Oblique scanning of the ligament teres and the left liver by subxiphoid

Oblique liver section • Ligament teres • Left liver by subxiphoid approach

Scanning Method

The patient should be fasted for 8–12 hours and examined in the supine position. Place the ultrasound probe obliquely in the subxiphoid region, with the transducer directed toward the left upper abdomen. Adjust the probe orientation and angulation to obtain an oblique subxiphoid view of the left hepatic lobe and the fissure for the ligamentum teres. The scan should demonstrate the ligamentum teres (round ligament), falciform ligament, left hepatic lobe, left portal vein, caudate lobe, and inferior vena cava (IVC) as appropriate. Optimize depth, gain, and focal position to clearly define the ligamentum teres and its relationship to the adjacent hepatic and vascular landmarks.

Key scanning point: Begin from the subxiphoid region with the probe oriented obliquely toward the left upper abdomen. Use gentle probe angulation and pressure to bring the fissure of the ligamentum teres into view. The ligamentum teres can be followed within the anterior portion of the liver toward the umbilical region, while the left portal vein and caudate lobe provide important anatomical reference points. Adjust depth and gain to maintain a well-defined hepatic parenchymal image and clearly demonstrate the ligamentum teres in relation to the left hepatic lobe and adjacent vascular structures.

Ultrasound Image

Figure 1.1 Oblique sonographic section of the left hepatic lobe obtained through the subxiphoid approach, demonstrating the ligamentum teres (round ligament) within the fissure of the liver, along with the left portal vein (LPV), caudate lobe (CL), inferior vena cava (IVC), aorta (Ao), and adjacent hepatic vascular landmarks.

Anatomical / Scanning Diagram

Figure 1.2: Diagram showing the subxiphoid probe orientation and oblique scanning plane directed toward the left upper abdomen, demonstrating the left hepatic lobe, fissure of the ligamentum teres, and caudate lobe, with the relevant hepatic and vascular anatomical landmarks including the left portal vein (LPV), inferior vena cava (IVC), and aorta (Ao).

Section Structure

The principal structures demonstrated in this oblique subxiphoid plane include the ligament teres (LTH), right hepatic lobe (RL), portal vein (PV), common hepatic artery (CHA), inferior vena cava (IVC), celiac artery/axis (CA), and aorta (Ao). These structures provide important anatomical landmarks for orientation of the upper abdominal and hepatic region.

Structures to identify

• Ligament teres (LTH)
• Right hepatic lobe (RL)
• Portal vein (PV)
• Common hepatic artery (CHA)
• Inferior vena cava (IVC)
• Celiac artery / celiac axis (CA)
• Aorta (Ao)
• Hepatic parenchyma

Abbreviations Used in the Figure

Short form	Full form	Identification
LTH	Ligamentum teres	Fibrous remnant of the fetal umbilical vein located within the fissure of the ligamentum teres along the anterior and inferior aspect of the liver.
CHA	Common hepatic artery	Arterial structure identified adjacent to the portal venous structures at the hepatic hilum.
PV	Portal vein	Portal venous structure coursing within the hepatic region.
IVC	Inferior vena cava	Major venous landmark located posterior to the liver.
RL	Right hepatic lobe	Hepatic parenchyma of the right hepatic lobe.
CA	Celiac artery / celiac axis	Arterial landmark located anterior to the aorta in the upper abdominal vascular region.
Ao	Aorta	Major arterial landmark posterior to the liver.

Measuring Method and Normal

In this oblique subxiphoid plane, measurements may be obtained when clinically indicated. The IVC and Ao should be measured only when the vessel is clearly visualized and the imaging plane is appropriate. Calipers should be placed perpendicular to the vessel wall according to the selected standardized measurement technique.

Measurement	Caliper method	Reference / interpretation
IVC	Measure the internal diameter perpendicular to the long axis of the vessel when an appropriate standardized view is obtained.	Interpret according to respiratory phase, measurement level, patient position, and clinical context.
Ao	Measure the aortic diameter at the appropriate anatomical level, with the calipers positioned across the vessel.	Interpret according to the measurement site and clinical context.

Measurement note: Obtain measurements only when the target structure is clearly defined. Avoid oblique measurements and inclusion of adjacent tissues or vessels.

The Clinical Application Value

This oblique subxiphoid plane provides an anatomical overview of the left and right hepatic lobes and demonstrates important vascular landmarks including the PV, CHA, IVC, CA, and Ao. Recognition of these structures assists in hepatic orientation and assessment of the upper abdominal vascular anatomy.

• Demonstration of the ligament teres (LTH).
• Demonstration of the right hepatic lobe (RL).
• Identification of the portal vein (PV).
• Identification of the common hepatic artery (CHA).
• Recognition of the IVC as an important posterior vascular landmark.
• Identification of the celiac artery / axis (CA).
• Recognition of the aorta (Ao) as a major arterial landmark.
• Assessment of the surrounding hepatic parenchyma.

Quick Scanning Checklist

1	Fast the patient for 8–12 hours when appropriate.
2	Position the patient in the supine position.
3	Place the probe obliquely in the subxiphoid region.
4	Angle the probe toward the left upper abdomen.
5	Obtain a clear oblique view of the hepatic parenchyma.
6	Identify the LTH and RL.
7	Identify the PV and CHA.
8	Identify the IVC, CA, and Ao.
9	Optimize depth, gain, focus, and probe pressure for clear visualization.
10	Assess hepatic contour and parenchymal echogenicity.

Diagnostic Pathology

This oblique subxiphoid view can assist in the assessment of hepatic, portal venous, and upper abdominal vascular abnormalities. The LTH, PV, CHA, IVC, CA, Ao, and surrounding hepatic parenchyma should be evaluated together with the complete abdominal sonographic examination.

Key Sonographic Findings

• Abnormal appearance of the ligamentum teres: Altered thickness, echogenicity, contour, or surrounding inflammatory or mass-like change should be documented when identified.
• Hepatic steatosis: Increased hepatic echogenicity with variable posterior attenuation and reduced visualization of deeper structures.
• Hepatomegaly: Increased hepatic size with alteration of normal hepatic contour or morphology.
• Cirrhotic change: Coarse hepatic echotexture, irregular contour, and altered hepatic architecture.
• Focal hepatic lesion: Focal abnormality differing in echogenicity or architecture from the surrounding hepatic parenchyma.
• Portal venous abnormality: Altered caliber, intraluminal thrombus, abnormal flow, or other abnormality involving the PV.
• Hepatic arterial abnormality: Altered caliber or abnormal Doppler flow involving the CHA.
• IVC abnormality: Altered caliber, narrowing, compression, thrombus, or other intraluminal abnormality involving the IVC.
• Celiac axis abnormality: Altered caliber, stenotic appearance, or abnormal Doppler flow involving the CA.
• Aortic abnormality: Abnormal aortic caliber, wall irregularity, atherosclerotic change, or aneurysmal dilatation involving the Ao.
• Portal hypertension: Abnormal portal venous caliber, altered flow, or collateral venous vessels may be identified in the appropriate clinical setting.
• Hepatic parenchymal abnormality: Altered echogenicity, coarse echotexture, focal lesions, or architectural distortion should be documented when present.

Diagnostic note: Sonographic findings should be interpreted together with the complete abdominal ultrasound examination, Doppler assessment, clinical history, and relevant laboratory findings. A single sonographic finding should not be used in isolation to establish a diagnosis.