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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 11  |  Issue : 2  |  Page : 118-121

A case of accessory anterior hepatic fissure: Cadaveric study with retrospective radiological investigation into its vascularity


1 Associate Professor, Department of Anatomy, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
2 Associate Professor, Department of Radiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
3 Additional Professor and Head, Department of Anatomy, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
4 Assistant Professor, Department of Anatomy, Trichy SRM Medical College Hospital and Research Centre, Trichy, Tamil Nadu; Former Senior Resident, Department of Anatomy, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India

Date of Submission10-Jul-2021
Date of Decision04-Feb-2022
Date of Acceptance06-Feb-2022
Date of Web Publication25-Mar-2022

Correspondence Address:
Praveen Kumar Ravi
Department of Anatomy, Trichy SRM Medical College Hospital & Research Centre, Trichy, Tamil Nadu - 621 105
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/NJCA.NJCA_91_21

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  Abstract 


The hepatic diaphragmatic surface is usually smooth and featureless. Although the existing literature mentions grooves or fissures on the diaphragmatic surface, there is no consensus regarding its causative factors. During routine dissection, the authors found a liver with a broad accessory fissure on the anterior surface of the anatomical right lobe. An enlarged hepatic area was observed on the left side of this accessory fissure. The undersurface of the right hemidiaphragm had a diaphragmatic band that extended into the hepatic fissure. The morphometry of the accessory fissure was studied. Retrospective magnetic resonance imaging showed that the middle hepatic vein was to the immediate right of the accessory fissure. Histological examination was done to confirm the presence of muscle tissue in the hypertrophied diaphragmatic band. As the need for surgeries and transplantations of the liver rises, there is a need to understand the hepatic macroscopic anatomy and its radiological correlation.

Keywords: Diaphragmatic bands, diaphragmatic groove, magnetic resonance imaging


How to cite this article:
Patnaik M, Mohakud S, Gaikwad MR, Ravi PK. A case of accessory anterior hepatic fissure: Cadaveric study with retrospective radiological investigation into its vascularity. Natl J Clin Anat 2022;11:118-21

How to cite this URL:
Patnaik M, Mohakud S, Gaikwad MR, Ravi PK. A case of accessory anterior hepatic fissure: Cadaveric study with retrospective radiological investigation into its vascularity. Natl J Clin Anat [serial online] 2022 [cited 2022 Jul 1];11:118-21. Available from: http://www.njca.info/text.asp?2022/11/2/118/346080




  Introduction Top


The hepatic diaphragmatic surface is usually smooth and featureless but may present one or more grooves named variously as diaphragmatic or hepatic grooves, sulci, or accessory hepatic fissures.[1] The hepatic fissure is an abnormal, permanent vertical indentation that partially subdivides the liver parenchyma and the existing literature puts the incidence at 5%–40%.[2],[3],[4] These may be confused with hepatic abscesses, malignancies, or macronodular liver during surgery or radiological imaging. The radiological imaging shows that the accessory fissures usually occur in the junctions between the branching of the right or left portal veins that correspond to the position of the right and middle hepatic veins and their tributaries in 67% of cases.[5] Although various hypotheses have been proposed for the occurrence of hepatic fissures, no causative factors have been defined.[5] The anatomical study of hepatic variations is needed due to the rise in hepatic imaging and surgical interventions. This work involved morphometric and retrospective radiological analysis of a cadaveric liver with an accessory anterior hepatic fissure and histological examination of the tissue from the diaphragm.


  Case Report Top


A liver with an accessory fissure on the anterior aspect of the anatomical right lobe was found during routine dissection in All India Institute of Medical Sciences, Bhubaneswar, on a donated body of an 88-year-old Indian male [Figure 1]. The medical reports of the body donor showed no history of any hepatic or pulmonary disease. The liver had no other variations. A hypertrophied muscle band on the inferior aspect of the right hemidiaphragm interlocked with the said accessory fissure in situ.
Figure 1: Photograph showing diaphragmatic surface of the liver; White arrow – Accessory fissure; Green arrow – Gall bladder; AL: Accessory lobe (hypertrophic segment IV); FL: Falciform ligament; IVC: Inferior vena cava

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The accessory fissure was wide, smooth-walled, and indented the hepatic inferior border 78.95 mm to the right of the fissure for the ligamentum teres hepatis [Figure 1]. The enlarged hepatic area between the accessory fissure and the falciform ligament could qualify as an accessory lobe,[3] and corresponded to surgical segment IV. The fissure was 67.37 mm long and the average depth was 1.8 mm and the average width was 12.98 mm measured by a digital vernier caliper. The liver weighed 1.020 kg.

The magnetic resonance imaging (MRI) traced the three main hepatic veins: the right, middle, and left to the inferior vena cava and delineated their relation to the accessory fissure. The veins from the accessory lobe (corresponding to surgical segment IV) were tributaries of the left hepatic vein. The deep projection of the accessory fissure contained no major hepatic veins. The middle hepatic vein was located immediately to the right of the accessory fissure [Figure 2].
Figure 2: Magnetic resonance imaging (a - Posterior view; b- anterior view) showing the accessory fissure or groove; middle hepatic vein was immediately right to accessory groove; hepatic vein of accessory lobe draining into the left hepatic vein; right hepatic vein

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Routine H and E staining confirmed that the diaphragmatic slip/band was skeletal muscle. The ImageJ software showed that the diaphragmatic slip was 2.8 mm thick in contrast to a tissue sample from another area of the right hemidiaphragm, which was 1.1 mm thick [Figure 3].
Figure 3: H and E stained section of normal diaphragm (a) and band part of the diaphragm (b). Band part is more than twice the thickness of normal part which was measured by the ImageJ software. SM: Skeletal muscle

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  Discussion Top


Similar to our finding, previous studies have also reported a single, wide, curved fissure on the anterior aspect of the hepatic right lobe [Table 1][3],[5],[6],[7],[8],[9],[10] with an incidence of 5%–40%.[2],[4] The broad range of incidence in existing literature may be due to these fissures being asymptomatic and incidental findings during surgery,[2] autopsy,[5] radiological imaging,[3] or cadaveric dissection.[6],[7],[8],[9],[10] Their occurrence showed racial variation[2] and was more common in females after 15 years.[11] The incidence rose with age and affected 71% of individuals between 81 and 84 years.[3] Previous studies show that the accessory fissure of the liver was common in the anterosuperior surface at the boundary of the two hepatic lobes;[3] Maachi et al. in 2005 state that accessory fissures were on the hepatic right side in 88% of cases as seen in this study.
Table 1: Review of literature

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When the main accessory sulci (MAS) were single, its mean length was 8.8 ± 2.1 cm; the mean depth was 1.7 ± 0.7 cm, and the average width was 0.8 ± 0.7 cm.[11] The fissure in the present study was 67.37 mm (6.73 cm) long; its average depth and width were 1.8 mm (0.18 cm), 12.98 mm (1.3 cm), respectively.

Previous studies have used radiological imaging, corrosion cast of the vascular tree of the liver, or cadaveric dissection to study these fissures.[5],[11] The morphometric analysis of a cadaveric liver specimen followed by an MRI scan was done in this case report.

Studies show that localized band-like thickening of the diaphragmatic muscle (diaphragmatic slip/band) protruded from its undersurface and indented the liver and these bands become prominent with age.[12] The present study reports similar findings, and routine histological staining has confirmed the diaphragmatic band as muscle tissue.

An imaging study by Maachi et al. in 2003 reported a correspondence between the location of the accessory fissure on the hepatic surface and the occurrence of either the right or middle hepatic veins or their tributaries in the deep projection of these fissures in 67% of cases. Our study showed no such correspondence like the remaining 33% of cases of the study by Maachi et al. 2003.[5] The lack of correspondence between fissure and the main hepatic veins or their tributaries maybe because of the territorial boundaries between hepatic segments and portal venous sectors (delineated by the occurrence of the major trunks of hepatic veins) were not flat but undulating planes.[5]

Many factors have been proposed in the past to explain the occurrence of accessory fissures which can be broadly classified as acquired (extrinsic) and embryological factors.

The acquired factors often cited in the past include respiratory diseases causing chronic cough (cough furrows) and long-term use of tight corsets for cosmetic or medical reasons (corset liver).[5],[13]

External hepatic compression can produce accessory fissures that show an age-related rise in incidence.[3],[9] It may be due to the pressure applied by the whole diaphragm,[5] partial diaphragmatic eventration,[3] or diaphragmatic bands[14],[15] that cause localized invagination of the liver tissue (with the incidence of 45.9% in existing literature).[3],[5],[9],[12] In this case report, we have found a hypertrophied diaphragmatic band extending into the floor of the said hepatic fissure.

The radiological and corrosion cast studies of hepatic vasculature have shown that there was a correspondence of the MAS with the right portal fissure and the right hepatic vein in 71% of cases.[11] According to Maachi et al. in 2005, the upper part of the right portal fissure represents an avascular watershed plane which is a potential weak zone in the superficial hepatic parenchyma that is likely to be deformed by external pressure.[11]

The pressure exerted by the diaphragm as a whole may lead to nonuniform growth of hepatic parenchyma at specific watershed regions in the young subjects,[11] which corresponds to weak hepatic zones described earlier.[5],[11] In adults, diseases may cause a chronic increase in the diaphragmatic activity, which in turn exerts pressure mainly on the preformed weak zones in the hepatic parenchyma to produce accessory fissures.[5] Clinically, accessory fissures can be taken as markers of weak zones and areas of low vascularization that can be used as planes for surgical resection of the liver.[5]

These fissures are more common in fetal age and may represent delayed intersegmental fusion.[16] The multiple signaling pathways such as beta catenins, Wnt genes, E-cadherins, fibroblast growth factors, tumor necrosis factors, and epithelial‒mesodermal transformation play a role in prenatal hepatic development. Thus, defective molecular regulation may contribute to the formation of accessory fissures.[11],[17]

The hepatic developmental anomalies are rare and attributed to excessive development (accessory lobes) or defective development.[14] The enlarged hepatic area between the falciform ligament and the accessory hepatic fissure (corresponding to the surgical segment 1V) could be due to excessive hepatic development although the exact cause is not known.[9],[16]


  Conclusion Top


The accessory fissures are normal anatomic variants but are likely confused with hepatic or other abdominal pathologies during imaging and laparoscopy. As the incidence of hepatic resections and transplantations rises, the knowledge of detailed hepatic anatomy and its variations are useful to surgeons, radiologists, and fellow anatomists.

Acknowledgment

The authors sincerely thank those who donated their bodies to science so that anatomical research could be performed. Results from such research can potentially increase humankind's overall knowledge that can then improve patient care. Therefore, these donors and their families deserve our highest gratitude.[18]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gardner MT, Cawich SO, Shetty R, Pearce NW, Naraynsingh V. Hepatic surface grooves in an Afro-Caribbean population: A cadaver study. Ital J Anat Embryol 2015;120:117-26.  Back to cited text no. 1
    
2.
Cawich SO, Spence R, Mohammed F, Gardner MT, Sinanan A, Naraynsingh V. The liver and Chilaiditi's syndrome: Significance of hepatic surface grooves. SAGE Open Med Case Rep 2017;5:1-4.  Back to cited text no. 2
    
3.
Auh YH, Rubenstein WA, Zirinsky K, Kneeland JB, Pardes JC, Engel IA, et al. Accessory fissures of the liver: CT and sonographic appearance. AJR Am J Roentgenol 1984;143:565-72.  Back to cited text no. 3
    
4.
Nayak SB, Padur AA, Kumar N, George BM. Accessory grooves on the diaphragmatic surface of the liver: A cadaveric study. J Clin Diagn Res 2017;11:C05-7.  Back to cited text no. 4
    
5.
Macchi V, Feltrin G, Parenti A, De Caro R. Diaphragmatic sulci and portal fissures. J Anat 2003;202:303-8.  Back to cited text no. 5
    
6.
Sreekanth T. Diaphragmatic fissures and accessory sulci of liver in the population of Telangana. Int J Anat Res 2016;4:3273-8.  Back to cited text no. 6
    
7.
Ono ML, Murakami G, Sato TJ, Sawada K. Hepatic grooves and portal segmentation. Kaibogaku Zasshi 2000;75:517-23.  Back to cited text no. 7
    
8.
Reddy N, Mittal PS, Joshi SS, Subhash DJ. Accessory fissures of liver and their clinical significance. J Evol Med Dent Sci 2016;5:6125-8.  Back to cited text no. 8
    
9.
Chaudhari HJ, Ravat MK, Vaniya VH, Bhedi AN. Morphological study of human liver and its surgical importance. J Clin Diagn Res 2017;11:C09-12.  Back to cited text no. 9
    
10.
Mehare T, Bekele A, Getachew A. Assessment of morphological variations and its specific location on the surface of adult human liver in Ethiopian cadavers university of Gondar, Bahir Dar university, Addis Ababa university, St. Paulos medical school and Hawassa university, Ethiopia. Int J Med Res Health Sci 2017;6:121-9.  Back to cited text no. 10
    
11.
Macchi V, Porzionato A, Parenti A, Macchi C, Newell R, De Caro R. Main accessory sulcus of the liver. Clin Anat 2005;18:39-45.  Back to cited text no. 11
    
12.
Yeh HC, Halton KP, Gray CE. Anatomic variations and abnormalities in the diaphragm seen with US. Radiographics 1990;10:1019-30.  Back to cited text no. 12
    
13.
Deshmukh VR, Seth S, Sahni C. Accessory sulci and segmentation on the surface of the liver: A clinical pitfall. Int J Res Med Sci 2017;5:1718.  Back to cited text no. 13
    
14.
Hawkins SP, Hine AL. Diaphragmatic muscular bundles (slips): Ultrasound evaluation of incidence and appearance. Clin Radiol 1991;44:154-7.  Back to cited text no. 14
    
15.
Arenson AM, McKee JD, Taylor I. Hypertrophied muscular bands in the region of the foramen of Bochdalek as a cause for an accessory fissure within the liver. Ultrasound Med Biol 1985;11:461-5.  Back to cited text no. 15
    
16.
Parke WW, Settles HE, Bunger PC, Van Demark RE. Malformations of the liver: Some prenatal and postnatal developmental aspects. Clin Anat 1996;9:309-16.  Back to cited text no. 16
    
17.
González Villarreal LC, Franco Zuluaga JA, Contreras MO, Gómez GML, Lüdeke AK. Hepatic malformations: Morphogenetic, anatomical and pathological features. Eur J Anat 2019;23:369-76.  Back to cited text no. 17
    
18.
Iwanaga J, Singh V, Ohtsuka A, Hwang Y, Kim HJ, Moryś J, et al. Acknowledging the use of human cadaveric tissues in research papers: Recommendations from anatomical journal editors. Clin Anat 2021;34:2-4.  Back to cited text no. 18
    


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