Ann Hepatobiliary Pancreat Surg.  2020 Nov;24(4):415-420. 10.14701/ahbps.2020.24.4.415.

Surgical anatomy of caudate bile ducts: Silicon-injected cadaveric-livers dissected under magnification

• Martins ACdA
• Martins C

• KMID: 2508849
• DOI: http://doi.org/10.14701/ahbps.2020.24.4.415

Abstract

Backgrounds/Aims
Caudate bile ducts are routinely presented using negative images as X-ray-cholangiograms. Such information does not provide for instant surgical orientation of the relationships between caudate ducts and the liver itself−a paramount skill for successfully performing hilar cholangiocarcinoma resection and living donor/split transplantation. This study presents a 4-step procedure to prepare, dissect and present, high-quality, 2D/3D anatomical images of biliary caudate ducts in a surgically meaningful way.
Methods
Fresh cadavers had arteries and veins injected with colored-silicone and ducts bile-stained to facilitate recognition. Dissections were performed under magnification with microsurgical instruments. Stepwise 2D and 3D images were acquired.
Results
Dissection of silicone-injected specimens under magnification allows identification of caudate structures, its portions and processes while preserving tridimensional arrangement of caudate vessels, biliary ducts and collectors. Such dissections can help enhance cholangiogram interpretation and favor its direct correlation to intraoperative findings.
Conclusions
A procedure including: a) preparation of high-quality cadaveric livers, b) with silicone-injected vessels, c) dissected under surgical microscope and d) documented using 2&3D images aimed at enhancing the clinical understanding of the anatomy of caudate ducts is presented. It has potential to enhance morphological and clinical understanding of caudate ducts, being useful to anatomists and surgeons alike.

Keyword

Liver; Anatomy; Bile ducts

Figure

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  Fig. 1 (A) Visceral surface of an injected liver. The vena cava is highlighted by the blue silicone and provides instant orientation around the porta hepatis. The gallbladder has a redundant cystic duct. Although not injected, the bile staining allows their clear differentiation from the red silicone-injected arterial branches. (B) Enlarged view of the caudate lobe and its parts after resection of the gallbladder. The common biliary duct and the portal vein have been displaced superiorly. According to Kumon,6 the caudate is divided into Spiegel lobe, paracaval portion and the caudate process. Much is debated about the boundaries of these three portions. The magnification allows identification of minute caudate structures. A microsurgical dissector depresses vena cava’s anterior wall, displaying the veins draining the caudate process. At this level there are two notches, close to the transition between the caudate process and the paracaval portion. These notches should not be confused with Kogure et al.17 external caudate notch. Although the external caudate notch as described by these authors is not present in this specimen, a slight indentation can be seen along the anterior caudate surface in relation to Spiegel lobe’s portal branches. (C) Posterior view of the diaphragmatic surface of the liver. The hepatic veins have been isolated using black ligatures. The superior pole of caudate corresponds to the venous confluence into suprahepatic vena cava (yellow dotted line). Insert: corresponding view of an injected specimen. (D) Liver parenchyma has been resected to expose venous tributaries of the major hepatic veins. This specimen presents an inferior right hepatic vein. (E) A microsurgical dissector has been used to displace the retro hepatic vena cava. A caudate vein can be seen entering its middle third. (F) The portal vein has been elevated to display caudate’s portal branches. The dissector is located at the level of portal bifurcation. Located to the right are a caudate process portal branch and the right portal vein. Paracaval and Spiegel’s lobe portal branches can be seen joining the left portal vein. A biliary duct can be devised through the spaces between these portal branches. (G) The portal vein has been partially resected to expose the caudate ducts. The duct partially visualized in (F) is in fact a Spiegel’s biliary duct passing along the anterior surface of the caudate to join the major biliary collectors.

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  Fig. 2 Microsurgical dissection of the caudate biliary ducts after removal of vascular structures along the porta hepatis. This specimen (L1) has been chosen as its anatomical arrangement can be expected in less than 5% of livers studied by cholangiography, according to Healey and Schroy7 and its anatomical images have seldom been presented. (A) Overview of porta hepatis after removal of arterial and venous branches. (B) Enlarged view of (A). Several biliary ducts drain the caudate and form a common biliary caudate collector that joins the major ducts close to its bifurcation. (C) Biliary ducts to the right liver have been exposed. In this specimen, biliary ducts draining the caudate process and paracaval portion collect into an intermediary duct. (D) Parenchymal resection has been undertaken to expose the biliary ducts to the left liver. (E) Caudate process and paracaval biliary ducts join into an intermediary duct. An intermediary duct also collects a set of short ducts from Spiegel lobe. These intermediary ducts join to form a single caudate biliary duct. (F) Although the caudate duct seems to join the major ducts at the bifurcation, view through the common duct lumen shows that this junction involves in fact the right duct. This specimen may explain differences between cholangiography descriptions and surgical findings. (G) The ductal tree has been resected to display its draining pattern. This last step on each dissection has served as model for the summarized data on Table 1.

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