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Abstract Objective This study aimed to compare the clinical efficacy of laparoscopic liver resection (LLR) and radiofrequency ablation (RFA) in treating solitary hepatocellular carcinoma (HCC) of the hepatic caudate lobe. Methods Patients with hepatic caudate lobe HCC who underwent LLR or RFA at three hospitals in China between February 2015 and February 2021 were included. In total, 112 patients met the inclusion criteria, of whom 52 underwent RFA and 60 underwent LLR. The outcomes of the two groups were compared and analyzed using propensity score matching (PSM) method. Results There were no significant differences between the two groups in terms of sex, HBV/HCV positivity, AFP positivity (>100 ng/mL), tumor position, Child–Pugh score, or preoperative liver function tests (ALT, AST, TBIL, ALB, and PT) (p > 0.05). Compared to the LLR group, the RFA group had a shorter operation time, less intraoperative bleeding, and shorter postoperative hospital stay (p 0.05). Despite the larger tumor size, the LLR group had better postoperative recurrence‐free survival (RFS) (p = 0.00027) and overall survival (OS) (p = 0.0023) than the RFA group. After one‐to‐one PSM, 31 LLR patients and 31 RFA patients were selected for further analyses. The advantages of LLR over RFA were observed in terms of RFS (p

In this case report we describe an occasional finding of intrathoracic caudate lobe protruding through the diaphragm foramen in a 73-year-old woman who came to our attention for a screening for coronary artery disease, due to the presence of cardiovascular risk. The patient had no symptoms. The computed tomography showed, a circumscribed homogeneous soft tissue mass that protruding through the aortic diaphragmatic foramen that was as isodense as the liver. Moreover was revealed an abnormal artery emerging from the celiac tripod which, through the diaphragmatic foramen, ends in an inferior pulmonary vein creating an arteriovenous malformation.

Abstract Aim The concept of Couinaud segmentation is widely used in clinical practice. However, there were no definite anatomical landmarks between segments V and VIII. Therefore, segmentation of the right anterior sector is still controversial. We aimed to investigate the portal segmentation of the right anterior sector using 3D image analysis, and to reveal the existence of the medial branch (PV8c), a unique, characteristic branch of the right anterior portal vein. Methods The ramification form and pattern of the tertiary portal branch of the right anterior portal vein were retrospectively analyzed, and the frequency of PV8c was evaluated in 261 patients between January 2016 and June 2020. Results The ramification pattern of tertiary portal branches of the right anterior portal vein was classified into four types: craniocaudal, 28.0% of patients; ventrodorsal, 21.8%; trifurcation, 39.5%; and quadfurcation, 5.7%, and each type was further subdivided into six patterns by focusing especially on the caudal branches. The ramification pattern in the remaining 5.0% of the livers did not belong to the above‐mentioned four types. The PV8c branch was identified in 140 of 261 livers (53.6%); the mean proportion of the feeding area of PV8c in the whole liver volume was 3.4%. Conclusion Since the ramification pattern of tertiary portal branches of the right anterior portal vein does not necessarily show a single pattern, it is important to confirm the portal vein branching in each case during hepatectomy. This is the first study of the details of PV8c by 3D computed tomography.

Abstract Background Tumors located in the caudate lobe may be primary tumor or metastases from other sites. Isolated caudate lobectomy (ICL) is a challenging procedure due to its complex structure and location. The access route to the caudate lobe has an important role in the success of the operation. Methods Based on the characteristics of the segment I location, which is the part of the liver located in front of the vena cava, below the hepatic veins, and cranial to the hilar plate, our approach aims to isolate the entire caudate lobe from these anatomical structures with the following steps: dissecting the caudate lobe from the hilar plate and isolating the caudate lobe from the IVC and from the hepatic veins along with parenchymal resection. Results We report two successful cases with the Glissonean pedicle transection method described by Takasaki and the combined right- and left-side approach: a 63-year-old female patient with a 46-mm-in-diameter HCC tumor and a 39-year-old female patient with a 45-mm lesion and the pathological result was focal nodular hyperplasia. Conclusions We found this to be a safe and effective approach, which can be applied to all cases of benign tumors or in the case of malignant tumors located entirely in the caudate lobe when extended hepatic resection is not possible due to poor liver function or small remnant liver volume.

Abstract Background Ingestion of fish bones leading to gastric perforation and inducing abscess formation in the caudate lobe of the liver is very rare. Case presentation A 67-year-old man presented to our hospital with a 2-day history of subxiphoid pain. There were no specific symptoms other than pain. Laboratory tests showed only an increase in the number and percentage of neutrophils. Contrast-enhanced Computerized tomography (CT) of the abdomen showed two linear dense opacities in the gastric cardia, one of which penetrated the stomach and was adjacent to the caudate lobe of the liver, with inflammatory changes in the caudate lobe. We finally diagnosed his condition as a caudate lobe abscess secondary to intestinal perforation caused by a fishbone based on the history and imaging findings. The patient underwent 3D laparoscopic partial caudate lobectomy, incision and drainage of the liver abscess, and fishbone removal. The procedure was successful and we removed the fishbone from the liver. The patient was discharged on the 9th postoperative day without other complications. Conclusions Liver abscess caused by foreign bodies requires multidisciplinary treatment. Especially when located in the caudate lobe, we must detect and remove the cause of the abscess as early as possible. Foreign bodies that perforate the gastrointestinal tract can penetrate to the liver and cause abscess formation, as in this case. When exploring the etiology of liver abscesses, we should investigate the general condition, including the whole gastrointestinal tract.

Zheng-Gang Xu,1– 3,* Fei-Hong Zhang,1– 3,* Dong-Wei Sun,1– 3,* Qi-Tong Zheng,1– 3 Gu-Wei Ji,1– 3 Ke Wang1– 3 1Hepatobiliary Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, People’s Republic of China; 2Key Laboratory of Liver Transplantation, Chinese Academy of Medical Sciences, Nanjing, People’s Republic of China; 3NHC Key Laboratory of Living Donor Liver Transplantation (Nanjing Medical University), Nanjing, People’s Republic of China*These authors contributed equally to this workCorrespondence: Ke Wang; Gu-Wei JiHepatobiliary Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, People’s Republic of China, Tel +86 18061675088; +86 15951758275, Fax +86 68136450, Email lancetwk@163.com; drjgw@njmu.edu.cnBackground: Resection of hepatocellular carcinoma (HCC) originating in the caudate lobe remains challenging, while the optimal extent of resection is debated. We aimed to evaluate the relative benefits of combined caudate lobectomy (CCL) versus isolated caudate lobectomy (ICL) for caudate HCC.Methods: Patients who underwent curative-intent resection for caudate HCC between January 2010 and December 2018 were identified from a single-center database. Surgical outcomes of the two strategy groups were analyzed before and after propensity score matching. A systematic review with meta-analysis was also performed to compare outcomes of CCL versus ICL for caudate HCC.Results: A total of 28 patients were included: 11 in the CCL and 17 in the ICL group. Compared with ICL, the CCL group contained patients with larger tumors and a higher incidence of vascular invasion. After propensity score matching, 6 pairs of patients were selected. In the well-matched cohort, CCL demonstrated significantly improved recurrence-free survival (RFS) (P = 0.047) compared with ICL; no significant differences were noted for overall survival (OS), operation time, blood loss and morbidity rate. A total of 227 patients from nine eligible studies and ours were involved in the systematic review. Meta-analysis revealed that CCL provided better RFS (hazard ratio 0.54, 95% confidence interval 0.31– 0.92) than ICL; no significant differences were observed in OS, operation time, blood loss and morbidity rate.Conclusion: CCL confers superior RFS over ICL without compromise of perioperative outcomes and should be prioritized for patients with caudate HCC when feasible, especially for those with large-sized tumors.Keywords: hepatocellular carcinoma, caudate lobe, surgery, outcomes, meta-analysis

Background and objective: Liver hemangioma (LH) is the most common benign tumour of the liver, but its origin is still not clear and not much is known about a possible familiarity. Caudate lobectomy is the most effective surgical treatment for benign tumors arisen in segment I. The occurrence of giant LH within the same liver segments in different members of the same family has never been described in literature. Herein we report the first two consecutive laparoscopic caudate lobectomy for familiar giant LH in a father and his daughter. Methods: The father showed a lesion in the caudate lobe (CL) suggestive of LH steadily grown, asymptomatic for 24 years until it has caused abdominal discomfort and pain (Dmax 89 mm). The daughter showed multiple hepatic hemangiomas with the biggest one located in the CL compressing the inferior vena cava (Dmax 88 mm). Results: Despite the size of the masses, we opted for a pure laparoscopic approach and a caudate lobectomy was performed in both cases. Operation time was 140 and 180 min. Patients had an uneventful recovery and a good outcome after the scheduled follow up exams 6 months after the procedure. Conclusions: A chance of familiarity transmission for hemangiomas exists and therefore should be further investigated. Laparoscopic isolated caudate lobectomy for symptomatic GLH is feasible and safely performed on selected patients by experienced hepatobiliary surgeons. Prospective randomized studies on larger populations are needed to assess if this minimally invasive approach can be proposed as a standard of care for S-I LH.

Objective: To evaluate the outcome of radiofrequency (RF) ablation using expandable electrodes in the treatment of hepatocellular carcinoma (HCC) located in the caudate lobe. Materials and Methods: Between January 2011 and April 2017, 29 consecutive patients with HCC at the caudate lobe were treated with RF ablation using expandable electrodes. The electrodes were placed on the targeted tumor under combined ultrasound and computed tomography (CT) guidance for each tumor in all the patients. Out of the 29 cases, 19 (65.5%) were accessed via the left hepatic lobe. The technical success, primary efficacy, local tumor progression, secondary efficacy, overall survival, and complications were evaluated. Univariate analysis was performed of the various prognostic factors for technical success, primary efficacy, and local tumor progression. Results: The technical success rate was 86.2%, primary efficacy was 89.7%, and secondary efficacy was 82.8%. The local tumor progression (LTP) rate was 12.3% at one year and 31.5% at two years. The median time of LTP was 6.9 months. The overall survival rate was 85.8% at one year and 57.1% at two years. Ten patients died during the follow-up period (mean 22.5 months; with a range of 3.6–53.2 months). A minor complication of asymptomatic biloma was found in one patient (3.5%). Small-sized tumors (≤2 cm) and Spiegel’s lobe location had significantly better treatment outcomes (p = 0.007 and 0.045, respectively). Conclusion: Radiofrequency ablation using expandable electrodes is feasible and safe in treating HCCs located in the caudate lobe, especially for small-sized tumors (≤2 cm).

Liangliang Yan,1,2,* Lei Chen,1,2,* Kun Qian,1,2 Xuefeng Kan,1,2 Hongsen Zhang,1,2 Bin Liang,1,2 Chuansheng Zheng1,2 1Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China; 2Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, People’s Republic of China*These authors contributed equally to this workCorrespondence: Chuansheng ZhengDepartment of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of ChinaEmail cszheng@hust.edu.cnPurpose: Resection of the hepatocellular carcinoma (HCC) in the caudate lobe (CL) is challenging even for accomplished surgeons. This retrospective study evaluated the safety and efficacy of transarterial chemoembolization (TACE) and iodine 125 seeds implantation (ISI) for unresectable or “ablation unsuitable” HCC-CL detected at the initial presentation in clinical practice.Patients and Methods: A total of 20 HCC-CL patients undergoing sequential TACE and ISI from January 2014 to October 2018 were enrolled in this study. The overall survival (OS), progression-free survival (PFS), tumor response rate, and complication rates were analyzed and compared to non-caudate lobe (NCL) HCC patients. Multivariate analyses for potential clinical and radiological factors were performed using the Cox proportional hazard model.Results: The technical success rate was 100%, as all the patients received 28 ISI treatments. The median OS was 35 months. The 1-, 3-, and 5-year OS rates were 100%, 63.2%, and 11.1%, respectively. The median PFS was 16 months. The objective response rate was 60.0%. The puncture tract bleeding (2/20) and pneumothorax (1/20) were the most common complications in operation, but no operation-related deaths occurred. One year after the surgery, biliary tract injury occurred in 1 patient, necessitating percutaneous biliary intervention. No statistical difference was observed between the CL and NCL groups. Multivariable analysis revealed that Barcelona Clinic Liver Cancer stage B and tumor size > 3 cm were two significant factors associated with OS.Conclusion: Sequential TACE and ISI were associated with the survival benefits in HCC-CL and should be considered as a reliable therapy for surgeons and interventional radiologists.Keywords: transarterial chemoembolization, iodine 125 seeds implantation, hepatocellular carcinoma, caudate lobe, survival

Abstract Background Hepatolithiasis often leads to atrophy–hypertrophy complex due to bile duct obstruction, inflammation or infection in the affected liver segments and compensatory response in the normal segments. In severe bilateral diffuse cases, main liver can all be atrophic, leaving the caudate lobe to be extremely hypertrophic. Subtotal (segment II–VIII) hepatectomy can be an option in selected patients under such circumstances. Since rare cases have been reported, our study aims to highlight the preoperative evaluation and key points of this procedure. Case presentation Two patients with primary and secondary bilateral diffuse hepatolithiasis, respectively, were enrolled in this case series. The atrophy of the left and right liver with an exceeding hypertrophy of the caudate lobe were observed. Since the liver anatomy had completely been changed, contrast computed tomography, magnetic resonance imaging combined with 3D liver reconstruction were employed for comprehensive evaluation and pre-operational planning. The patients underwent standard subtotal (segment II–VIII) hepatectomy. During operation, the hepatoduodenal ligament around porta hepatis was dissected firstly to expose the hepatic artery, portal vein, bile duct and their branches successively. And then the vessels and bile duct to caudate lobe were preserved safely through cutting off the left and right hepatic artery, portal vein and bile duct at a safe point distal to the origin of the branches to caudate lobe. Operation time was 300 min and 360 min, respectively. Blood loss was 200 ml and 300 ml. No evidence of liver dysfunction, hepatolithiasis relapse or cholangitis was observed during the follow-up of 12 and 26 months. Conclusions Subtotal (segment II–VIII) hepatectomy may be one of several treatments possible in selected patients with compensatory caudate lobe hypertrophy caused by bilateral diffuse hepatolithiasis.

Abstract Objective To investigate the surgical indication and tactics for liver hemangioma in the caudate lobe Methods From January 1994 to July 2019, 137 patients, including 51 males and 86 females with the average age of 49.2 years old were diagnosed with liver hemangioma in caudate lobe and received treatment at five tertiary referral hospitals. Clinical features, correlations between tumor size and clinical manifestations, treatments, and prognosis were analyzed. Results Of the 137 patients identified, 40 (29.20%) patients were asymptomatic, whereas other 94 patients had clinical symptoms mainly presented as upper abdominal discomfort, epigastric distention, upper abdominal dull pain, nausea, and vomiting. Fifteen (93.75%), 18 (39.13%), and 7 (10.45%) patients presented no clinical symptoms among those tumor size was less than 3 cm (D ≤ 3 cm, n = 16), 3 cm

ObjectivesTo analyze the clinical outcomes of Transarterial chemoembolization (TACE) for unresectable or “ablation unsuitable” hepatocellular carcinoma (HCC) in the caudate lobe (CL) found at initial presentation in clinical practice.MethodsFifty-eight patients with HCC-CL undergoing conventional TACE from January 2015 to January 2020 were enrolled in our medical center. Overall survival (OS), progression-free survival (PFS), tumor response rate and major complication rates were analyzed. Multivariate analyses for potential clinical and radiologic factors were performed by using the Cox proportional hazard model.ResultsThe median OS was 23 months (95%CI: 18.1-27.9), and the median PFS was 11 months (95%CI: 7.4-14.6). The 1-, 3-, and 5-years OS rates were 66.5%, 31.9% and 15.7%, respectively. The 0.5, 1-, and 3-years PFS rates were 60.3%, 44.5% and 6.3%, respectively. Objective response rate was 53.4% and disease control rate was 79.3%. The most serious complication was bile duct injury, with an incidence of 3.4%. Multivariable analysis revealed that total bilirubin, Barcelona Clinic Liver Cancer stage, nonselective chemoembolization and TACE session were four significant factors associated with OS.ConclusionsSuperselective TACE treatment might be associated with better survival benefits in unresectable or “ablation unsuitable” HCC in the CL without macroscopic vascular invasion (MVI) and adequate liver function, compared with the non-selective TACE group, and should be considered as an important reliable therapy for surgeons and interventional radiologists.

Background: To explore the safety and feasibility of laparoscopic caudate lobe (CL) resection for the treatment of hepatolithiasis. Methods: A retrospective study of nine patients who received laparoscopic CL resection for treatment of hepatolithiasis in our hospital from January 2013 to April 2017. Of these cases, we studied the patients' demographic data, the operation time, blood loss, post-operative hospital stay, post-operative complications and prognosis. Results: All the nine cases are performed successfully; the post-operative recovery was symptom free except for one case of post-operative bile leakage. Among them, there were six cases of CL resection in combination with other lobe, three cases of separate CL resection, and three cases of whole CL resection. The average operative time was 310 min (Range: 180–450 min), the average intraoperative blood loss was 530 ml (Range: 100–1000 ml), average post-operative hospital stay was 9 days (Range: 6–13 days), average total hospital stay was 10 days (Range: 9–19 days). Intraoperative calculi exhaustion rate was 66.7% (6/9), which at the end of treatment was 88.9% (8/9). No cases had calculi recurrence. Conclusion: The application of laparoscopic CL resection is feasible and safe.

Abstract Background Hepatocellular carcinomas (HCC) arising in the caudate lobe is rare and the treatment is difficult. The aim of this study is to summarize the experience of ultrasound-guided percutaneous ablation therapy for HCC located in the caudate lobe and to investigate the predictive factors of the treatment outcomes. Methods From August 2006 to June 2017, 73 patients (63 males and 10 females; mean age, 54.9 ± 11.6 years; age range, 25–79 years) with 73 caudate lobe HCCs (mean size, 2.6 ± 1.1 cm; size range, 1.0–5.0 cm) were treated with percutaneous ablation, including 33 patients with radiofrequency ablation (RFA), 23 patients with ethanol ablation (EA), and 17 patients with combination of RFA and EA. The treatment outcome and survival after ablation for caudate lobe HCC were assessed and the predictive factors were calculated by univariate and multivariate analyses. Results A total of 72 patients achieved complete ablation after the first or second session of ablation. The treatment effectiveness was 98.6% (72/73). During the follow-up, 16 tumors developed local tumor progression (LTP) and a total of 61 patients (61/73, 83.6%) were detected distant recurrence (DR). According to univariate and multivariate analyses, tumor size > 2 cm (hazard ratio[HR] = 3.667; 95% confidence interval[CI], 1.043–12.889; P = 0.043) was a significant prognostic factor of LTP after ablation for HCC in the caudate lobe, while tumor number (HR = 2.245; 95%CI, 1.168–4.317; P = 0.015) was a significant prognostic factor of DR. The mean overall survival time after ablation was 28.7 ± 2.8 months, without independent predictive factors detected. Four patients (4/73, 5.5%) were detected treatment-related major complications, without independent predictive factor detected. Conclusion Ultrasound-guided percutaneous ablation is a feasible treatment for a selected case with HCC in the caudate lobe. Tumor size > 2 cm increases the risk of LTP and intrahepatic tumor number is associated with DR after ablation.

Introduction: The liver is the largest organ of the abdominal viscera. Knowledge of anatomy of liver and its variations is indispensable for accurate diagnosis of cases by radiologists, and prevention of unwanted surgical complications by surgeons. Many researchers have studied the segmental anatomy of the liver, but there are very few studies regarding the surface variations of liver. Aim: To document the surface variations of liver and discuss them from clinical perspective. Materials and Methods: This observational cross-sectional study was conducted from August 2015 to May 2019 on 50 liver specimens in the Department of Anatomy, Vardhman Mahavir Medical College. These livers were observed for any surface variations such as abnormal fissures or lobes, elongation or hypoplasia of lobes, etc. Data were tabulated and stats were calculated in percentages. Descriptive analysis of data has been carried out and mentioned in the study. Results: In the present study, out of 50 liver specimens, variations were observed in 42 (84%) specimens. Accessory fissures were seen in 16 (32%) specimens. Elongated left lobe was present in 7 (14%) specimens. Pons hepatis, which is a bridge of tissue connecting the quadrate lobe and the left lobe was observed in 8(16%) specimens. Caudate lobe variations observed in this study were abnormal fissures and hypertrophied papillary process. Conclusion: The present study documents frequent morphological variations of liver such as elongated left lobe, accessory lobes, etc. Elongated left lobe may be related to fundus of stomach which should be kept in mind during left lobe resection. The radiologists can confuse accessory lobes or projections with pathological mass. Knowledge of these variations will undoubtedly help radiologists and surgeons to prevent misdiagnosis of cases and plan newer and safer surgical procedures.

Background: Congenital anomalies of liver are rare as opposed to anatomical variations. In the past these anomalies were found accidently on autopsy and during laparotomy. Today CT and US are important in evaluation of hepatic morphology. The liver has four lobes and eight segments, whether it is defined by its gross appearance or its internal architecture. Although the segmental anatomy of liver has been researched extensively but very less literature is available on variations of surface anatomy of liver. Purpose: This study was conducted with the aim to observe and note various surface variations of liver for better results in radiological diagnosis and surgical outcomes. Material and Methods: This observational study was conducted on 50 formalin fixed human livers. Results: In the current study various shapes of the caudate lobe were encounter owing to the presence of various fissures. In 2% cases pear shape caudate lobe was seen with fissure along its superior border. Small caudate lobe was observed in 8% cases. Bicornuate caudate lobe with vertical fissure along its inferior border was observed in 24% of livers. Presence of pons hepatis was an important finding in 4% cases and in 8% cases, prominent papillary process was observed. Fusion of quadrate lobe with left lobe was noticed in 4 cases. Ligamentum teres was attached to left margin of gall bladder fossa in few cases. Transverse fissure in quadrate lobe was a common finding in our study. Conclusion: Thorough knowledge of hepatic anatomy and such commonly occurring segmental variations acquires significance for radiologists in imaging interpretation and for surgeons for better outcomes in hepatic surgeries.

Background: No studies evaluating the clinical outcomes of radiotherapy (RT) for hepatocellular carcinoma (HCC) in the caudate lobe have been available to date. The purpose of this study was to evaluate the effectiveness and safety of RT for HCC in the caudate lobe.Material and Methods: Seventy patients with HCC in the caudate lobe treated with RT from a multi-institutional database were included in this study. The median equivalent dose in 2 Gy (EQD2) was 80.0 Gy10 (range, 31.3–99.3), and freedom from local progression (FFLP), progression-free survival (PFS), and overall survival (OS) rates were evaluated.Results: The median time of follow-up was 47.9 months (range, 3.4–127), and the 5-year FFLP, PFS, and OS rates were 80.6% [95% confidence interval (CI), 70.8–91.8], 13.8% (95% CI, 7.5–25.4), and 51.3% (95% CI, 39.9–66.1), respectively. In the multivariate analysis, the radiation dose was significantly associated with the FFLP rate [hazard ratio (HR), 0.57 per 10 Gy10 increase, p = 0.001], and the status of FFLP was significantly associated with OS (HR, 2.694, p = 0.014). The overall rate of ≥grade 3 adverse events was 5.7% (4 of 70), and RT-related mortality was not observed.Conclusion: RT for HCC in the caudate lobe showed promising FFLP and OS rates with safe toxicity profiles. These findings suggest that RT may be a promising treatment option for HCC in the caudate lobe.

A 5-year-old girl presented with abdominal pain, dysphagia, respiratory distress, and fever for the past 3 weeks. The pain was dull in character; present in the epigastrium and right hypochondrium. The patient was unable to swallow solid food and there was difficulty in swallowing even semi-solids and liquids. On examination, there was decreased air entry on the right side with epigastric tenderness. The radiological evaluation suggested caudate lobe liver abscess in close relation with abdominal esophagus resulting in mild compression at gastro-esophageal junction. Pleural effusion on the right side was drained. Broad-spectrum antibiotics including amoebicidal therapy resulted in the dissolution of symptoms and rapid recovery. Caudate lobe liver abscess may result in dysphagia (as its unusual complication) due to inflammation and extraluminal compression at gastro-esophageal junction.

Introduction: Liver is largest gland in the body and shows rare variation. Additional fissure, additional lobes, enlarged papillary process, variations of gall bladder are more common. Morphological variations have been classified into congenital or acquired. Aim: To evaluate embryological rational of rare variations of liver and find out their impact on diagnostic and clinical procedures. Materials and Methods: We studied 20 formalin fixed liver specimens in Anatomy Department during undergraduate teaching to find out variant gross morphological features of liver. Results: Some rare variations were observed like grooves on hepatic surface (10%), tunnel for ligamentum teres (15%), enlarged papillary process (10%), absence of quadrate lobe (5%), additional fissures (20%), lingular process (15%). Conclusion: Atrophy, agenesis, presence of accessory lobes, additional fissures may mislead the diagnostic procedures. Therefore, the knowledge of these variations may be a fruitful finding for diagnosticians as well as surgeons.

Introduction: Liver is the largest abdominal organ located in right hypochondrium, epigastrium and left hypochondrium in upper abdominal cavity. Although the segmental anatomy of the liver has been extensively researched, very few studies have dealt with surface variations of the liver. The major fissures are important landmarks for interpreting the lobar anatomy and locating the liver lesions. Aim: To determine gross anatomical variations of liver and their clinical and surgical implications. Materials and Methods: Present morphological study was conducted on 80 formalin-fixed livers which were observed for the study in the Department of Anatomy, Baroda Medical College, Vadodara, Gujarat, India. Different variations in lobes, fissures and accessory lobes, decrease in size of lobes, lobar atrophy and any other variations on the surface of the livers were observed. The liver specimens were also classified according to netter’s six types of liver variations. Results: Total 80 cadaveric livers were studied. Out of which 14(17.5%) livers were normal and 66(82.5%) were abnormal. Out of 66, abnormal fissures were in 28(35%), abnormal lobes were in 29(36.25%), large papillary process in 1(1.25%), Pons hepatis joining the left lobe with quadrate lobe in 1(1.25%) liver, deep renal impression and corset constriction observed in 1(1.25%) and deep diaphragmatic groove were observed in 6(7.5%). Conclusion: The findings of our study may be helpful for surgeons and radiologists to avoid possible errors in interpretations and subsequent misdiagnosis, and to assist in planning appropriate surgical approaches.

Introduction: Inferior Vena Cava (IVC) is the largest vein of the body. It runs vertically upwards in the abdomen, behind the liver. Its course is very constant in relation to liver. However, the amount of liver parenchyma related to it can vary from person to person. The data regarding its course and relations may be very useful to radiologists and surgeons during surgical treatment procedures for Budd-Chiari syndrome, liver carcinoma, liver transplant, venous cannulations and many other clinical procedures. Aim: Aim of this study was to document the incidence of straight and curved course of IVC in relation to liver and also to note the pattern in which the liver tissue was related to the IVC. Materials and Methods: In the current study, 95 adult cadaveric livers were observed; specifically to study the course/ direction of the hepatic segment of IVC in relation to the liver. The extent of liver tissue related to various aspects of IVC was also studied. The course of the IVC was classified as straight and curved; and the relationship of liver parenchyma to the IVC was classified into 6 categories. The data was expressed as percentage incidence. Results: In 78.94% cases, the IVC had a straight course in relation to the liver; whereas in 21.06% cases, it had a left sided curve (concavity of the curve towards the caudate lobe) in its course. In 6.31% cases, IVC travelled in a tunnel, being encircled by the liver parenchyma all around; in 36.84% cases, it was covered by liver parenchyma on front and sides so that only posterior surface of IVC was visible; in 3.15% cases it was covered by liver tissue on front, sides and also partly on posterior aspect; in 50.52% of cases, its anterior surface, sides and left edge of the posterior surface was covered by liver tissue; and in 3.15% cases it was covered only from the front by the liver tissue. Conclusion: The data being reported here might be useful for surgeons while planning and executing various hepatic surgeries and also to the radiologists in planning and performing venous cannulation and therapeutic procedures. Since in many livers, the curvature of IVC was associated with enlarged caudate lobe, the curved IVC could hint about the increase in the volume of caudate lobe or liver itself.

To investigate the impact of short hepatic vein reconstruction in the transplanted left liver plus caudate lobe graft. Methods: Six left liver plus caudate lobe grafts used for living donor adult liver transplantation were included in this study. The liver grafts were divided into two groups: those with (V1 group; n = 4) or without (control group; n = 2) short hepatic vein reconstruction. The changes in the transplanted left lobe (segments II-IV) and caudate lobe were compared between the two groups at 1 month after transplantation. Results: The addition of the caudate lobe increased the graft volume by 15 mL, which corresponded to a 4.3% gain of graft volume at the time of transplantation. Although the graft volume/standard liver volume ratio of the whole grafts after transplantation showed no difference between the two groups, the regeneration rate of the caudate lobe in the V1 group was significantly greater than that in the control group (p= 0.04). Conclusion: Although no definite advantage from the V1 reconstruction was demonstrated, hepatic vein reconstruction with a significantly-sized short hepatic vein might provide an additional margin of safety for marginally-sized liver grafts during the early phase of graft regeneration.

Resection of the caudate lobe (segment I- dorsal sector, segment IX- right paracaval region, or both) is often technically difficult due to the lobe's location deep in the hepatic parenchyma and because it is adjacent to the major hepatic vessels (e.g., the left and middle hepatic veins). A literature search was conducted using Ovid MEDLINE for the terms "caudate lobectomy" and "anterior hepatic transection" (AHT) covering 1992 to 2007. AHT was used in 110 caudate lobectomies that are discussed in this review. Isolated caudate lobectomy was performed on 28 (25.4%) patients, with 11 case (11%) associated with hepatectomy, while 1 (0.9%) was associated with anterior segmentectomy. Complete caudate lobectomy was performed on 82 (74.5%) patients. Hepatocellular carcinoma was observed in 106 (96.3%) patients, while 1 (0.9%) had hemangioma and 3 (2.7%) had metastatic caudate tumors. AHT was used in 108 (98.1%) caudate resections, while AHT associated with a right-sided approach was performed in 2 (1.8%) cases. AHT is recommended for tumors located in the paracaval portion of the caudate lobe (segment IX). AHT is usually a safe and potentially curative surgical option.

The caudate lobe often exhibits enlargement and nodularity in cases of cirrhosis, which makes differentiation of hepatocellular carcinoma from other mass- like lesions of the caudate lobe difficult in cirrhotic patients. A 12×6 cm mass-like enlargement of the caudate lobe was incidentally found by computed tomography in a 38-year-old man suffering from alcoholic liver cirrhosis. Magnetic resonance imaging, liver colloidal scan, and sonoguided liver biopsy were used for the differential diagnosis. A literature review revealed two case reports, all of which (like ours) presented with an enlarged caudate lobe supplied with blood via a branch of the portal vein. Therefore, in cases of giant hyperplasia of the caudate lobe, confirmation of the caudate lobe blood supply and the enhancement pattern might be important for the differentiation. (Gut and Liver 2008;2:205-208)

Abstract We report a rare case in which hemothorax occurred in addition to hemoperitoneum due to spontaneous rupture of hepatocellular carcinoma (HCC) originating from the caudate lobe of the liver. The case pertains to a 56-year-old female who was transported to our hospital for impaired consciousness due to hemorrhagic shock. Computed tomography (CT) demonstrated ruptured HCC originating from the caudate lobe and accompanying hemoperitoneum and right hemothorax. Hemostasis was carried out by transcatheter arterial embolization (TAE), and surgery was conducted approximately one month after TAE. In the present case, no lesions as possible sources of bleeding were observed inside the pleural cavity, and, moreover, the diaphragm had no abnormalities in the intraoperative findings, suggesting that blood from the ruptured tumor may have traversed the intact diaphragm to enter the right pleural cavity soon after the HCC rupture. However, to the best of our knowledge, no similar cases of HCC have been reported to date, and this case is thus believed to be very rare. This unusual phenomenon may therefore be strongly associated with the location of the ruptured tumor and the formation of a hematoma inside the omental bursa. We discuss the mechanism causing hemothorax in the present case and also review the previously reported cases of ruptured HCC complicated by hemothorax.

An isolated hepatic caudate lobectomy was performed in a fifty-seven-year-old white woman presenting a colo-rectal metastasis to hepatic segment I. The resection was performed under total liver vascular exclusion due to the proximity to hepatic veins. The patient presented an uneventful hospitalization being discharged on day seven.