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The Characteristics of Right Hepatic Vein in Middle Hepatic Vein Dominant Type, and the Variation of Glissonian Pedicle at Left Lobe of the Liver, Using Cadaver Liver Dissection

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The Characteristics of Right Hepatic

Vein in Middle Hepatic Vein Dominant

Type, and the Variation of Glissonian

Pedicle at Left Lobe of the Liver, Using

Cadaver Liver Dissection

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Acknowledgement (감사의 글) 2003년 3월 박사과정을 시작하고, 어느새 13년이라는 세월이 훌쩍 지났습니다. 짧으면 짧 고, 길다면 긴 10여년간의 시간을 돌이켜보면서, 많은 생각과 추억을 떠올리게 됩니다. 먼저 미욱한 저를 제자로 받아주신 영원한 스승님이신 왕희정 교수님께 진심으로 감사드립 니다. 선생님의 가르침 덕분에 연구에 대해서 의미 있는 성찰을 할 수 있었습니다. 학문을 함에 있어 소홀함이 없어야 한다고 말씀을 늘 해주셨는데 제가 많이 부족하였습니다. 부족 함을 하나 하나 채워나가는 모습으로 큰 가르침에 답하겠습니다. 더불어 논문을 준비하는 과정에서 아낌없는 조언을 해주신 김진홍 교수님과 임인경 교수님께 감사를 표합니다. 저의 가족 모두에게 감사를 드립니다. 특히, 아버지께서는 10여년 동안 제가 자포자기하 고, 석사학위로 만족하는게 어떨까 싶은 생각을 하고 있을 때마다, 저의 마음을 이미 잘 알 고 계신 것처럼 저를 타이르고 격려를 아끼지 않으셨습니다. 아버지의 말씀을 듣노라면, 의 지가 불끈 솟아 논문에 전념하다가, 연구 중에 어려움을 만나서 곧 의지가 꺽이고, 다시 격 려를 받고 또 다른 시작을 하는... 지난 10여년이었던 것 같습니다. 저의 아내 또한, 저의 바쁜 병원 생활 속에서 박사학위 만큼은 꼭 하기를 바란다는 무언과 유언의 메시지를 보내 면서, 많은 이해와 배려를 하며, 아들 도윤과 함께 늘 저를 응원해 주었습니다. 위의 감사해야 할 분들께 어떻게 보답을 해야 할지를 고민하는 것이 저의 앞으로의 숙제입 니다. 매우 즐겁고 행복한 숙제가 될 것입니다. 감사합니다. 2016년 8월 김 인 규

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- Abstr

act-TheCharacteristicsofRightHepaticVein in MiddleHepaticVein

DominantType,and theVariation ofGlissonian PedicleatLeftLobe

oftheLiver,Using CadaverLiverDissection

Introduction: Many liver resection and liver transplantation surgeries are performed worldwide,and clinicaloutcomes have recently improved.Studies of liver anatomy have developed alongside clinical and technical achievements as these types of research complement each other. I intended to evaluate some controversies for liver anatomy,using cadaver dissection.For righthemiliver,I tried to evaluate the relation ofrighthepatic vein (RHV)and middle hepatic vein (MHV)because rightlobe ofthe liverhas been mainly used as a graftin living related donor liver transplantation.For left hemiliver,I had two concerns.The firstonewasto evaluatethefeasibility ofthe'isolated IVb (inferior)resection of the liver'.The second aim was to define the borderbetween leftmedialsection and left lateralsection. Unexpectedly,I found 'new Glissonian pedicles (GPs)' between the two sections,and I also discussed whether or not the portalvein branches(P4d)in ‘Nagino’strisectionectomy’arerelatedwith the'new GPs'. Methods:Forrighthemiliverstudy,Idissected ten adultcadavers from Aprilto July 2012.Idefined thetypesofMHV and RHV according to theircharacteristics ofthebrancheswhich drain thesegmentsoftherighthemiliver.Ievaluatedwhich typeofMHV matched which type ofRHV,and identified whetheraccessory right hepaticvein (ARHV)existin whatmatch ofMHV andRHV.

Forisolated IVb resection in lefthemiliver,Idissected ten adultcadavers from May 2004toJune2004.Ifollowedthedefinition thatIVaissuperiorportion ofIV segment,and thatIVb is inferiorportion ofIV segment.Imeasured the numbers ofGlissonian pedicles(GPs)in IV segment,IVa,and IVb,respectively as wellas thedistancesbetween theorigin ofIVabranchesandIVb.

Forborderbetween leftmedialsection and leftlateralsection study,from April 2012toJuly 2012,31adultcadaversweredelicately dissected simultaneously from the visceral (inferior) and diaphragmatic (superior) surfaces. We defined a ‘NewGP’asan extraGP otherthan thetraditionalGPs,which supply segmentsII,

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III,IVa,and IVb in theordinary direction,and anatomically located superiortothe umbilicalfissure (UF).We subdivided ‘NewGPs’into ‘IINewGPs,’‘IIINewGPs,’ ‘IVaNewGPs,’‘IVb NewGPs,’and ‘centralNewGPs’(neutraltothetraditionalGP) according tothedistancefrom theorigin ofthetraditionalGP.

Results:Forrighthemiliverstudy,MHV typeA (MHV dominant)was3/10(30%), typeB was3/10(30%),andtypeC was4/10(40%).RHV typeA was2/10(20%), type B was 6/10 (60%),type C was 1/10 (10%),and type D was 1/10 (10%).In MHV dominanttypeA,RHV typeB was2/3,and typeC was1/3.ARHV existed in 3/3(100%)forMHV dominanttypeA,and ARHV existedonly in 1/4(25%)for MHV typeC.

For isolated IVb resection study in left hemiliver,the numbers of GPs in IV segmentwas 5 (±1.3)in on average,4 to 7.The mean numbers ofGPs in IVa was1.6(±0.7),from 1to3.ThenumbersofGPsin IVb was3.4(±0.9),from 2to 5.There were 2 cases which were considered as having their common origin becausethedistancebetween theoriginsofIVaandIVb werevery close.

Forborderbetween leftmedialsection and leftlateralsection study,theumbilical fissurevein (UFV)wasidentifiedin 83.8% ofcases.TheUFV mainly drainedinto thelefthepaticvein (LHV),with an incidenceof88.5%.Theincidenceofdrainage into the MHV was 3.8%,and independentdrainage from the LHV or MHV was identified in 7.6% of cases.The incidence of ‘NewGPs’was 30/31 (96.8%).Of them,‘centralNewGPs’were mostprevalent,with an incidence of28/31 (90.3%). The diameter of the ‘NewGPs’ranged from 3.5 mm to 5.6 mm,which was not significantly differentfrom thatoftraditionalGPs(II-,III-,orIV-GP).

Conclusions:For right hemiliver study,the incidences of MHV type and RHV typewere much differentfrom thepreviousreports.ThecharacteristicsofARHV according to MHV and RHV type were also from the otherarticles.Itcould be furtherly evaluated with much more numbers of cadaver dissection or using modernizedthree-dimensionalimaging technique.

Forisolated IVb resection study in lefthemiliver,oneofimportantpointsin this study isthattwo often cases(20 %)had common origin ofIVaand IVb.In case of 'IVb + IV resection', which is commonly performed for patients with gallbladder cancer. When we clamp temporarily IVb segment-looking GPs originating from UF and someportion ofIVa discolorsaswellasIVb segment,I

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believe we have to ligate selectively IVb segment GP because it should mean common origin ofIVaandIVb segment.

Forborderstudy between leftmedialsection and leftlateralsection,we believe that‘centralNewGPs’togetherwith the UF can serve as a new borderbetween the leftmedialsection and lateralsection.In addition,we think thatthe P4d in ‘Nagino’strisectionectomy’correspondsto the‘IVaNewGP’in ourstudy.Therole of the ‘NewGP’ would be to complement the traditional II,III,IVa, and IVb pedicles in supplying the liver.When liversurgeons face the livermalignancy of IV orII/IIIsegmentsuperficially invading overtheumbilicalfissure,Ibelievethat they can secure the needed margin resecting the area supplied by 'NewGP'.It could preventfrom expanding thesurgery in patientswhoseliverfunction ispoor ormarginal.

---Key words:livertransplantation,hepatectomy,anatomy

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TableofContents

Acknowledgement--- i

Abstract--- ii TableofContents--- v

ListofFigures--- vi

ListofTable--- vii I.INTRODUCTION --- 1 II.METHODS --- 2 III.RESULTS --- 4 IV.DISCUSSION --- 36 REFERENCES --- 44 국문 요약 --- 47

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ListofFigures

Figure1.Case1showsMHV typeA --- 5

Figure2.Case5showsMHV typeB --- 6

Figure3.Case7showsMHV typeC --- 7

Figure4.Case7showsRHV typeA --- 8

Figure5.Case2showsRHV typeB --- 10

Figure6.Case4showsRHV typeC --- 12

Figure7.Case3showsRHV typeD --- 14

Figure8.Case5showstwoARHVsfrom IVC --- 15

Figure9.Photograph ofdissectedspecimen ofcase2--- 19

Figure10.Photograph ofdissectedspecimen foradditionalpedicle-- 20

Figure11.Case16showssegmentIIandIIIGPsof thelefthemiliver--- 24

Figure12.Case10showssegmentIVaandIVb GPsof thelefthemiliver--- 25

Figure13.Case1showsadditionalpedicle(arrow)and oneofNewGP (arrowheads)--- 26

Figure14.Drainagepattern ofthelefthepaticvein according toReichert,etal.12--- 28

Figure15.MultipletypesofUFV --- 29

Figure16.NewGPsofcase8--- 33

Figure17.NewGPsofcase5--- 35

Figure18.Schematicillustration ofNewGP and additionalpediclecomparedwith traditionalGPs--- 40

Figure19.Computedtomography ofa54-year-oldwoman showstheonly portalvein of'NewGP' thatwaslocatedanatomically superiorto theumblicalfissure--- 42

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ListofTables

Table1.CharacteristicsofRHV,MHV,andARHV --- 16 Table2.CharacteristicsofGlissonian pedicleofsegmentIV --- 18 Table3.CharacteristicsoftraditionalGP (II,III,IVa,andIVb)

andadditionalpedicle--- 22 Table4.CharacteristicsoftheLHV andtheUFV --- 27 Table5.NewGP basedon theUF --- 32 Table6.NumberofGP with orwithoutNewGP

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INTRODUCTION

Controversies regarding the anatomy of the liver have not yet been fully resolved,even among liver surgeons.Classicalanatomic classifications such as those of Couinaud1 and Healey2 are based on the characteristics of the portalvein and bile duct,respectively.More recently,Ryu and Cho3provided a new anatomic description based on the portalsegmentation and drainage veins.Universalterminology forhepaticanatomy and liverresection hasonly recently been adopted.4

Meanwhile, many liver resection and liver transplantation surgeries are performed worldwide,andclinicaloutcomeshaverecently improved.Studiesof liver anatomy have developed alongside clinicaland technicalachievements and these types of research complement each other. One of the new pioneering technical advancement, 'the hanging maneuver', was recently introduced9and consequentialanatomicalstudies have been published.5,6Ihad participated in developing a ventral hilum exposure method for liver resection,7,8 which was based on anatomicalstudies relevantto this specific surgicaltechinique.9,10

Forrighthemiliver,there are some arguments for rightand middle hepatic vein becauserightlobeoftheliverhasbeen mainly used asagraftin living related donorlivertransplantation.Classification ofhepatic vein is classified according to some studies.11,12We callRHV dominantwhen rightlobe drains less than 40% into MHV,and MHV dominantwhen rightlobe drains 40% or moreintoMHV.13

For left hemiliver, I have been interested in for the left hemilver was argumentofleftmedialsection.Healey14divided segmentIV ofthe liveras the 'superiorportion (IVa)'and the 'inferiorportion (IVb)'.On the contrary, Launois15suggested thatthere was no usefulpurposein dividing segmentIV into IVa and IVb.He insisted IVa would be only 20 % ofIV segment,and thatitwould be very difficultto isolated IVa orIVb resection technically.I planned to evaluate the feasibility ofthe 'isolated IVb (inferior)resection of

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theliver'asthesecondcadavericstudy forthelefthemiliver.

Second of my concern for lefthemiliver was to define the border between leftmedialsection and leftlateralsection.Strasberg16,17criticized Couinaud’s classification,insisting thatthe umbilicalfissure (UF)is a landmark forthe border of the left medial and left lateral sections based on Healey’s classification.Actually,the left medialsection is much larger in area and volumethan thelateralsection according to Couinaud.On thecontrary,when weconsidertheUF asaborderlandmark based on Healey’sclassification,the area and volume of the leftmedialand lateralsections are similar to each other.Couinaud18partially agreed with Strasberg’s criticism,buthemaintains thattheumbilicalfissurevein (UFV;tributary ofthelefthepaticvein)should be considered a portalfissure and thatresection of the academic lobe is a portal resection. Unexpectedly, I found 'new Glissonian pedicles (GPs)' between thetwo sections,and Ialso discussed whetherornottheportalvein branches (P4d) in ‘Nagino’s trisectionectomy’19,20 are related with the 'new GPs'.21

METHODS

Forrighthemiliverstudy wedissected ten adultcadaversfrom Aprilto July in 2012.The hepatic parenchyma was removed using mosquito clamps under directvision in ordertoidentify theGlissonian pedicle(GP)andhepaticveins. Idefined the types ofMHV and RHV as next.22Forthe definition ofMHV, ThetypeA is approximately equalvenousdrainagefrom segmentIV,V,and VIIIvialargesecondary branchesuniting deep within thehepaticparenchyma. The type B is a single large vessel receiving secondary branches from segmentsIV,V,and VIIIthroughoutitscourse.ThetypeC isa broad MHV vascular tree thatreceives multiple trunks from the anterolateralrightlobe and segment IV.For the definition of RHV,the type A is a single large

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within the hepatic parenchyma. The type C is very short and posterior, providing limited venous drainage to segments VII and VIII with no involvementof the anterolateralsurface of the righthemiliver (segments V and VI). The type D is approximately equal venous drainage from right anterior section and right posterior section via large secondary branches uniting justbefore RHV confluence to inferiorvena cava.Ialso checked the existence of accessory right hepatic vein (ARHV) and the characteristics according tothematchesofRHV/MHV types.

For IVb isolated resection study in left hemiliver,we dissected ten adult cadavers from May 2004 to June 2004.Firstly,Idissected the cadaverlivers from the perspective of GP,secondly dissected bile duct and portal vein, respectively. I followed the definition that IVa is superior portion of IV segment,and that IVb is inferior portion of IV segment. I measured the numbers of GPs in IV segment,IVa,and IVb,respectively as wellas the distances between the origin of IVa branches and IVb.Also,I studied the characteristicsof'additionalpedicles'thatwereknown toappearin IVa.

For border study between left medialsection and left lateralsection,we dissected thirty-one adult cadavers from April 2012 to July 2012. The specimensweredelicately dissected simultaneously from thevisceral(inferior) and diaphragmatic (superior) surfaces. All identified GPs were dissected, exceptthose with a diameter less than 1 mm.The leftand middle hepatic veinsand theirbranchesweredissected,exceptin casesofvasculaturewith a diameter less than 1 mm.We estimated the number of II,III,IVa and IVb segmentGP.The number of ‘additionalpedicles’introduced by Launois and Jamison23,and theirdiameters were also determined.We followed the hepatic vein classification system described by Reichertetal.24 Type A is union of segmentIIand IIIhepaticveinsto form theprincipallefthepatic vein atthe UF.TypeB involvesseparatelargehepaticveins,each draining an individual segment,which uniteto form thelefthepaticvein attheleveloftheinferior

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vena cava.Type C is union ofsegmentIIand IIIdraining hepatic veins in theliverparenchymatoform thelefthepaticvein lateraltotheUF.

Unexpectedly,wefound variationsornew GPsduring thecadaverdissection. We defined these newly identified GPs (‘NewGPs’)as extra GPs other than thetraditionally described GPsthatsupply theII,III,IVa,and IVb segments, and areanatomically located superiorto theUF.Wesubdivided the‘NewGPs’ into ‘IINewGPs (nearto traditionalIIGP)',‘IIINewGPs (nearto traditional IIIGP)',‘IVa NewGPs (nearto traditionalIVa GP)',‘IVb NewGPs (near to traditional IVb GP)', and ‘central NewGPs’ (neutral to traditional GPs) according to their distance from the traditionalGP origin.‘CentralNewGPs’ hadthesameorvery similardistancesfrom thetraditionalGP origin.

RESULTS

For right hemiliver study,MHV type was classified as mentioned above (Figure1 toFigure3).RHV typewasalsoclassified assamemanner(Figure 4 to Figure7).ARHV wasconsidered when itwas5 mm ormore(Figure8). MHV type A (MHV dominant)was 3/10 (30%),type B was 3/10 (30%),and typeC was 4/10 (40%)(Table 1).RHV typeA was 2/10 (20%),typeB was 6/10 (60%),type C was 1/10 (10%),and type D was 1/10 (10%).In MHV dominanttypeA,RHV typeB was2/3,andtypeC was1/3.ARHV existedin 3/3 (100%)forMHV dominanttype A,and ARHV existed only in 1/4 (25%) forMHV typeC.

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Figure1.Case1 showsMHV typeA.(a)ThereappearRHV and MHV after dissection.(b)The same as (a),white bars representcharacteristics ofMHV typeA.MHV,middlehepaticvein;RHV,righthepaticvein.

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Figure 2.Case 5 shows MHV type B.(a)There appear RHV,RAGP,and MHV after dissection. (b) The same figure as (a), white bars show characteristics of MHV type B. MHV, middle hepatic vein; RAGP, right anteriorGlissonian pedicle;RHV,righthepaticvein.

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Figure3.Case7 showsMHV type C.(a)ThereappearRHV and MHV after dissection.(b)White bars represents characteristics of MHV type C.MHV, middlehepaticvein;RHV,righthepaticvein.

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Figure4.Case7 shows RHV typeA.(a)There appearRHV and MHV after dissection.MHV,middlehepaticvein;RHV,righthepaticvein.

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Figure4.Case7showsRHV typeA.(b)Thick whitebarand thin whitebars show characteristics ofMHV type C.MHV,middle hepatic vein;RHV,right hepaticvein.

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Figure5.Case2 showsRHV typeB.(a)ThereappeasRHV afterdissection. RHV,righthepaticvein.

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Figure 5. Case 2 shows RHV type B. (b) The similar thickness of two branchesaredrainedtoRHV.RHV,righthepaticvein.

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Figure 6.Case 4 shows RHV type C.(a) There appear RHV,RAGP,and MHV after dissection. RHV, right hepatic vein; RAGP, right anterior Glissonian pedicle;MHV,middlehepaticvein.

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Figure 6.Case 4 shows RHV type C.(b)The same as (a),butwhite bars represents characteristics of RHV type C.RHV,right hepatic vein;RAGP, rightanteriorGlissonian pedicle;MHV,middlehepaticvein.

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Figure7.Case 3 shows RHV type D.(a)There appearRHV and MHV after dissection.(b)Thethick whitebarsrepresentcharacteristicsofRHV typeD, which bifurcateattheproximalRHV.RHV,righthepaticvein;MHV,middle hepaticvein.

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Figure8.Case5showstwoARHVsfrom IVC.ARHV,accessory righthepatic vein;IVC,inferiorvenacava.

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RHV type MHV type ARHV number/diameter(mm) Case1 B A 2/(5,5) Case2 B A 2/(5,5) Case3 D A 1(10) Case4 C C 0/ -Case5 B B 2/(5,5) Case6 B B 2/(8,5) Case7 A C 0/ -Case8 A C 2/(6,10) Case9 B B 0/ -Case10 B C 0/

-Table1.CharacteristicsofRHV,MHV,andARHV

RHV,righthepaticvein;MHV,middlehepaticvein;ARHV,accessory hepatic vein

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ForIVb isolated resection study in lefthemiliver,thenumbersofGPs in IV segmentwas5 (±1.3)in on average,4 to 7 (Table2).Themean numbersof GPsin IVawas1.6 (±0.7),from 1 to3.ThenumbersofGPsin IVb was3.4 (±0.9),from 2 to 5.Imeasured the shortestdistance between the GP ofIVa and the one of IVb, which was 5.6 mm (±3.9). Eight of 10 cases have definitely farfrom each origin ofGP in IVa and IVb.However,therewere2 cases (case 2 and case 9) which were considered as having their common origin because the distance between the origins of IVa and IVb were very close (Figure 9)The additionalbranches ofIVa were identified in allthe 10 cases,8caseshad 1in number,andtheother2caseshad 2in number.They directed from theleftmain GP to IVa,and allthe10 caseshad thebranches ofIIsegmentwhich originatedfrom theleftmain GP (Figure10).

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IV (each) IVa (each) IVb (each) IVa – IVb (mm) A dditional pedicleofIVa (each) Case 1 4 1 3 4 1 Case 2 5 2 3 Common origin 1 Case 3 4 1 3 10 1 Case 4 3 1 2 10 1 Case 5 4 1 3 8 1 Case 6 6 1 5 6 1 Case 7 5 2 3 5 1 Case 8 5 2 3 10 1 Case 9 7 3 4 Common origin -Case 10 7 2 5 3 -Mean (±SD*) 5 (±1.3) 1.6 (±0.7) 3.4 (±0.9) 5.6 (±3.9)

Table2.CharacteristicsofGlissonian pedicleofsegmentIV.

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Figure 9. Photograph of dissected specimen of case 2. (a) It shows the branches ofsegmentII,III,IVa and IVb.(b)The distance bewteen segment IVaandIVb origin looksvery short.

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Figure10.Photograph ofdissected specimen foradditionalpedicle. (a)(Case 3)Itshows the additionalpedicle ofsegmentIVa from leftmain Glissonian sheath. (white arrow = additionalpedicle of segment IVa; MHV = middle hepatic vein;LHV = lefthepatic vein).(b)(Case 10)Itshows the additional pedicle ofsegmentIVa from leftmain Glissonian sheath.Itoriginates before thebranch ofsegmentII(black arrow = additionalpedicleofsegmentIVa;II

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For border study between left medialsection and left lateralsection,the characteristicsoftraditionalGPs,including segmentsII,III,IVa,IVb,and the additionaldiscovered pedicleswerereported (Table3).OnetofoursegmentII GPs were found in each case,and had an average diameterof7.7 mm.We found one to five segmentIIIGPs in each case with an average diameterof 9.7 mm.There were zero to three segmentIVa GPs in each case,and the average diameterwas 3.7 mm.Two to fivesegmentIVb GPs were identified in each case,and they had an average diameter of 5.5 mm. The overall incidenceofadditionalpedicleswasonetotwo in each case,with an average diameterof1.9mm.

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Number,mean,each (range) Diameter,mean,mm, (range) II 1.8(1-4) 7.7(2-18) III 1.5(1-5) 9.7(2-17) IVa 1.5(0-3) 3.7(1-8) IVb 3.7(2-5) 5.5(2-12) Additionalpedicle 1.3(1-2) 1.9(1-4)

Table3.CharacteristicsoftraditionalGP (II,III,IVa,and IVb)and additional pedicle.

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The IIand IIIsegmentGPs ofthe lefthemiliverwere shown (Figure 11), and theIVa and IVb segmentGPsofthelefthemiliverappeared (Figure12). Additionalpedicleswerealso shown (Figure13).Allcasesin thisstudy had thepediclesin addition tothoseoftheIVasegment.Thesepediclesoriginated just before II GP origin,not just after the II GP origin.We analyzed the characteristicsoftheLHV and theUFV,and theresultswerereported (Table 4).Based on the methods described by Reichertetal.24,allofthe LHV and MHV typescould beseen (Figure14).AlltheLHV wasmainly typeA,with an incidence of67.8%.The UFV was identified in only 83.8% ofcases.The UFV mainly drained into theLHV,with an incidenceof88.5%.Theincidence ofdrainageinto theMHV was3.8%,and independentdrainagefrom theLHV or MHV was identified in 7.6% of cases.Case-by-case descriptions of the UFV were provided (Figure 15).Five cases had no definite UFV.The UFV wasthoughtto haveoriginated primarily from thelefthepaticvein,butitdid arise from the middle hepatic vein orindependently from the LHV and MHV in afew cases.

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Figure11.Case16 showssegmentIIand IIIGPsofthelefthemiliver.Some part of the left hepatic vein was lifted upward in the field. The forcep indicates additionalpedicle.GP,Glissonian pedicle; LHV,left hepatic vein; LMS,leftmeidalsection.

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Figure 12.Case 10 shows segmentIVa and IVb GPs of the lefthemiliver. GP,Glissonian pedicle;LMS,leftmedialsection;LLS,leftlateralsection.

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Figure 13. Case 1 shows additional pedicle (arrow) and one of NewGP (arrowheads).GP,Glissonian pedicle;LMS,leftmedialsection.

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Type Incidence Existence Origin Incidence LHV A 21/31(67.8%) UFV 26/31(83.8%) LHV 23/31(88.5%)

B 8/31(25.8%) MHV 1/31(3.8%)

C 2/31(6.5%) Identndepen 2/31(7.6%)

Table4.CharacteristicsoftheLHV andtheUFV.

LHV ,Lefthepatic vein;UFV,Umbilicalfissure vein;MHV,Middle hepatic vein UFV,Umbilicalfissurevein

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Figure 14.Drainage pattern ofthe lefthepatic vein according to Reichert,et al.12.(a)TypeA:Case4showsaunion ofsegmentIIandIIIveinstoform a principalLHV atthe UF.(b)Type B:Case 16 shows separate large veins, each draining an individualsegment,thatunited to form thelefthepatic vein attheleveloftheinferiorvenacava.

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Figure 15. Multiple types of the UFV. (a) Case 3 shows the UFV (arrowheads)from LHV.(b)Case 22 shows the UFV (arrowheads)from the MHV. LHV, left hepatic vein; MHV, middle hepatic vein; UF, umbilical fissure;UFV,umbilicalfissurevein;LMS,leftmedialsection.

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Figure 15.(c)Case 1 shows the UFV (arrowheads)independenton the LHV or MHV (d) Case 2 shows no definite UFV related to the LHV or MHV. Forceps indicate the branches of the LHV and MHV,respectivel.LHV,left hepaticvein;MHV,middlehepaticvein;UF,umbilicalfissure;UFV,umbilical fissurevein;LMS,leftmedialsection.

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We identified a pedicle as a ‘NewGP’ based on the UF (Table 5). The incidence of ‘NewGPs’was 30/31 (96.8%).‘CentralNewGPs’were the most prevalent (28/31,90.3%),and ‘II NewGPs’ were the least prevalent (6/31, 19.4%).The diameters ofthese ‘NewGPs’ranged from 3.5 to 5.6 mm,which was notsignificantly differentcompared to traditionalGPs having a diameter ranging from 3.7to9.7mm (Table3).Typical‘NewGPs’areshown in Figure 16 and Figure 17. These cases had several ‘NewGPs’ superior and perpendicularto theUF,which clearly differentiatesthem from thetraditional GPs.

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Incidence Number of total, each (range) D iam eter, mean, mm (range) IINewGP 6/31(19.4%) 7(0-2) 3.6(2-5) IIINewGP 17/31(54.8%) 24(0-2) 5.3(1.5-9) CentralNewGP 28/31(90.3%) 49(0-3) 4.7(1-11) IVaNewGP 20/31(64.5%) 28(0-2) 3.5(2-6) IVb NewGP 24/31(77.4%) 39(0-4) 5.6(2-10)

Table5.NewGP basedon theUF.

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Figure 16.NewGPs of case 8.(a),(b)They show those three NewGPs are located superior(anatomically)and perpendicularto the UF between theUFV and III GP. GP, Glissonian pedicle; UF,umbilical fissure; UFV, umbilical fissurevein;LMS,leftmedialsection;LLS,leftlateralsection.

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Figure 16.NewGPs of case 8.(c) Two fingers push III NewGP and IVb NewGP.A 'centralNewGP' appears between them.GP,Glissonian pedicle; UF,umbilicalfissure;UFV,umbilicalfissure vein;LMS,leftmedialsection; LLS,leftlateralsection.

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Figure 17.NewGPs ofcase 5.This panelshows that'IVa NewGP'(arrows) is located superior (anatomically) to the UF near traditional IVa GP (arrowheads).GP,Glissonian pedicle;UF,umbilicalfissure;LMS,leftmedial section;LLS,leftlateralsection;MHV,middlehepaticvein;LHV,lefthepatic vein.

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DISCUSSION

Forrighthemiliverstudy,the incidences ofMHV type and RHV type were much different from the previous reports.11-13 The characteristics of ARHV according to MHV and RHV type were also from the other articles.21 They described thatRHV type C orMHV type C had more ARHV than the other types.21In this study,ARHV existed in 3/3 (100%)forMHV dominanttype A,and their matched types were type B (2/3)and type D (1/3).For MHV type C,ithad ARHV in 1/4 (25%)less than in MHV type A.When we use modified right lobe graft of the liver in living donor liver transplantation, outflow reconstruction has been known to be one ofimportantfactors which could influence on the graft function after the surgery.25 Whether or not significantARHV exists is also essentialas wellas significantV and VIII  segmenthepatic veins in using rightlobegraft.Itired to find some patterns forthoseby cadaverdissection,butitdid notappearclearly.Itcan bedueto smallnumberof materials in this study.Ibelieve thatitcould be furtherly evaluated with much morenumbersofcadaverdissection orusing modernized three-dimensionalimaging technique.26

Forisolated IVb study,IV segmentofthe liveris bordered by main portal fissure to the right, umbilical fissure to the left, and caudate lobe/dorsal fissure to the posterior direction.IV segment is known to have the most various portalvein,bile duct and hepatic artery in whole segments of the liver.15 Launois15 described the additional branches of IVa originate from proximaland distalportion ofIIsegmentpedicle'sorigin in leftmain GP,but Ifoundalltheadditionalbranchesoriginatefrom only proximalportion in this study.

One ofimportantpoints in this study is thattwo often cases (20 %)had common origin of IVa and IVb.In case of 'IVb + IV resection',which is commonly performed for patients with gallbladder cancer,they resect5 mm

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as IVb segmentatthe time,itmightmean thatcommon origin ofIVa and IVb isligated.Discoloredportion ofthelivercouldbenecrotictissueafterthe surgery,and itcould bea causeofpost-operativemorbidity.When weclamp temporarily IVb segment-looking GPs originating from umblicalfissure and some portion ofIVa discolors as wellas IVb segment,Ibelieve we have to ligate selectively ligate IVb segment GP because it should mean common origin ofIVaandIVb segment.

For border study between left medialsection and left lateralsection,the characteristics ofthe GPs forsegments II,III,IVa,and IVb were similarto those of findings described in other studies in terms of the number and structure ofthe pedicles.27-29We found ‘NewGPs’through cadaverdissection. Multiple ‘NewGPs’were noted,and were usually located between the left medialand leftlateralsections.We analyzed the number of GPs,including ‘NewGPs,’based on the UF and the UFV (Table 6).When considering only traditionalGPs in this study,the incidence ofsegments II,III,IVa,and IVb was 1.8,1.5,1.5,and 3.7,respectively.When considering ‘NewGPs’based on both the UF and the UFV,the incidence of allGPs increased.A greater increasein IIIsegmentGPswasnoted when 'New GPs'wereidentified based on the UFV,because we found many UFVs were located very close to the originsof‘centralNewGPs.’MostUFVsoriginated from thelefthepaticvein, and we classified cases of‘centralNewGP’thatwere very close to the UFV as part of the left lateralsection.Of course,we think that these ‘central NewGPs’could be IVb segmentGPs ratherthan IIIsegmentGPs.Summing the numbers of ‘NewGPs’and traditionalpedicles indicated that we found many more pedicles than two previous studies,15,30 and a similar number to onepriorstudy27(Table4).Couinaud27describedmultiplebranchesofthe

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Mean No. Mean No. with NewGP by UF Mean No. with NewGP by UFV

Mean No.in otherarticleortextbook

II 1.8 2.1 2.2 Usually only asingleGP15,27

III 1.5 1.9 3.7 1- 2,occasionally 3

15, 2.227

Central - 1.6 0.1

-IVa 1.5 2.5 2.5 1.630 2or3forIV (IVa+IVb)15,

7.2forIV (IVa+ IVb)27

IVb 3.7 4.9 4.9 3.430

Table6.NumberofGP with orwithoutNewGP basedon theUF/UFV.

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umbilicalportion ofGPs,butheclassified thesebranchesintosegmentIVaor IVb GPs.Wepositthatall‘NewGPs’arenotnecessarily IVaorIVb GPs,and thatthey are partly IIand IIIGPs as wellas IVa orIVb GPs.Additionally, we did find that‘centralNewGPs',‘IINewGPs', and ‘IIINewGPs’werenot partofCouinaud’sdescription.

We proposed that Healey’s classification is superior to Couinaud’s in its description ofthe leftlateralsection and the medialsection.31When we used the UF as a landmark,we could almost always localize ‘NewGPs’(30/31, 96.8%).In addition,itwasfrequently difficultto classify ‘centralNewGPs’as traditionalIII or IVb GP.This is one of the reasons we can insist that ‘NewGPs’really arenew.Webelievethat‘centralNewGPs’togetherwith the UF can serve as a new border between the leftmedialsection and lateral section.This is the firststudy to reportvariations ornew GPs,which could serveaspartoftheborderbetween theleftmedialsection andlateralsection. Theverticallength ofliverparenchymasupplied by 'NewGP'looks20-30mm orso,and thevolumesupplied by 'NewGP'issmallcompared with otherIVa, IVb,IIorIIIsegment.We believe its clinicalsignificance would supplement thetraditionalII,III,IVa,and IVb pediclesin supplying theliver.When liver surgeons face the liver malignancy of IV or II/III segment invading superficially overtheUF,Ibelievethatthey can securetheneeded margin by resecting the area supplied by 'NewGP'. It should mean to prevent from expanding the surgery (i.e. left lateral sectionectomy or left medial sectionectomy into lefthemihepatectomy)in patients whose liver function is poorormarginal.Wesuggesta schematicillustration (Figure18)forNewGP and additionalpedicle,which is modified from Couinaud's description27based on thisstudy.

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Figure 18. Schematic illustration of NewGP and additionalpedicle compared with traditionalGPs.'A'(branchesfilled with black color)showsatraditional IVa GP,a IVa NewGP,an additionalpedicle,and a IINewGP from leftto right.'B'(branches filled with black color)shows a IVb NewGP,a central NewGPs,andaIIINewGP from lefttoright.GP,Glissonian pedicle.

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There was a problem using UFV as a landmark for ‘NewGP’as much as using UF. There were severalambiguous situations with regard to variation in the characteristics ofthe UFV.Most‘centralNewGPs’could be classified asoneofthetraditionalGPs,IIIorIVb.In twocases,‘centralNewGPs’could not be classified into any traditional category because the UFV was not apparentand all‘centralNewGPs’werea similardistance from the LHV and MHV (Figure 15d).Couinaud18 reported that only 29% of cases had along tributary following the length of the UF,and Hwang et al.32 reported that only 35.4% ofcaseshadaprominentUFV.

The tip ofthe ‘NewGP’can be seen clinically with commonly-used imaging techniques such as computed tomography.However,whatis seen is only the portalvein ofthe‘NewGP’(Figure19).Morestudiesfocused on this specific areaofliveranatomy arenecessary todefinethisnew GP ormoreaccurately identify itasavariation orbranchofaGP.

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Figure 19.Computed tomography of a 54-year-old woman shows the only portalvein of'NewGP'thatwaslocated anatomically superiortotheumbilical fissure. From left to right, arrows and a long arrowhead indicate 'IVb NewGP','centralNewGP',and'IIINewGP'.GP,Glissonian pedicle.

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For newly found 'NewGP',I could find that Nagino et al.19 reported an anatomicrightlivertrisectionectomy.Severalbranchesoftheumbilicalportion ofthe portalvein (P4d)20were carefully ligated,and then the cranialside of theumbilicalportion oftheleftportalvein wascompletely detached from the umbilical plate. This maneuver was one of the important points they emphasized in their article. However, P4d are unfamiliar to the many surgeons,and this may make them hesitant to accept and apply Nagino’s procedure in patients undergoing liver trisectionectomy.We believe thatthe P4d in Nagino’s trisectionectomy19are the same as the ‘IVa NewGPs’in the presentstudy.

Afterallthe three studies in this article,Ibelieve thatanatomicalstudy for the liver could give some substantial evidences when the liver surgeons deveolp their surgical techniques. In addition, recently being introduced 3-dimensional imaging technique as well as modernized conventional diagnostic tools such as computed tomography or magnetic resonance image could bemuch morehelpfulfortheliversurgeonstounderstand theliverand developthenew surgicaltechniquein thenearfuture.

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국문 요약 -사체 간 해부를 통한 중간정맥 우세형에서 우간정맥의 특징과,간좌엽의 글리슨 지 의 변이에 대한 연구 서론 현재 간절제나 간이식과 같은 수술이 세계적으로 광범위하게 시행되고 있고,그 결과도 매우 양호하다.간의 해부에 대한 연구는 임상 술기의 발달과 같이 병행되어 왔 다.저자는 사체 해부를 통하여,최근의 간 해부에 대한 몇가지 쟁점을 연구하고자 하 였다.우측 간에 대하여,생체간이식시 공여 간으로 사용되는 우측 간의 우간정맥(right

hepaticvein)과 중간정맥(middlehepaticvein)의 관계를 연구하였다.좌측 간에 대하여

두가지 관심이 있었는데,첫 번째는 좌측간의 ‘단독 IVb(4번 하분절)절제술’에 관계된 주제였다.다른 하나는 좌내측구역과 좌외측구역의 경계에 관한 것이었는데,연구 도중 의외의 ‘새로운 글리슨지’를 발견하게 되어 이에 대한 검토도 시행하였다. 방법 및 대상 우측 간 연구를 위하여,저자는 2012년 4월부터 7월까지 10구의 사체 간 을 해부하였다.우간정맥과 중간정맥을 각 분절에서 배액되는 정맥 분지의 형태에 따라 분류하였고,같은 사체의 간에서 우간정맥과 중간정맥의 어떤 형태가 서로 대응하는지, 이때 부우간정맥(accessory righthepatic vein)이 존재하는 지의 여부를 조사하였다. 좌측 간 연구중 ‘단독 IVb절제술’에 대한 연구를 위하여 저자는 2004년 5월부터 6월까 지 10구의 사체 간을 해부하였다.IV 분절의 전체 글리슨 지의 숫자,IV 상분절과 하분 절 각각의 숫자와 함께,IV 상분절및 하분절의 기시부 간의 거리도 측정하였다.좌내측 구역과 좌외측구역의 경계에 대한 연구를 위하여 저자는 2012년 4월부터 7월까지 31구 의 사체 간을 해부하였다.‘새로운 글리슨지’를 II,III,IV 분절을 담당하는 기존의 글리 슨 지와 달리,제대열(umbilicalfissure)의 위쪽으로 나오는 글리슨 지라고 정의하였다. 결과 우측 간 연구에 대하여,중간정맥 A형 (중간정맥 우세형)은 3/10 (30%),B형도 3/10(30%),C형은 4/10(40%)였다.우간정맥 A형은 2/10(20%),B형은 6/10(60%), C형은 1/10910%),D형은 1/10(10%)였다.좌측간의 ‘단독 IVb절제술’에 대한 연구에 대하여,IV 분절 전체의 글리슨 지의 숫자는 평균 5개 (±1.3)였고,4개에서 7개의 분포

였다.IVa분절의 글리슨 지는 평균 1.6개 (±0.7)였고,1개에서 3개 사이였다.IVb 분

절의 글리슨 지는 평균 3.4개 (±0.9)였고,2개에서 5개 사이였다.10예중 2예에서 IVa와

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좌외측구역의 경계에 대한 연구에서,제대열 정맥이 전체의 83.8%에서 관찰되었다.제 대열 정맥은 주로 좌간정맥으로 배액되었고,그 빈도는 88.5%였다.‘새로운 글리슨지’의 빈도는 30/31 (96.8%)였고, 그중 ‘중앙의 새로운 글리슨지’가 가장 많았고, 28/31 (90.3%)였다.‘새로운 글리슨지’의 직경은 3.5mm에서 5.6mm 로서,기존의 II,III,IV 글리슨지와 큰 차이가 없었다. 결론 우측 간연구에서,우간정맥과 중간정맥의 형태는 기존의 보고와 상당한 차이가 있었다.부간정맥의 관찰되는 우간정맥-중간정맥 조합에 대해서도 기존의 연구와 다소 다른 결과를 보였다.향후 더 많은 개수의 사체 간해부를 시도한다든지,혹은 최근 각 광받고 있는 삼차원 영상 기술을 이용한 연구가 필요할 것으로 보인다.‘단독 IVb절제 술’에 대한 연구에서,중요한 결과로 판단되는 것은 전체의 20%에서 IVa와 IVb의 기시 부가 공통강을 형성하고 있었다는 사실이다.‘단독 IVb 절제술’시에 IVa와 IVb의 공통 강을 안전하게 처리하는 것이 필요할 것으로 생각된다.좌내측구역과 좌외측구역의 경 계에 대한 연구에서,‘새로운 중앙 글리슨지’는 제대열과 함께 경계를 이루는 해부학적 인 지표로서 이용할 수 있을 것으로 생각된다.또한,‘새로운 글리슨지’는 간의 악성종 양에서 제대열을 간표면주위로 반대쪽 구역(좌내측 <-> 좌외측)으로 침범하는 경우에, 안전한 절제연을 얻을 수 있는 임상적 의미가 있고,아울러 Nagino의 간 우측 삼구역 절제술에서 결찰해야 할 구조로 보고된 ‘P4d'는 ’새로운 글리슨지‘중 ’IVa새로운 글리 슨지‘에 해당할 것으로 사료된다. ---핵심어 :간이식,간절제,해부학

수치

Tabl e1.Char act er i st i csofRHV,MHV,andARHV ------------ 16 Tabl e2.Char act er i st i csofGl i ssoni an pedi cl eofsegmentI V ----- 18 Tabl e3.Char act er i st i csoft r adi t i onalGP ( I I ,I I I ,I Va,andI Vb)
Tabl e1.Char act er i st i csofRHV,MHV,andARHV
Tabl e2.Char act er i st i csofGl i ssoni an pedi cl eofsegmentI V.
Tabl e3.Char act er i st i csoft r adi t i onalGP ( I I ,I I I ,I Va,and I Vb)and addi t i onal pedi cl e.
+4

참조

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