The Brisbane 2000 Terminology of Liver Anatomy and Resections. HPB 2000; 2:333–39

Sir,

I read with much interest the article on the newly-proposed terminology for liver surgery ¹. I realise that the terminology committee members tried very hard to come up with a precise and relatively simple system for describing liver anatomy and resections. We have started to apply this system in our institution, and we do appreciate very much the accuracy of the recommended terminology. However, I would like to express my opinion and propose some modifications to this system.

Firstly, there has been long debate on the issue of segmentation of the liver between the Couinaud and Healey systems ², and I suppose the terminology committee can help to settle the dispute. However, the addendum to the second order division actually makes the terminology more complicated by allowing the use of both ‘sector’ and ‘section’, whiles these two terms actually describe the different combinations of Couinaud segments anatomically. To simplify this matter, I would suggest avoiding the use of the terms ‘section’ or ‘sector’ and naming the Couinaud segments only by Arabic numerals instead. Likewise in ‘terms for surgical resection’, the actual segment(s) resected should be reported rather than ‘sectionectomy’ or ‘sectorectomy’; that is, the third-order division should be considered the preferred nomenclature rather than the second order division in this Brisbane system. I think that this modification helps to improve the simplicity of the terminology without compromising accuracy and precision.

Secondly, the Brisbane terminology causes some confusion after translation into our Chinese language. The translation words for ‘segments’, ‘sectors’ or ‘sections’ are (not surprisingly) very much similar linguistically ³, and it adds to the terminology problem if we simply translate the English articles based on Brisbane recommendation into our native language. The translated Chinese terms for ‘left medial section’ and ‘left medial sector’ are very similar, though anatomically they are different according to the Brisbane terminology. However, if we stick to a single term like ‘segment’, the confusion will resolve automatically. I think this problem may apply to other non-English-speaking countries as well.

Thirdly, the Brisbane version did not mention non-anatomical liver resection. Although it is seldom performed now, I would propose using ‘subsegmentectomy’ as the preferred term of description. For instance, non-anatomical wedge resection of tumour in segment 6 should be termed subsegmentectomy 6.

Finally, I hope my suggestions will bring forward constructive discussion on the final adoption of a world-wide acceptable terminology in liver surgery.

Yeung Yuk Pang

Department of Surgery

Kwong Wah Hospital

25 Waterloo Road

Kowloon

Hong Kong

Tel: (852) 278 15051

Fax: (852) 278 15264

Author's reply:

Sir,

I will take the liberty of replying on behalf of the Terminology Committee of the IHPBA. I thank the author for his interest in the IHPBA terminology and for his thoughtful comments.The author suggests that the third order division (segments 1–9) can be used to name all liver resections. In fact this is permitted by the terminology as stated in our paper. For instance, a left lateral sectionectomy can be called ‘Resection segments 2,3’, or ‘Resection Sg2,3’. A right hepatectomy can be called ‘Resection segments 5–8’. However, it is felt by the committee that oral communication is enhanced by allowing reference to hepatectomies and sectionectomies and segmentectomies.

The author also notes that the terminology is somewhat confusing because the addendum allows for second order divisions to be called ‘sections’ as well as ‘sectors’ and in some cases the sections and sectors do not cover the same anatomical zones. All of this is correct. Considerable discussion went on in the committee in regard to this very feature. There were three opinions. The majority opinion was that the Couinaud method of dividing the liver into the second order based on the portal vein should be added as an addendum. One minority opinion was that the addendum should be omitted entirely, and another minority opinion in the committee was that the addendum should be included as part of the main terminology. When attempting to get agreement among international experts in an effort such as this, a degree of compromise is often needed to achieve completion. For those who have a historic and extensive interest in hepatic terminology, the terminology as it is presented gives a complete picture. For those who wish to have a more encapsulated view of terminology, the addendum can be omitted and the terminology used will be completely accurate.

Finally, the author notes difficulties in translating certain English words into other languages. The terms ‘segment’, ‘sector’ and ‘section’ all come from the Latin term ‘to cut’. English is fortunate in being very rich in words that have subtle differences in meaning, in part because words have been freely taken from other languages when needed to fulfill a meaning. Obviously it was beyond the scope of the committee to consider the effects of these terms on all possible languages. We would suggest, however, that it is possible to adapt these terms directly into any language.

Once again we are grateful for the interest of the author in the terminology, and we hope that others in the IHPBA will take the same level of interest.

Steven M Strasberg

Pruett Professor of Surgery

Section of Hepatobiliary, Pancreatic and

Gastrointestinal Surgery

Washington University in St Louis School of

Medicine

Washington University Medical Center

One Barnes-Jewish Hospital Plaza

Box 8109

St Louis, Missouri 63110

USA

Editor's Note

The Editor welcomes letters of comment or question arising out of previous publications in HPB.