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Liver resection
Introduction
Partial hepatectomy is possible because liver regeneration is rapid (Plate 1) and because the liver is segmental in structure (Plate 2) .
Hepatic resection for removal of lesions of the liver may be necessary for a wide variety of conditions ( Table 2.1 ).
Table 2.1.
Most Common Conditions for Which Liver Resection May Be Used for Therapy
| Benign liver tumors |
| Hemangioma |
| Adenoma |
| Focal nodular hyperplasia |
| Cystadenoma |
| Malignant liver tumors |
| Primary |
| Hepatocellular carcinoma |
| Cholangiocarcinoma |
| Metastatic arising from |
| Colorectal cancer |
| Noncolorectal cancers and neuroendocrine tumors |
| Tumors directly invading the liver |
| Adrenal tumors |
| Renal carcinoma |
| Gastric cancer |
| Colonic cancer |
| Retroperitoneal and IVC sarcoma |
| Gallbladder cancer hilar cholangiocarcinoma benign conditions |
| Intrahepatic biliary strictures/fistulae |
| Intrahepatic biliary stones |
| Recurrent pyogenic cholangitis |
| Caroli disease |
| Liver cysts/polycystic liver disease |
| Parasitic cysts |
| Liver trauma |
| Liver resection in living donors for transplantation |
General principles
Benign disease
Partial hepatectomy for the removal of benign tumors or cysts of the liver should be performed only for symptomatic patients, when there is doubt as to the diagnosis, or for tumors with known malignant potential. Removal of liver tissue should be kept to a minimum, and the use of techniques for enucleation of such tumors is often appropriate.
Liver resection may be necessary in the management of some complex benign biliary strictures, especially when associated with unilateral liver atrophy and a variety of other benign biliary conditions, including the removal of intrahepatic stones sometimes in association with recurrent pyogenic cholangitis and in some cases of Caroli disease.
Malignant disease
Partial hepatectomy as treatment for malignant tumors of the liver must be guided by the principle of complete tumor removal with a margin of parenchymal transection clear of the tumor. Despite the need to resect with clear margins, every effort should be made to minimize removal of functional liver tissue.
Wedge resections carry an increased local recurrence rate, and the principle of achieving clearance is best met by performing resection along anatomic lines.
Gallbladder carcinoma and cholangiocarcinoma at the confluence of the hepatic bile ducts frequently occlude biliary flow, and resection may be compromised not only by obstructive jaundice but also by infection that may have been introduced before surgery as a result of interventional radiologic or endoscopic procedures. Hilar blood vessels may be involved by tumor, and vascular resection and reconstruction may be necessary.
Principal hazards
The main hazards of hepatic resection are biliary leakage and bleeding. Biliary leakage is a particular problem with patients in whom biliary reconstruction is necessary. Bleeding from the hepatic veins and the inferior vena cava (IVC) during parenchymal transection is a major concern. Bleeding is especially likely to occur during major resection for high and posteriorly placed tumors ( Fig. 2.1 ).
Postoperative functional hepatic reserve
A noncirrhotic, healthy patient may tolerate a resection of 80% of liver volume. The enormous regenerative capacity enables functional compensation within a few weeks.
There is virtually no risk if most of the specimen volume has been replaced by an extensive tumor mass. In such patients, compensatory hypertrophy of the unaffected residual liver already has occurred, and the loss of functional parenchyma is limited. A comparable resection performed for multiple or unfavorably located smaller lesions carries a much greater risk of postoperative liver failure. More recent approaches have advocated the use of portal vein embolization in this situation, but there is little evidence that portal vein embolization is associated with improved postoperative results in patients with normal liver parenchyma.
In patients with a steatotic liver, there is an increased risk. Portal vein embolization may prove to be justified in this group of patients.
In the cirrhotic liver, liver regeneration is much less effective, and impairment of liver function is greater, may last longer, and may result in liver failure. Nonspecific postoperative surgical complications, such as abdominal infection, may trigger postoperative liver failure. In cirrhotic patients, portal hypertension is augmented and is related to the amount of parenchyma removed. The increase in portal hypertension also may be related to the increased risk of variceal bleeding. Although there is evidence that major hepatic resection can be performed safely in cirrhotic patients with Child’s A liver function, portal vein embolization may improve hepatic functional reserve in the remnant of the liver.
Infection
There is a serious risk of infection after liver resection in patients with biliary obstruction, especially in the presence of previous radiologic or endoscopic intubation and in cirrhotic patients.
Summary
- 1.
Noncirrhotic patients in whom clearance of tumor or removal of benign lesions can be obtained without compromising hepatic arterial and portal venous inflow, hepatic venous outflow, or biliary drainage to or from the remnant are suitable for hepatic resection.
- 2.
Cirrhotic patients with one or two tumors should be considered for resection. Resection is contraindicated in patients with multiple nodules. Liver function is the major risk factor, and resection should not be carried out in patients with a serum bilirubin greater than 2 mg/dL or in the presence of clinically detectable ascites. Evident portal hypertension is also a contraindication.
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