Liver Anatomy
Sherif R. Z. Abdel-Misih, MD, Mark Bloomston, MD*
KEYWORDS
Liver Anatomy Surgery Hepatic vasculature Biliary tree
At present, liver resections are based upon the precise knowledge of the natural
lines of division of the liver which define the anatomical surgery of the liver.
Henri Bismuth1
Although many of the advances in hepatic surgery have been linked to improvements
in technology, there is no denying the impact of thorough knowledge of the internal
anatomy of the liver on improved outcomes. This is largely due to the work of the
French surgeon and anatomist, Claude Couinaud (1922–2008), who detailed his early
work in Le Foie: Etudes anatomiques et chirurgicales (The Liver: Anatomic and
Surgical Studies), in 1957, regarding segmental anatomy of the liver. Couinaud was
able to closely examine the intrahepatic anatomy and demonstrated that hepatic func-
tional anatomy is based on vascular and biliary relationships rather than external
surface anatomy, improving the safety and feasibility of hepatic surgery today.2
GENERAL ANATOMY
The liver is the largest organ, accounting for approximately 2% to 3% of average body
weight. The liver has 2 lobes typically described in two ways, by morphologic anatomy
and by functional anatomy (as illustrated in Fig. 1).1 Located in the right upper quad-
rant of the abdominal cavity beneath the right hemidiaphragm, it is protected by the rib
cage and maintains its position through peritoneal reflections, referred to as ligamen-
tous attachments (Fig. 2). Although not true ligaments, these attachments are avas-
cular and are in continuity with the Glisson capsule or the equivalent of the visceral
peritoneum of the liver.
Ligamentous Attachments
The falciform ligament is an attachment arising at or near the umbilicus and continues
onto the anterior aspect of the liver in continuity with the umbilical fissure. The falci-
form ligament courses cranially along the anterior surface of the liver, blending into
the hepatic peritoneal covering coursing posterosuperiorly to become the anterior
portion of the left and right coronary ligaments. Of surgical importance, at the base
Division of Surgical Oncology, The Ohio State University Medical Center, Arthur G. James
Cancer Hospital, Richard J. Solove Research Institute, 410 West, 10th Avenue, N-924 Doan
Hall, Columbus, OH 43210, USA
* Corresponding author.
E-mail address:
Surg Clin N Am 90 (2010) 643–653
doi:10.1016/j.suc.2010.04.017 surgical.theclinics.com
0039-6109/10/$ – see front matter ª 2010 Elsevier Inc. All rights reserved.
, 644 Abdel-Misih & Bloomston
Fig. 1. Anterior and posterior surfaces of liver illustrating functional division of the liver into
left and right hepatic lobes with Couinaud’s segmental classification based on functional
anatomy. From Brunicardi FC, Andersen DK, Billiar TR, et al. Schwartz’s principles of surgery.
9th edition. New York: McGraw-Hill Publishing; 2010. p. 31–3; with permission.
of the falciform ligament along the liver, the hepatic veins drain into the inferior vena
cava (IVC).3 A common misconception associated with the falciform ligament is that
it divides the liver into left and right lobes. Based on morphologic anatomy, this may
be true; however, this does not hold true from a functional standpoint (discussed later).
Within the lower edge of the falciform ligament is the ligamentum teres (round liga-
ment), a remnant of the obliterated umbilical vein (ductus venosus) that travels from
the umbilicus into the umbilical fissure where it is in continuity with the ligamentum
venosum as it joins the left branch of the portal vein. The ligamentum venosum lies
within a fissure on the inferior surface of the liver between the caudate lobe posteriorly
and the left lobe anteriorly, where it is also invested by the peritoneal folds of the lesser
omentum (gastrohepatic ligament). During fetal life, the ductus venosus is responsible
for shunting a majority of blood flow of the umbilical vein directly into the IVC,
Sherif R. Z. Abdel-Misih, MD, Mark Bloomston, MD*
KEYWORDS
Liver Anatomy Surgery Hepatic vasculature Biliary tree
At present, liver resections are based upon the precise knowledge of the natural
lines of division of the liver which define the anatomical surgery of the liver.
Henri Bismuth1
Although many of the advances in hepatic surgery have been linked to improvements
in technology, there is no denying the impact of thorough knowledge of the internal
anatomy of the liver on improved outcomes. This is largely due to the work of the
French surgeon and anatomist, Claude Couinaud (1922–2008), who detailed his early
work in Le Foie: Etudes anatomiques et chirurgicales (The Liver: Anatomic and
Surgical Studies), in 1957, regarding segmental anatomy of the liver. Couinaud was
able to closely examine the intrahepatic anatomy and demonstrated that hepatic func-
tional anatomy is based on vascular and biliary relationships rather than external
surface anatomy, improving the safety and feasibility of hepatic surgery today.2
GENERAL ANATOMY
The liver is the largest organ, accounting for approximately 2% to 3% of average body
weight. The liver has 2 lobes typically described in two ways, by morphologic anatomy
and by functional anatomy (as illustrated in Fig. 1).1 Located in the right upper quad-
rant of the abdominal cavity beneath the right hemidiaphragm, it is protected by the rib
cage and maintains its position through peritoneal reflections, referred to as ligamen-
tous attachments (Fig. 2). Although not true ligaments, these attachments are avas-
cular and are in continuity with the Glisson capsule or the equivalent of the visceral
peritoneum of the liver.
Ligamentous Attachments
The falciform ligament is an attachment arising at or near the umbilicus and continues
onto the anterior aspect of the liver in continuity with the umbilical fissure. The falci-
form ligament courses cranially along the anterior surface of the liver, blending into
the hepatic peritoneal covering coursing posterosuperiorly to become the anterior
portion of the left and right coronary ligaments. Of surgical importance, at the base
Division of Surgical Oncology, The Ohio State University Medical Center, Arthur G. James
Cancer Hospital, Richard J. Solove Research Institute, 410 West, 10th Avenue, N-924 Doan
Hall, Columbus, OH 43210, USA
* Corresponding author.
E-mail address:
Surg Clin N Am 90 (2010) 643–653
doi:10.1016/j.suc.2010.04.017 surgical.theclinics.com
0039-6109/10/$ – see front matter ª 2010 Elsevier Inc. All rights reserved.
, 644 Abdel-Misih & Bloomston
Fig. 1. Anterior and posterior surfaces of liver illustrating functional division of the liver into
left and right hepatic lobes with Couinaud’s segmental classification based on functional
anatomy. From Brunicardi FC, Andersen DK, Billiar TR, et al. Schwartz’s principles of surgery.
9th edition. New York: McGraw-Hill Publishing; 2010. p. 31–3; with permission.
of the falciform ligament along the liver, the hepatic veins drain into the inferior vena
cava (IVC).3 A common misconception associated with the falciform ligament is that
it divides the liver into left and right lobes. Based on morphologic anatomy, this may
be true; however, this does not hold true from a functional standpoint (discussed later).
Within the lower edge of the falciform ligament is the ligamentum teres (round liga-
ment), a remnant of the obliterated umbilical vein (ductus venosus) that travels from
the umbilicus into the umbilical fissure where it is in continuity with the ligamentum
venosum as it joins the left branch of the portal vein. The ligamentum venosum lies
within a fissure on the inferior surface of the liver between the caudate lobe posteriorly
and the left lobe anteriorly, where it is also invested by the peritoneal folds of the lesser
omentum (gastrohepatic ligament). During fetal life, the ductus venosus is responsible
for shunting a majority of blood flow of the umbilical vein directly into the IVC,
