PICTORIAL ESSAY

Sonographic Demonstration of
Couinaud’s Liver Segments
Dean Smith, MD, FRCPC, Donal Downey, MB, BCh, FRCPC,
Alison Spouge, MD, FRCPC, Sue Soney, RT, RDMS, RCMS

The segmental localization of liver tumors is critical
to planning appropriate resection. Couinaud’s
nomenclature is a surgically relevant system of hepat-
ic segmental anatomy, which defines the liver seg-
ments by their relationships to vascular structures,
hepatic ligaments, and the gallbladder. We demon-
strate a way to accurately localize hepatic masses
with sonography. KEY WORDS: Liver; Ultrasonography;
Couinaud classification.

C ouinaud’s system of hepatic nomenclature

provides the anatomic basis for modern
hepatic surgical resections.1,2 In this system,
the liver segments are defined by their relationships
to vascular structures, hepatic ligaments, and the gall-
In this paper we present a systematic method for
the segmental localization of liver masses using
ultrasonography. With some practice, the technique
should be within the capability of most experienced
sonographers. We also review the anatomy of the
bladder. The multiplanar imaging capability of ultra- common hepatic resections.
sonography is well suited to the identification of
these structures and to the precise localization of
masses to hepatic segments. Accurate preoperative
localization is essential to surgical planning. Figure 1 Couinaud’s hepatic segments. Diagrammatic repre-
sentation of the liver from an anterior perspective (all segments
numbered appropriately). The caudate lobe (1) is situated
posteriorly.
ABBREVIATIONS

PV, Portal vein; FL, Falciform ligament; RHV, Right hepatic vein;
MHV, Middle hepatic vein; LHV, Left hepatic vein; IVC, Inferior
vena cava; GB, Gallbladder; RPV, Right portal vein; MPV, Main
portal vein; LPV, Left portal vein

Received November 27, 1995, from the Department of Diagnostic

Radiology and Nuclear Medicine, London Health Sciences Centre,
University Campus, University of Western Ontario, London,
Ontario. Revised manuscript accepted for publication February 20,
1998.
Address correspondence and reprint requests to Dean F. Smith,
MD, FRCPC, Department of Diagnostic Radiology and Nuclear
Medicine, London Health Sciences Centre, University Campus,
University of Western Ontario, 339 Windermere Road, London,
Ontario, Canada, N6A 5A5.

 1998 by the American Institute of Ultrasound in Medicine • J Ultrasound Med 17:375–381, 1998 • 0278-4297/98/$3.50
376 COUINAUD LIVER SEGMENTS J Ultrasound Med 17:375–381, 1998

Procedure for Localizing a Hepatic Mass to One of Couinaud’s Segments with Sonography

1. Image along the plane that separates any two segments.

2. Rotate the transducer 90 degrees.
3. Keep the separating boundary in the image, and scan through the liver until the mass and the
boundary are seen in the same image.

Which Lobe, Right or Left?

A B
Figure 2 The sagittal plane defined by the MHV and the IVC separates the right and left lobes. A, Transverse subcostal view in
deep inspiration through the superior portion of the liver reveals the main fissure separating the right and left lobes (dashed line).
In the inferior portion of the liver, a plane connecting the long axis of the gallbladder to the left side of the IVC separates the right
and left lobes. B, Transverse subcostal view in deep inspiration through the inferior portion of the liver; dashed line divides right
and left lobes.

Right Lobe Segments: 5/6 or 7/8?

A B
Figure 3 A transverse plane through the horizontal portion of the RPV separates segments 7/8 superiorly from 5/6 inferiorly.
A, Transverse subcostal view in deep inspiration through the right lobe at the level of the RPV branch. B, Turning the transduc-
er 90 degrees will obtain a sagittal intercostal view of the right lobe in the left posterior oblique position. The transverse portion
of the RPV is shown in cross section. Dashed line separates segments 7/8 superiorly from segments 5/6 inferiorly.
J Ultrasound Med 17:375–381, 1998 SMITH ET AL 377

Right Lobe Segments: 5/8 or 6/7?

A B
Figure 4 A, A longitudinal plane defined by the RHV and the IVC separates segments 5/8 medially from segments 6/7 laterally.
B, Turning the transducer 90 degrees will obtain a transverse intercostal view of the right lobe in the left posterior oblique
position. This image shows the descending portion of the RHV and the IVC. Dashed line separates segments 6/7 laterally from
segments 5/8 medially.

Left Lobe Segments: 4 or 2/3?

A B
Figure 5 A, A longitudinal plane containing the ligamentum teres (lig. teres), the ascending portion of the LPV, and the fissure
for the ligamentum venosum (lig. venosum) separates segments 2/3 laterally from segments 4A/4B medially. B,Turning the
transducer 90 degrees will obtain a transverse scan through the left lobe. Dashed line separates segments 2/3 laterally from
segments 4A/4B medially.
378 COUINAUD LIVER SEGMENTS J Ultrasound Med 17:375–381, 1998

Left Lobe: 2 or 3?

A B
Figure 6 A, A longitudinal plane containing the LHV and the IVC separates segment 2 posteromedially from segment 3 antero-
laterally. B, Turning the transducer 90 degrees will obtain a transverse image through the lateral portion of the left lobe. This
image shows the descending portion of the LHV and the IVC. Dashed line separates segment 2 from segment 3. Confusion exists
in the literature regarding the separation of segments 2 and 3. According to Couinaud,1 the LHV is the dividing landmark
between these two segments. However, other authors have stated that these segments are separated by an imaginary plane con-
taining the transverse portion of the LPV.3–5 This error results in the creation of nonanatomic segments, placing segment 2 supe-
rior to segment 3 rather than posteromedial to it.

Left Lobe: 4A or 4B?

A B
Figure 7 A, An oblique transverse plane through the transverse portion of the LPV separates segment 4A superiorly from seg-
ment 4B inferiorly. B, Turning the transducer 90 degrees will obtain a sagittal view through the medial portion of the left lobe.
This image shows the transverse portion of the LPV; dashed line separates segment 4A from segment 4B.
J Ultrasound Med 17:375–381, 1998 SMITH ET AL 379

Caudate Lobe

Figure 8 The caudate lobe (Couinaud’s segment 1) is

bordered by the fissure for the ligamentum venosum ante-
riorly, the IVC posteriorly, and a line connecting the MHV
and the GB laterally. The lobe extends cephalad to junction
of the MHV and the IVC.6 A, Schematic representation of
lateral view of caudate lobe. B, Longitudinal midline image
shows caudate lobe relationships. Lig. venosum, Fissure for
the ligamentum venosum. C, Transverse midline image
shows caudate lobe relationships.

B C
380 COUINAUD LIVER SEGMENTS J Ultrasound Med 17:375–381, 1998

Hepatic Resections

Patients with primary hepatic neoplasms or fewer

than five metastases are potential candidates for
resection. The goal of surgery is to remove the entire
lesion or all the lesions with tumor-free margins,
while preserving a sufficient quantity of residual
liver with intact blood supply and biliary drainage to
sustain life. This requires the removal or preserva-
tion of entire liver segments. Inoperable tumors are
those involving the MPV, hepatic artery, or both the
right and left hepatic ducts.7

Figure 9 In a left lobectomy, segments 2, 3, 4A, and 4B are

removed; the caudate lobe (segment 1) and the entire right
lobe are left intact. Black nodule represents tumor; yellow por-
tion, resected area.

A B
Figure 10 A, In a left lateral segmentectomy, segments 2 and 3 are removed. Black nodule, Tumor; yellow portion, resected area.
B, Postoperative image, left lateral segmentectomy. No liver is seen lateral to segments 4A/4B (arrow).

Figure 11 Transverse hepatectomy is performed most often

for GB carcinoma. This resection removes segments 1, 4B, 5,
and 6. Black nodule, Tumor; yellow portion, resected area.
J Ultrasound Med 17:375–381, 1998 SMITH ET AL 381

A B
Figure 12 A, In a right lobectomy, segments 5 through 8 are removed. Black nodule, Tumor; yellow portion, resected area.
B, Postoperative image, right lobectomy. Bowel has filled the space previously occupied by the right lobe (arrow).

References

1. Couinaud C: Le foie: Etudes anatomiques et chirurgi-

Figure 13 If a process involves all but the lateral segments of
the left lobe, a right trisegmentectomy is performed to
remove segments 1, 4A, 4B, and 5 through 8. Black nodule,
Tumor; yellow portion, resected area.
cales. Paris, Masson, 1957
2. Bismuth H: Surgical anatomy and anatomical surgery of
the liver. World J Surg 6:3, 1982
3. Soyer P: Segmental anatomy of the liver: Utility of a
nomenclature accepted worldwide. AJR 161:572, 1993
4. Mukai JK, Stack CM, Turner DA, et al: Imaging of surgi-
cally relevant hepatic vascular and segmental anatomy.
I. Normal anatomy. AJR 149:287, 1987
5. Rumack CM, Wilson SR, Charboneau JW: Diagnostic
Ultrasound. St. Louis, Mosby–Year Book, 1991, p 45
6. Dodds WJ, Erickson SJ, Taylor AJ, et al: Caudate lobe of
the liver: Anatomy, embryology, and pathology. AJR
154:87, 1990
7. Gazelle GS, Haaga JR: Hepatic neoplasms: Surgically rel-
evant segmental anatomy and imaging techniques. AJR
158:1015, 1992

Conclusion

Advances in hepatic oncologic surgery require that

radiologists specify the location of masses according
to the segmental anatomy of the liver. The systematic
application of ultrasonography can accurately local-
ize masses to Couinaud’s segments, thereby provid-
ing vital information for preoperative planning.