, or 6-segmentectomy
on the left.
It is hoped that this terminology of hepatectomies will find a
consensus among the liver surgical community from America, Asia,
and Europe.
REFERENCES
1. Couinaud C. Lobes et segments hepatiques. Press Med. 1954;62:709–712.
2. Couinaud C. Le foie; études anatomiques et chirurgicales. Paris: Masson; 1957.
3. Rex H. Beitrage zur Morphologie der Saugerleber. Morphol Jahrb.
1888;14:517–617.
4. Goldsmith NA, Woodburne RT. Surgical anatomy pertaining to liver resection.
Surg Gynecol Obstet. 1957;195:310–318.
5. Couinaud C. Surgical approach to the dorsal section of the liver. Chirurgie.
1993–1994;119:485–488.
6. Bismuth H. Surgical anatomy and anatomical surgery of the liver. World J Surg.
1982;6:5–9.
7. Takasaki K, Kobayashi S, Tanaka S, et al. Highly selected hepatic resection by
Glissonean sheath-binding method. Dig Surg. 1986;3:121–121.
8. Terminology Committee of the International Hepato-Pancreato-Biliary Asso-
ciation. IHPBA Brisbane 2000. Terminology of liver anatomy and resections.
HPB Surg. 2000;2:333–339.
9. Strasberg SM. Nomenclature of hepatic anatomy and resections: a review
of the Brisbane 2000 system. J Hepatobiliary Pancreat Surg. 2005;12:351–
355.

C 2013 Lippincott Williams & Wilkins