Liver Segments Explained with Mnemonic

Couniaud divided liver into 8 functional segments, each of which is supplied by its own
portal triad (composed of a portal vein, hepatic artery and a bile duct).
Hepatic veins divide the liver in saggital plane:
1. Middle hepatic vein: Divides the liver into right and left functional lobe.

Cantles line: run from middle of gall bladder fossa anterior to Inferior venacava
posteriorly

Left lobe = Segment I-IV (Segment I is separately the caudate lobe)

Right lobe = Segment V-VIII

2. Left hepatic vein: Divides left lobe into lateral and medial segments.

Lateral segment = Segment II and III

Medial segment = Segment IV

Falciform ligament: left hepatic vein is located slightly left to the left hepatic vein;
hence, falciform ligament roughly divides liver into right and left lobe.
3. Right hepatic vein: Divides right lobe into anterior and posterior segments.

Anterior segment = Segment V and VIII

Posterior segment = Segment VI and VII

Portal vein divides the liver in transverse plane:

1.
Upper segment = Segment II, IVa, VIII, VII
2.
Lower segment = Segment III, IVb, V, VI

How to remember the orientation of Couniaud Liver

Segments?
We have a handy hand mnemonic for this purpose 1. Also, remember that the segments
are numbered in a clock-wise fashion.
With the right hand, make a fist while tucking the thumb behind the remainder of the
fingers.

Tucked in thumb = Segment I (Caudate Lobe)

Line of Proximal Interphalangeal (PIP) joints = Plane of portal vein,
separating liver into upper and lower segments.
Interdigitary spaces = Intersegmental planes (hepatic fissures left, middle
and right) in which corresponding hepatic veins run and divide liver sagitally

For the remaining 7 segmets, go in a clockwise direction starting from the

lateralmost upper left part, i.e. Proximal phalax of 1st finger.

o
o

Proximal phalanx of 1st finger = Left superior lateral segment = Segment II

Distal phalanx of 1st finger = Left inferior lateral segment = Segment III
2nd finger = Left medial segment = Segment IV
Proximal phalanx = Segment IVa
Distal phalanx = Segment IVb
Distal phalanx of 3rd finger = Right inferior anterior segment = Segment V
Distal phalanx of 4th finger = Right inferior posterior segment = Segment VI
Proximal phalanx of 4th finger = Right superior posterior segment = Segment VII
Proximal phalanx of 3rd finger = Right superior anterior segment = Segment VIII

Segmental Anatomy of Liver

Portal vein:
The left portal vein supplies Couinaud segments I, II, III, and IV.
The right portal vein subdivides into anterior and posterior branches.

Anterior branch: supplies segments V and VIII

Posterior branch: supplies segments VI and VII.

Hepatic vein:
Right hepatic vein: drains all of segment VI and VII and some of segments V and VIII.
Left hepatic vein: drains segments II and III and IV.
Middle hepatic vein: drains segment IV, V and VIII.
Intrahepatic bile ducts:
Segment II-IV: Left hepatic duct
Segment V and VIII: Right anterior hepatic duct
Segment VI and VII: Right posterior hepatic duct
Caudate lobe Segment I):
The left lobe is supplied or drained by left branches from porta hepatis components and
right from right. The caudate lobe is anatomically different from other lobes:
1.
2.
3.

It hase direct connections to the IVC through hepatic veins

It may be supplied by both right and left branches of the portal vein.
It is drained drained by both right and left hepatic ducts.

Hepatectomy and Sectionectomy

Right hepatectomy = Segment V-VIII ( segment I)

Extended right hepatectomy or Right trisectionectomy = Right hepatectomy +
Segment IV
Left hepatectomy = Segment II-IV ( segment I)
Extended left hepatectomy or Left trisectionectomy = Left hepatectomy +
Segment V and VIII
Right posterior sectionectomy = segment VI and VII
Right anterior sectionectomy = segment V and VIII
Left medial sectionectomy = segment IV
Left lateral sectionectomy = segment II and III

Answering Techniques for Surgery Papers

How to answer definitions ?
Definitions are often asked in the exams both in theory exams and viva-voce. As the
content is vast, mugging them up is not a good idea. If you have a good understanding
over the topic, you can write down a good definition by including following things
wherever possible:
1.

Basic pathophysiology or process: Nature of infection, Premalignant condition,

Benign/malignant neoplasm, Localized collection, etc.
2.
Involved structures: Layers of skin, Structures invaded by malignancy, etc.
3.
Peculiar identifying feature: certain size, duration, etc.
4.
Can include: Diagnostic clinical feature(s), Indication, The difference from a
common differential diagnosis
Example:
Delayed Primary Closure (DPC): Surgical closure of a wound (1) 3-5 days after the
thorough cleansing or debridement of the wound bed (3) when there is contamination
or high risk of contamination (4).
Aneurysm: Pathological, localized, permanent dilation of an artery (1) to >1.5
times (3) the original diameter involving all 3 layers (2 and 4 mentions the involved
layers and also differentiates from pseudoaneurysm which doesnt involve all the 3
layers of arterial wall) of its parent wall.
Locally Advanced Breast Carcinoma (LABC): Malignant neoplasm of the breast (1)
that has not spread to distant sites i.e. Mo (3) but may be one of the following (2):

Primary tumor >5 cm (T3)

Chest wall and/or skin involvement including inflammatory carcinoma (T4)

Ipsilateral fixed axillary lymph nodes and/or internal mammary nodes or

infraclavicular or supraclavicular nodes (N2 or N3)

How to answer causes and etiologies ?

List down the causes in a systematic manner after classifying them. The general rules for
doing them are
a. Causes involving conditions in a hollow viscus:
1.
Mechanical:
o
In the lumen: usually stones, foreign body or worms
o
In the wall: usually inflammatory or neoplastic conditions and strictures
o
Outside the wall: usually enlargement of adjacent structures, lymph nodes
or abnormal protrusions
2.
Non-mechanical: usually neuromuscular and metabolic causes
Example:

Causes of dysphagia:
1.
Mechanical:
o
In the lumen: Foreign body (dentures, coin)
o
In the wall:

Inflammation: Infectious esophagitis, tuberculosis

Neoplasm: Carcinoma esophagus

Inflammatory or post-irradiation strictures

o
Outside the wall: Aortic aneurysm, retropharyngeal abscess, thyroid
enlargement, cardiomegaly, mediastinal nodes
2.
Non-mechanical: Myasthenia gravis, Polymyositis, Achalasia, Scleroderma,
Cranial nerve IX and/or X lesions
Causes of intestinal obstruction:
1.
Mechanical:
o
In the lumen: gallstones, impacted feces, meconium, worms, foreign body
o
In the wall: Inflammatory or malignant strictures, Diverticulitis
o
Outside the wall: Adhesions and bands, cancers, hernia, volvulus
2.
Non-mechanical:
o
Paralytic ileus: postoperative abdominal surgery, mesenteric ischemia,
hypokalemia, hypothyroidism, etc.
o
Pseudo-obstruction
b. For answering all other etiologies:
Use a surgical seive and remember them using a mnemonic like MEDIC HAT PIN

Metabolic

Endocrine

Degenerative


Infective

Congenital

Hematological

Autoimmune

Trauma

Psychological

Inflammatory

Neoplastic
Example:
Causes of splenomegaly
1.
Idiopathic: Idiopathic thrombocytopenic purpura
2.
Vascular: portal vein obstruction, Budd-Chiari syndrome, haemoglobinopathies
(Sickle-cell disease, thalassemia)
3.
Infective: AIDS, mononucleosis, septicaemia, tuberculosis, brucellosis, malaria,
infective endocarditis
4.
Traumatic: haematoma, rupture
5.
Autoimmune: rheumatoid arthritis, SLE
6.
Metabolic: Gauchers disease, mucopolysaccharidoses, amyloidosis, Tangier
disease
7.
Inflammatory: sarcoidosis
8.
Neoplastic: CML, metastases, myeloproliferative disorders
Note: Always highlight the commonest and more common causes when using these
systems for answering.

How to answer the clinical features of the given disease

conditions ?
Classify into symptoms (subjective complaints and remember to elaborate using a
mnemonic SOCRATES; elaborate the main complaint and keep others as associated
features) and signs (objective findings) expected in the disease condition; Use
eponymous signs and elaborate in one line whenever possible
Example:
In Acute Appendicitis
A) Symptoms:

Site of pain: Right iliac fossa

Onset of pain: Acute over 24-48 hours
Character of pain: Initially dull visceral pain, later becoming sharp and localized
due to parietal peritoneum involvement
Radiation or migration: Migrating to RIF from umbilicus
Associated symptoms: Anorexia, Nausea/vomiting, Fever, etc. (Murphys triad
pain, vomiting and fever)
Timing: No association

Exacerbating and relieving factor: As in all cases of peritonism increased by

movement and coughing and relieved partially by rest
B) Signs:

Pointing sign, Blumbergs sign, Obturator sign, Psoas sign, Rovsigs sign,
Sherrens triangle hyperesthesia, Rectal wall tenderness on PR, etc.

How to answer the investigations for given disease

conditions ?
Always mention the expected findings of the tests and answer in the following order
1.
2.
3.

Investigations to prove diagnosis

Investigations to rule out differential diagnoses
Routine investigations, pre-operative investigations and Investigations to rule out
or identify complications
4.
Investigations for monitoring the disease
Example:
In Acute Pancreatitis
1. Investigations to prove diagnosis:

Serum amylase and lipase: Increased by atleast 3 times

Abdominal USG: Can detect gallstone, biliary obstruction and pseudocyst
formation

CECT abdomen: Confirms the diagnosis and aids in providing prognosis to the
disease

Plain AXR: Sentinel loop sign, Colon cut-off sign, Renal halo sign, Pancreatic
calcifications

LFT: can suggest if the cause is gallstone or alcohol

2. Investigations to rule out differential diagnosis:

ECG: To rule out MI

Plain abdominal X-ray erect and supine: To rule out perforation

Stool for occult blood: To rule out mesenteric ischemia

USG abdomen: To rule out cholecystitis

3. Routine, Pre-op investigations and Investigations to identify complications:

CBC and HCt: resembling SIRS or septic shock

RFT: to rule out renal failure due to hypovolemia
RBS: Hyperglycemia
Serum albumin: Decreased
Serum calcium: Decreased
ABG: Metabolic acidosis
Plain Chest X-ray: Pleural effusion, ARDS
Pre-op investigations: Serology, Blood grouping and cross-matching

4. Investigations for monitoring disease progression: CBC and HCt, ABG, Serum
calcium, RFT, etc.

How to answer treatment for a give disease

conditions ?
Whenever possible, follow the following order

Firstly: Stabilization of vitals (Go with ABC approach as in BLS) and emergency
management

Secondly: Conservative management (if possible)

Thirdly: Medical and Surgical management

Example:
For treatment of nephrolithiasis
Firstly: Manage acute pain, UTI and deranged renal function if present
1.
Analgesics: NSAIDs (1st choice), Opioids (2nd choice)
2.
Anti-emetics: If vomiting
3.
Alpha-blockers: reduces recurrent colic
4.
IV hydration
5.
Antibiotics for UTI
6.
Percutaneous nephrostomy for decompression may be required
Secondly: Conservative management if possible

Adequate water intake (atleast 2 litres per day)

Exercise

Urine alkalizer +/- allopurinol for suspected urate stones

Periodic evaluation
Thirdly: Medical or Surgical management with indications

Replicate contents from textbooks into concise flowcharts whenever possible.

This has 2 advantages:
1.
2.

Saves time
Easy to the examiners eyes.

How to answer the asked procedures ?

Be concise and answer in following order Indications, Requirements, Description of
procedre site, Procedure (Position, Anesthesia, Incision, Dissection, Performing
targeted procedure, Closure), Confirm correct placement and if the intervention is
functional and Complications
Example:
Explaining Chest tube insertion
1.
Indications:
o
Traumatic hemothorax
o
Traumatic pneumothorax
o
Drainage of empyema
o
Following thoracotomy

2.
3.
4.

5.

6.

Requirements: Sialistic chest tube drain, Underwater seal drainage bag, Inj. 1%
lignocaine, Straight and curved clamp, Suture and dressing set
Working site: Safety triangle bounded by anterior border of latissimus dorsi,
posterior border of pectoralis major, superior border of 5th rib
Procedure:
o
Anesthesia: Backrest lifted to 45 degrees
o
Anesthesia: LA 1% inj. lignocaine (skin to parietal pleura)
o
Incision: Over safety triangle
o
Dissection: Intercostal muscles separated using curved clamp, Blunt
dissection with finger down upto pleura
o
Chest tube inserted towards apex for pneumothorax and towards base for
effusion
o
Chest tube clamped and closed end cut-off to connect to a water seal
draiange bag (2-3 cm inside water)
o
Drain fixed stictch in a circular fashion
o
Sterile dressing pad applied
Confirmation:
o
Correct placement: Chest X-ray
o
Functional: Tidalling, Bubbles in the underwater seal drain
(pneumothorax)
Complications:
o
Hemorrhage
o
Intercostal neurovascular injury
o
Lung and mediastinal injury
o
Infection

How to answer the complications of a procedure or

surgery ?
Classify and present as following:
1. Per-operative:

Surgery-related: Anatomical injury (Vessels and Organs)

Anesthesia related
2. Post-operative:

Immediate (<24 hrs):

o
Local: Reactionary hemorrhage
o
General: Asphyxia (Airway obstruction with tongue fall or aspiration of
vomitus)

Early (upto 3 weeks):

o
Local:

Paralytic ileus (abdominal surgeries)

Infection (wound, peritonitis, pelvic, subphrenic)

Secondary hemorrhage

Dehiscence (wound, anastomosis)

Obstruction (fibrinous adhesions)
o
General:

Pulmonary: Collapse, Bronchopneumonia, Emboli

Urinary: Retention, ATN

DVT

Enterocolitis

Bedsores

Parotitis

Late (>3 weeks):

o
Local:

Obstruction (fibrous adhesions)

Incisional hernia

Persistent wound sinus

Recurrence of original lesion

Scar probles (hypertrophic scars, keloid)

o
General: After extensive resections or gastrectomy

Anemia

Vitamin deficiency

Steatorrhea and/or diarrhea

Dumping syndrome

Osteoporosis
Example:
After thyroidectomy
1. Per-operative:

Surgery related:
Vascular injury: Primary hemorrhage from superior or inferior thyroid
artery, thyroid ima. artery, carotid artery, jugular vein
o
Nerve injury: External laryngeal nerve
o
Solid organ injury: Injury to parathyroid gland, apex of lung
o
Hollow viscus injury: Trachea, esophagus, larynx

Anesthesia related
2. Post-operative:
o

o
o

o
o
o

Immediate:
Local: Reactionary hemorrhage, Asphyxia due to hematoma, Hoarseness
due to recurrent laryngeal nerve injury
General: Asphyxia, Thyrotoxic crisis
Early:
Local: Wound infection, Laryngeal edema
General: Chest infection
Late:
Local: Scar, Stitch granuloma

General: Thyroid and parathyroid insufficiency