Diagnostic Operation of the Liver and Techniques of Hepatic Resection

CHAPTER

124 

Diagnostic Operation of the Liver and Techniques of Hepatic Resection Alessandro Paniccia 

|

  Richard D. Schulick

LIVER BIOPSY PERCUTANEOUS AND TRANSJUGULAR LIVER BIOPSY Liver biopsy was originally described by Ehrlich in 1883 to determine glycogen stores in patients with diabetes.1 A variety of approaches and techniques have been described for performing liver biopsy, including percutaneous, transjugular, laparoscopic, and open techniques. For focal lesions, percutaneous liver biopsies are often conducted under image guidance either with the use of ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI). The goal of percutaneous biopsy is to obtain a core of tissue with good preservation of the underlying hepatic architecture. The presence of significant ascites or underlying coagulopathy is a relative contraindication to percutaneous biopsy. In this scenario a transjugular biopsy may be necessary. However, transjugular biopsies are best used for large and easily targetable lesions and are of limited use for small focal lesions because of the inability to accurately place the needle. Furthermore, the amount of tissue obtained is often smaller and more fragmented compared with percutaneous core needle biopsies, making pathologic assessment more difficult. If multiple percutaneous attempts have failed to obtain adequate material, if there is suspicion that a liver lesion is highly vascularized and prone to bleeding, if there is a need to obtain tissue from multiple sites, or if it is otherwise preferable to biopsy the liver under direct vision, then either laparoscopic or open liver biopsy may be used.

LAPAROSCOPY AND BIOPSY Laparoscopy examination of the liver consists of visual inspection, palpation (using standard laparoscopic instruments is possible to appreciate any parenchymal nodularity or change in tissue consistency), and tissue biopsy. Superficial lesions can be biopsied under direct visualization using cupped biopsy forceps, whereas deeper lesions might require laparoscopic ultrasound guidance and the use of percutaneous core needle biopsy devices. The authors recommend performing core needle biopsy rather than fine-needle aspiration (FNA) because the former allows for the identification of the architectural structure of the underlying liver parenchyma and often delivers more reliable results compared with FNA. In addition, the direct laparoscopic visualization of the liver parenchyma allows for quick identification and treatment of any potential bleeding complications caused by a large needle biopsy.

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Preoperative laparoscopy, as a diagnostic tool in hepatobiliary malignancies, has been discussed extensively during the past two decades. Although no definitive consensus has been achieved, with the improvement of modern radiographic imaging modalities its role appears to be limited to select cases. A particular case is represented by gallbladder and hilar cholangiocarcinoma where the yield of staging laparoscopy and ultrasonography is relatively high and the value of surgical palliation is relatively low, thus arguing in favor of laparoscopic staging in order to prevent an unnecessary laparotomy.

OPEN LIVER BIOPSY AND EXAMINATION An open liver biopsy can be performed through a limited right subcostal incision. The incision should be placed over the inferior edge of the liver but should be at least 3 cm below the costal margin to allow for adequate fascial closure. The liver can be examined both visually and by palpation, but care should be taken to not disturb any portosystemic collateral vessels. If these friable vessels are disrupted, or if the hepatic capsule is ruptured during examination, a major abdominal operation may be required to gain control. Visual inspection for gross evidence of cirrhosis, nodularity, abnormal color or texture, or neoplasm may be revealing. A laparoscopic ultrasound probe can be used through a small incision, or, if the incision is large enough, the regular probe may be used. A wedge biopsy can be obtained using a No. 15 scalpel and removing a specimen measuring 1 cm at its base. A core needle biopsy can be obtained through the same site, directed deeper into the liver parenchyma but away from the porta hepatis. If significant bleeding is expected, hemostatic 2-0 chromic catgut or Vicryl mattress sutures can be placed in an interlock V shape outside the biopsy site prior to biopsy. After the biopsies are taken, the base of the biopsy site is treated with the argon beam coagulator for hemostasis. The fascia should be closed with running permanent suture if ascites is anticipated. Similarly, the skin should be closed with a running long-lasting suture if ascites is anticipated.

INCISION FOR LIVER OPERATIONS SUBCOSTAL APPROACH Most hepatectomies can be accomplished via a right subcostal incision made 3 to 4 cm below the right costal margin with an upper midline extension in a supine patient. The right rectus abdominis muscle is completely divided, as are the medial portions of the external oblique, internal oblique, and transversus abdominis muscles.

Diagnostic Operation of the Liver and Techniques of Hepatic Resection  CHAPTER 124 1456.e1

ABSTRACT The indications for liver resection are various and include benign or malignant, as well as primary or secondary, conditions of the liver. The surgeon performing liver resection must have a clear understanding of the liver functional anatomy and must always strive for the resection of the minimum amount of liver parenchyma necessary to achieve appropriate removal of the pathologic lesion(s) with appropriate margins. The techniques of liver resection have varied minimally throughout the years, with the exception of the introduction of new instrumentation dedicated to liver parenchymal transection, and the popularization of laparoscopy in the armamentarium of the liver surgeon. A few fundamental principles must always be adhered to and includes extremely careful preoperative patient selection aimed at ensuring an adequate functional liver remnant with good vascular inflow, vascular outflow, and biliary drainage. In this chapter, we present an overview of the liver functional anatomy and illustrate the most common techniques of liver biopsy and liver parenchymal transection and their associated complications.

KEYWORDS Hepatectomy, Laparoscopic liver resection, Transection of hepatic parenchyma, Liver biopsy, Segmental resection, Extended hepatectomy, Functional liver remnant

Diagnostic Operation of the Liver and Techniques of Hepatic Resection  CHAPTER 124 

1457

Incision Xiphoid excised

Rib cage

VC m

nu

e od

Du

Renal veins

Depending on the exposure required, the incision can be made up to and beyond the midaxillary line between the costal margin and the iliac bone. This incision exposes the anterior and inferior surfaces of the right and left liver and provides good access to the porta hepatis. For exposure of the dome of the liver, a midline extension over and above the xiphoid is performed and the xiphoid removed. For even more exposure, the incision can be extended under the left subcostal area (Figs. 124.1 and 124.2). With this full incision, the surgeon has excellent exposure to the entire upper abdomen, including the liver as well as the retrohepatic and suprahepatic inferior vena cava (IVC). Because of the appearance when closed, this incision is often referred to as the Mercedes incision. In extreme circumstances, a median sternotomy or right thoracotomy through the costal margin can even further increase access and exposure.

MIDLINE APPROACH The midline incision can be used in thin patients, especially when a pelvic procedure, such as a low anterior resection, is being performed at the same time, or if the hepatic resection will be limited to the left half of the liver. The patient is positioned supine. This approach does not generally allow good access to the retrohepatic vena cava, the right hepatic vein, or the right posterior sector of the liver until the liver is completely mobilized off the diaphragm and retroperitoneum. It is commonly used in exploration for trauma where hepatic injury may be found.

FIGURE 124.1  Bilateral subcostal incision with a short midline extension. This is a versatile incision appropriate for most major hepatic resections and portosystemic shunts. VC, Vena cava.

If greater exposure is required, a median sternotomy or right thoracotomy through the costal margin can be performed.

RIGHT THORACOABDOMINAL APPROACH The thoracoabdominal incision is sometimes used in patients with large bulky lesions involving the right dome or right posterior section of the liver. It gives the best access to the suprahepatic and retrohepatic vena cava, as well as the right hepatic vein. In addition, it is sometimes used in instances of significant right diaphragmatic involvement. The patient is positioned on a bean bag with the chest in a lateral position but the hips at 45 degrees. The incision is made from the umbilicus to the right costal margin, and, depending on the location of the lesion, the seventh, eight, or even ninth rib interspace is opened. If keeping the right lung unventilated will help, then a double-lumen endotracheal tube should be used. The diaphragm should be incised circumferentially to avoid the neurovascular bundle supplying it. Care should be taken to leave 3 to 4 cm of diaphragm on the rib cage to allow for later closure.

MORPHOLOGIC AND FUNCTIONAL ANATOMY The morphologic and functional anatomy of the liver has been discussed and revised for more than a century, and it is paramount that the surgeon performing any hepatic resection is intimately familiar with the most current anatomic understanding and most recent nomenclature.2–5

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SECTION III  Pancreas, Biliary Tract, Liver, and Spleen Suprahepatic inferior vena cava and right, middle, and left hepatic veins

Liver

Divided triangular ligament

Tumor

FIGURE 124.2  Mercedes sign incision. Excision of the xiphoid process and downward traction on the liver provide excellent exposure of the hepatic veins and suprahepatic inferior vena cava.

FIGURE 124.3  The liver can be divided into right and left halves by forming a plane through the gallbladder fossa (Cantlie line) and inferior vena cava. (From Blumgart LH, Fong Y. Surgery of the Liver and Biliary Tract: Selected Operative Procedures. CD-ROM, 3rd ed. London: Harcourt; 2000.)

Historically, the liver anatomy has been defined by morphologic landmarks visible on the liver surface. As such, the liver can be divided into right and left halves by forming a plane through the gallbladder fossa (Cantlie line) and the IVC (specifically at its junction with the middle hepatic vein, when visible) (Fig. 124.3).6 Furthermore, the left half of the liver can be further subdivided into a left medial section and left lateral section, based on the location of the umbilical fissure and the falciform ligament. In addition, the caudate of the liver is identified as lying posterior to the gastrohepatic ligament and

emanating from a process of liver situated posterior to the main portal pedicle and anterior to the IVC. The need for an understanding of the liver’s functional anatomy has led to the acceptance of division of the liver anatomy based on the vascular watershed area rather than purely based on liver surface landmarks. As such, the most widely accepted nomenclature of liver anatomy is based on Couinaud’s description of eight discrete anatomic segments of the liver (Fig. 124.4). Therefore, in addition to surface anatomy (i.e., Cantlie line, umbilical fissure, and falciform ligament), the eight segments of the liver are determined using the location of the three main hepatic veins and the location of the portal pedicle bifurcation. The right and left halves of the liver are delineated by a plane through the middle hepatic vein and IVC. Segment II, III, and IV lie to the left of this plane and form the left half of the liver. Segments V, VI, VII, and VIII lie to the right of this plane and form the right half of the liver. Segment I, or the caudate, is morphologically distinct from the two halves of the liver and emanates from a process of liver lying posterior to the portal pedicle and anterior to the IVC. The right and left halves of the liver derive blood supply from the corresponding right and left portal veins and hepatic arteries, respectively, whereas segment I derives blood from both. In addition, the right half of the liver has venous drainage mostly through the right and middle hepatic vein, and the left half of the liver has drainage mostly through the left and

Diagnostic Operation of the Liver and Techniques of Hepatic Resection  CHAPTER 124 

VII

TABLE 124.1  Child-Pugh Classification*

VIII II

Score

I

V

III

IV VI

Parameter Bilirubin (mg/dL) Albumin (g/dL) Ascites Encephalopathy

PROTHROMBIN TIME

A

Seconds prolonged INR VIII

V

1 <2 >3.5 Absent Absent

2 2–3 2.8–3.5 Moderate Moderate

3 >3 <2.8 Severe Severe

<4 <1.7

4–6 1.7–2.3

>6 >2.3

*The Child-Pugh classification: grade A = 5–6 points; grade B = 7–9 points; grade C = 10–15 points. INR, International normalized ratio.

II I

VII

1459

III IV

VI

B FIGURE 124.4  Couinaud’s eight anatomic segments of the liver: anterior (A) and posterior (B) views. (From Blumgart LH, Fong Y. Surgery of the Liver and Biliary Tract: Selected Operative Procedures. CD-ROM, 3rd ed. London: Harcourt; 2000.)

middle hepatic veins. However, segment I drains directly via small branches into the IVC. The right half of the liver can be further subdivided using a plane through the right hepatic vein and the IVC. The liver anterior to this plane forms the right anterior sector of the liver, and liver posterior to this plane forms the right posterior sector. The right anterior sector of the liver comprises segment V (caudal to the bifurcation) and segment VIII (cephalad to the portal bifurcation). The right posterior sector of the liver comprises segment VI (caudal to the portal bifurcation) and segment VII (cephalad to the portal bifurcation). The left half of the liver can be further subdivided using a plane through the umbilical fissure and falciform ligament. Liver medial to this plane forms the left medial section of the liver or segment IV, and liver lateral to this plane forms the left lateral section of the liver. The left lateral section of the liver is further subdivided into segment II (closer to segment I) and segment III (closer to segment IV), which are supplied by separate portal pedicles from the umbilical fissure.

PREOPERATIVE EVALUATION OF HEPATIC RESERVE A functional liver remnant (FLR) must be ensured at the end of every liver resection; as such, fundamental principles of liver resection require ensuring appropriate hepatic arterial and portal venous inflow, adequate venous outflow, and biliary drainage in continuity with the small bowel.

Therefore, when proper hepatic inflow and outflow are secured, up to 70% to 75% of hepatic volume can be resected in patients with relatively normal hepatic parenchyma (without active hepatitis, cirrhosis, or metabolic derangements). Several different strategies have been described to predict hepatic reserve; however, many hepatobiliary centers in the United States commonly rely on the two following strategies: • Child-Pugh score that assesses hepatic synthetic ability (albumin, prothrombin time, and ascites), bile excretory function (total bilirubin), and metabolic function (changes in mental status from ammonia retention) (Table 124.1).7 • Volumetric measurements of the liver and predicted liver remnant after resection based on three-dimensional reconstruction from CT scan and MRI.8 When the predicted FLR is inadequate, a technique of portal vein embolization to the right or left half of the liver can be used to generate a compensatory hypertrophy of the future liver remnant prior to resection. However, following embolization, the liver requires approximately 4 to 6 weeks to reach an adequate hypertrophic response.9–11 Another available strategy is associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) because this technique produces a rapid increase of the FLR, usually within 7 to 14 days. A key aspect is that the liver partition results in ligation of the bridging veins between the two hemilivers and therefore truly isolates the future specimen from the liver remnant.12–14 However, the ALPPS technique remains at the center of a heated debate due to its associated complications, between 7% and 36%, among which the most common are sepsis and bile leak.12,15,16 The indications for ALPPS are still being debated; however, its best outcomes are seen in patients with colorectal liver metastasis and in patients ≤60 years of age.17 Nevertheless, portal vein embolization is still the preferred method to obtain hypertrophy of the FLR, and additional studies are needed to properly delineate the role of ALPPS. Particular attention should be given to patients undergoing preoperative chemotherapy, such as in the setting of metastatic colorectal cancer. In fact, modern chemotherapeutic agents are associated with considerable liver toxicity. Two of the most common chemotherapeutic agents including oxaliplatin and irinotecan are associated with sinusoidal congestion and

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SECTION III  Pancreas, Biliary Tract, Liver, and Spleen

Left pedicle in umbilical fissure

Right anterior pedicle

Middle hepatic vein

Left hepatic vein

Right hepatic vein

Right posterior pedicle

Bifurcation

FIGURE 124.5  Intraoperative ultrasound image of bifurcation of the main portal pedicle into the right and left branches.

steatohepatitis, respectively.18 Therefore thorough understanding of the underlying metabolic status of the liver parenchyma is of primary importance to appropriately define the extent of hepatic resection that will guarantee an adequate FLR. A common rule of thumb is to consider adequate an FLR of greater than or equal to 25% of total liver volume in patients with healthy liver. However, patients with chronic liver disease but without cirrhosis require an FLR of at least greater than or equal to 30%, whereas patients with cirrhosis but without portal hypertension require an FLR of at least 40%.19,20

INTRAOPERATIVE ASSESSMENT Intraoperative assessment of the liver allows the surgeon to identify unrecognized lesions missed by preoperative imaging, to delineate the plane of resection and proximity to the index lesions, and to identify any aberrant anatomy. Intraoperative ultrasonography is of incommensurable value and each hepatobiliary surgeon should be intimately familiar with its application. Mobilization of the liver is often required if the surgeon’s intent is to perform a thorough bimanual examination or a diagnostic intraoperative ultrasonography evaluation. Ultrasonography evaluation begins with the identification of the main portal pedicle within the hepatoduodenal ligament. This is followed cephalad to the portal bifurcation to the main right and left pedicles. It is key to understand that the portal pedicles are invested with the Glisson capsule and have a very echogenic covering, which is in contrast to hepatic vein branches. The main portal pedicle is followed toward the right, where it gives off an anterior and posterior branch (Fig. 124.5). The right anterior branch gives off separate pedicles to segment V (caudal) and to segment VIII (cephalad). The right posterior branch gives off separate pedicles to segment VI (caudal) and to segment VII (cephalad). The main left pedicle is usually much longer and courses intact to the base of the umbilical fissure before branching into various segmental pedicles. At the base of the umbilical fissure, the main left pedicle courses anteriorly toward the round ligament

IVC

FIGURE 124.6  Intraoperative ultrasound image of the three main hepatic veins. The left and middle hepatic veins often join together before emptying into the inferior vena cava (IVC).

and gives off a pedicle to segment IV medially and pedicle to segments II and III laterally. Next, if the bare areas around the junction of the hepatic veins and IVC have been well mobilized, the hepatic veins can easily be visualized using intraoperative ultrasonography (Fig. 124.6). As described previously, usually a larger right hepatic vein can be delineated, and smaller left and middle hepatic veins joining into a common trunk before emptying into the IVC are seen. Commonly, an umbilical hepatic vein branch can be identified coursing between the middle and left hepatic veins and running under the falciform ligament. Not uncommonly, significant accessory right hepatic veins can be seen emptying from the posterior surface of the right liver directly into the IVC as it courses posterior to the liver. The identification of these accessory right hepatic veins is quite important for both vascular control and preservation of outflow from the liver. Finally, the hepatic parenchyma is systematically scanned to identify lesions within the liver.

GENERAL MANEUVERS FOR HEPATECTOMY The porta hepatis can be dissected to identify the main bifurcation of the hepatic artery, bile duct, and portal vein and to allow individual ligation of these structures. Ligation of the hepatic artery and portal vein to one side causes the liver parenchyma to demarcate between the right and left liver. Greater exposure of the cephalad aspect of the hepatic hilum and exposure of a high or intraparenchymal bifurcation of the portal triad structures may be aided by lowering the hilar plate (Fig. 124.7) and dividing the Glisson capsule at the most inferior border of segment IV. Control of the inflow hepatic artery and portal vein branches to a specific anatomic section of the liver may also be obtained by pedicle ligation in which small hepatotomies are made around the main right pedicle, main left pedicle, right anterior pedicle, or right posterior pedicle after identification with ultrasound (Fig. 124.8).21 The pedicle of interest can be dissected out bluntly with a right angle or by finger fracture. The pedicle should be test clamped atraumatically to confirm that it does indeed

Diagnostic Operation of the Liver and Techniques of Hepatic Resection  CHAPTER 124 

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Segment IV

Anterior

Right lobe

A

B

Diaphragm

C

FIGURE 124.7  The hilar plate of the liver can be “lowered” by dividing the Glisson capsule at the lowest edge of segment IV. This maneuver gains access to the most cephalad portion of the bifurcation of the porta hepatis. (A) Left hepatic duct. (B) Portal vein. (C) Hepatic artery. (Modified from Blumgart LH, Fong Y. Surgery of the Liver and Biliary Tract: Selected Operative Procedures. CD-ROM, 3rd ed. London: Harcourt; 2000.)

IV

V

3

5

2 4 VI

1 I

FIGURE 124.8  Sites for intraparenchymal portal pedicle ligation. Incisions at 1 and 2 allow isolation of the main right pedicle. Incisions at 1 and 4 allow isolation of the right posterior pedicle. Incisions at 2 and 4 allow isolation of the right anterior pedicle. Incisions at 3 and 5 allow isolation of the left pedicle. (From Fong Y, Blumgart LH. Useful stapling techniques in liver surgery. J Am Coll Surg. 1997;185:93.)

supply the area of liver of interest. If the proper pedicle is clamped, the appropriate portion of the liver (i.e., right half, left half, right anterior section, right posterior section) should demarcate. Once confirmed, it can be divided. Alternatively, the specific inflow pedicles can be divided

Vena cava

FIGURE 124.9  The right hepatic vein can be divided with the aid of an endoscopic stapling device with a vascular load. (From Fong Y, Blumgart LH. Useful stapling techniques in liver surgery. J Am Coll Surg. 1997;185:93.)

as they are encountered during parenchymal transection. With this technique, hemorrhage can be minimized by intermittent portal inflow occlusion accomplished by atraumatically clamping the main portal triad within the hepatoduodenal ligament (Pringle maneuver). Outflow control of the hepatic veins can be obtained at different time points, depending on the situation. If there is a sufficient length of extraparenchymal hepatic vein, often it is easier to divide the hepatic vein early and prior to parenchymal transection (but after inflow control). If the extraparenchymal portion of the hepatic vein is short (or absent), it may be easier and safer to divide the hepatic vein or veins within the hepatic parenchyma after most of the parenchymal transection has been performed. The use of endoscopic vascular stapling devices has made the ligation of the hepatic veins whether extraparenchymally or intraparenchymally much quicker and safer (Fig. 124.9).21 Another technique used to minimize blood loss is a low central venous pressure technique in which the central venous pressure of the patient is kept low (<5 mm Hg) until after parenchymal transection. 22 After the parenchymal transection is completed and the bleeding is controlled, the patient is made euvolemic. This minimizes the bleeding coming from hepatic vein branches.

MAJOR HEPATECTOMIES To understand the different types of hepatectomies, one must be familiar with the hepatic anatomy and nomenclature. A great effort was made by the International Hepato-Pancreato-Biliary Association in the Brisbane 2000 Nomenclature of Hepatic Anatomy and Resections to unify and standardize the terminology in the field of hepatic surgery.23

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SECTION III  Pancreas, Biliary Tract, Liver, and Spleen

This new terminology transitions from a nomenclature driven by the liver surface anatomic landmarks (i.e., the ligamentum teres, the falciform ligament) to a more functional anatomy based on vascular distribution and watershed areas. Therefore the liver can be divided in two hemilivers (right and left) based on the vertical plane intersecting the gallbladder fossa and the IVC. The Couinaud classification remains largely used to identify the different segments of the liver (i.e., I to VIII) and a major liver resection is still defined as the resection of three or more contiguous segments based on the aforementioned classification. Right hepatectomy or right hemihepatectomy involves the resection of segment V through VIII; left hepatectomy or left hemihepatectomy involves the resection of segment II through IV. Segment I may or may not be included in either of these resections. Extended right hepatectomy (also known as right trisectionectomy) involves the resection of segment IV through VIII; extended left hepatectomy (also known as left trisectionectomy) involves the resection of segment II through V plus VIII. Again either of these extended resections may or may not include resection of segment I. Right anterior sectionectomy includes segment V and VIII. Right posterior sectionectomy includes segment VI and VII. Left medial sectionectomy removes segment IV. Left lateral sectionectomy includes segments II and III. A segmentectomy involves the resection of a single segment, and a bisegmentectomy involves the resection of two contiguous segments. In general, there are four key steps involved in major hepatectomies; these consist of optimal exposure, vascular inflow control, vascular outflow control, and parenchymal transection. Vascular inflow control may be obtained by directly ligating the main right or left branches of the hepatic artery and portal vein in the hilum and/or by intermittent 10- to 20-minute intervals of a Pringle maneuver with 3 minutes in between to reestablish blood flow. The authors prefer to encircle the hepatoduodenal ligament twice with a 1 4 -inch Penrose drain that is tightened and clamped for a Pringle maneuver. Alternatively, pedicle ligation can be performed as described previously, or the pedicle can be controlled as they are encountered during parenchymal transection. The authors prefer to obtain vascular inflow control by ligating the appropriate vessels in the hilum or by pedicle ligations and to supplement this with intermittent Pringle maneuvers as necessary during parenchymal transection for hemihepatectomies. Vascular outflow to the right or left liver can be obtained by exposing and ligating the hepatic veins as previously described or by ligating the vessels intraparenchymally during transection of the tissue. The routine use of closed-suction drains after a major hepatectomy remains controversial because no definitive decrease in postoperative intervention has been consistently shown.24,25 Furthermore, a series from the Memorial Sloan Kettering Cancer Center reviewed 2173 hepatectomies and found that symptomatic perihepatic collections (SPHCs) developed in only 200 cases (9% of patients), and in one-third were nonbilious and noninfected. On

multivariate analysis, major hepatic resections, greater than median blood loss (>360 mL), simultaneous performance of colorectal procedure use, as well as use of surgical drains were associated with an SPHC.26 The authors of this chapter routinely place closedsuction drainage when biliary reconstruction is performed.

TRANSECTING THE HEPATIC PARENCHYMA Several different techniques are used to achieve liver parenchymal transection; most often a combination of different techniques is used during the same case, depending on the surgeon’s preference and experience, tumor location within the liver parenchyma, and need for margin clearance. Regardless of the method used, certain key principles must be adhered to. These include safety, speed, minimization of blood loss, and avoidance of significant liver injury. It is good practice to identify the plane of liver parenchymal transection and to demarcate the area of interest by incising the liver capsule with the use of electrocautery. This will not only facilitate parenchymal transection but will also provide an easily visible reference on the liver surface to orient the surgeon along the resection boundaries. The most classic approach to liver parenchyma transection consists of digitoclasy (also known as finger fracture technique) or clamp crushing technique; both these techniques allow for fracture of the liver parenchyma while sparing vessels and bile ducts encountered along the transection plane. These tubular structures are then controlled with a variety of approaches, including suture ligation, metal clips placement, energy device, or stapling device application, according to vessel size and to surgeon’s preference. Although the digitoclasy and the clamp crush technique have been the backbones of liver surgery for decades, several additional surgical devices have currently become available. These include water jet–based devices, ultrasound, radiofrequency, microwave energy devices, as well as bipolar devices; however, none of these devices has been shown to be superior to the others.27–31 A detailed description of these devices is beyond the scope of this chapter; however, a few key points are worth mentioning. Commonly used devices are the Hydrojet (water jet– based device) and the Cavitron Ultrasonic Surgical Aspirator (CUSA; Valleylab, Inc., Boulder, Colorado). Their use allows for parenchymal destruction while preserving crossing vessels and bile ducts. These devices allow for greater accuracy compared with the clamp-crushing technique and may increase the speed of dissection; however, they have poor to no hemostatic capacity. Radiofrequency-based devices, including the TissueLink, Aquamantys, and Habib 4X, are considered hemostatic devices and can facilitate liver parenchymal transection, as they are able to rapidly coagulate the cut edge of the liver surface, requiring ligation of only larger vessels. Other devices able to achieve parenchymal coagulation include bipolar (i.e., LigaSure) and ultrasonic vessel-sealing device (i.e., Harmonic Scalpel); both devices are able to seal vessels up to 7 to 8 mm in diameter. In addition, the argon beam coagulator can be used to control diffuse blood oozing from the cut edge of the liver parenchyma. An important transection technique is the use of stapling devices, especially in the setting of laparoscopic

Diagnostic Operation of the Liver and Techniques of Hepatic Resection  CHAPTER 124 

liver resection.32 Stapling devices can be used to control large vessels crossing through the transection plane or alternatively can be used as the primary means of liver parenchymal transection.33 In this latter scenario, a track along the liver parenchyma is usually created with the application of a large clamp and the parenchyma is then transected with serial application of the stapling device. The operating surgeon should be mindful of the effect that the various available transection techniques have on the resection margins width and on the interpretation of margin positivity in the setting of oncologic resection. In fact, the use of nonablating techniques (digitoclasy, clamp crush technique), as opposed to ablative techniques such as the CUSA, Harmonic Scalpel, LigaSure, and Aquamantys, has been shown to have an impact on the importance of margin width and on the interpretation of margin positivity.34–37 Hammond et al. conducted an experimental study comparing different surgical devices commonly used to accomplish liver parenchymal transection and concluded that the use of the CUSA was associated with a parenchymal ablation of approximately 7 mm at the edge of the transection that was greater than all the other tested devices.38

RIGHT HEPATECTOMY WITH HILAR DISSECTION A right hepatectomy can usually be accomplished through a right subcostal incision with upper midline extension and involves resection of segments V, VI, VII, and VIII. If greater exposure of the left is required, a trifurcated incision can be used. The hepatic flexure of the colon is mobilized caudad. The round ligament and falciform ligament are divided. The right bare area of the liver is exposed by dividing the right triangular ligament. The right inferior liver edge is mobilized out of the retroperitoneum. This dissection reveals the upper pole of the right kidney, right adrenal gland, and suprahepatic IVC. The liver is then rotated to the left and the subhepatic IVC is dissected by controlling the small venous branches draining directly from the liver. Care must be given to the IVC ligament; this structure is often present and extends from the right liver and around the right side of the IVC just caudad to the right hepatic vein and occasionally contains liver parenchyma or a vein. This can be often controlled with an endoscopic stapler with a vascular load after it is dissected out. At this point, the right hepatic vein can be identified and dissected out, whereupon a vessel loop can be placed around it. If dissection of the right hepatic vein is not safe at this time, it can be controlled later after parenchymal transection. A cholecystectomy is then performed. The hepatic artery bifurcation is localized. The right hepatic artery is ligated. The common hepatic duct is then dissected and mobilized anteriorly and to the left to expose the portal vein (Fig. 124.10). Dissection is then continued into the hilum of the liver to expose the bifurcation of the portal vein. The right portal vein is circumferentially dissected (Fig. 124.11). Care should be taken to make sure that the left portal vein takeoff is clear of the dissection and that small branches draining the caudate are sufficiently controlled and divided. The right portal vein can be divided with ties using a reinforcing suture ligature on

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the stump or with an endoscopic stapler with a vascular load. Hilar dissection is then completed by identifying and isolating the right hepatic duct, which is next ligated and divided. The liver is then rotated to the left and the previously isolated right hepatic vein is divided between vascular clamps or an endoscopic stapler with a vascular load. If vascular clamps are used, the caval stump is closed with a running 4-0 Prolene suture and the specimen side simply suture ligated. Several minutes after the right hepatic artery and portal vein are ligated, the right liver should become devascularized and turn dusky. The Glisson capsule is then scored with an electrocautery device, starting at the level of the divided right hepatic vein to the gallbladder fossa on the anterior surface. If preservation of the middle hepatic vein is intended, then the line of transection should be moved slightly lateral. If the intention is to take the middle hepatic vein, then the line of transection should be moved medially. Intraoperative ultrasound should be used to carefully map this out. On the posterior surface of the liver, the liver is scored along the right lateral border of the IVC, toward the portal bifurcation. Parenchymal transection is then performed by any of the previously described techniques. Intermittent portal inflow clamping, as described previously, can be used to help decrease blood loss if this is a problem during parenchymal transection. During parenchymal transection vascular and biliary structures are controlled by the appropriate combination of clips, suture ligatures, and stapling devices. After the parenchyma is transected, the specimen can be removed.

LEFT HEPATECTOMY WITH HILAR DISSECTION A left hepatectomy can also be accomplished through a right subcostal incision with an upper midline extension and involves resection of segments II, III, and IV. For large bulky tumors on the left or if the liver extends significantly laterally, a left subcostal component may be needed to trifurcate the incision. Alternatively, a midline incision can be used, but this may limit exposure to the right liver should unexpected findings be encountered during exploration. The round ligament and falciform ligament are divided. The left bare area is next exposed by dissection of the left triangular ligament. Usually the left hepatic vein and middle hepatic vein join together within the parenchyma of the liver before emptying into the IVC, which precludes extrahepatic dissection of these vessels without taking the middle hepatic vein. If it is separate and dissectible, a vessel loop is encircled around it. A cholecystectomy is performed. The lesser omentum is divided to fully expose the margins of the hepatoduodenal ligament. Care should be taken to note a replaced or accessory left hepatic artery running in this location. The proper hepatic artery is identified and dissected above the bifurcation of the right and left branches. The left hepatic artery is then divided. The common hepatic duct is next exposed, and the left hepatic duct is then divided above the bifurcation. The left portal vein can then be identified at the base of segment IV and traced to the hilus of the liver. It is circumferentially dissected and can be ligated or controlled with an endoscopic stapler with a vascular load. The left

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Common duct

Portal vein

Small tributaries to portal vein, ligated

FIGURE 124.10  Right hepatectomy. Initial exposure of the portal vein before hilar ligation of its right branch is shown. The area to be dissected, closer to the hilus of the liver than shown, has no branches. (From Nora PE. Operative Surgery: Principles and Techniques. Philadelphia: Lea and Febiger; 1980:647.) Gall bladder Teres ligament Lateral segment of left lobe

Right lobe Cystic duct Right portal vein

Inferior vena cava Caudate lobe

Hepatic artery Portal vein Common duct Foramen of Winslow

FIGURE 124.11  Right hepatectomy: Exposure of the right branch of the portal vein from the posterior approach. The liver has been retracted anteriorly and to the left. The looped ligature is around a branch to the caudate lobe. (From Starzl TE, Bell RH, Baert RW. Hepatic trisegmentectomy and other liver resections. Surg Gynecol Obstet. 1975;141:429.)

liver should become devascularized and become dusky. If the left hepatic vein was previously successfully dissected, then it can be divided with either ligatures or an endoscopic stapler with a vascular load. The anterior surface of the liver is then scored with the electrocautery device from the left hepatic vein (or stump) to the top of the gallbladder fossa. The posterior surface of the liver is then scored with the electrocautery device from the top of the gallbladder fossa to the portal bifurcation. If preservation of the middle hepatic vein is intended, then the line of transection should be moved slightly to the left; if the intention is to take the middle hepatic vein, then the line of transection should be moved to the right. Intraoperative ultrasound can be used to carefully map this out. Parenchymal transection is then performed by any of the previously described techniques. Intermittent portal inflow clamping as described previously can be used to help decrease blood loss if this is a problem during parenchymal transection. During parenchymal transection, vascular and biliary structures are controlled by the appropriate combination of clips, sutures, suture ligatures, and stapling devices. After the parenchyma is transected, the specimen can be removed (Fig. 124.12). If the caudate must also be removed to provide adequate tumor clearance, it can be mobilized off the IVC by sequentially dividing the short veins that directly drain into the IVC.

Diagnostic Operation of the Liver and Techniques of Hepatic Resection  CHAPTER 124 

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Left hepatic vein

Inferior vena cava

Left portal vein Left hepatic artery

Large vessels and ducts Left hepatic duct Omentum

FIGURE 124.12  Left hepatectomy. The hilar structures have been dissected and ligated, and the parenchymal transection is complete. In this case, the left hepatic vein has been left for last. This also depicts a resection that includes the caudate lobe. (From Schwartz SI. Surgical Diseases of the Liver. New York: McGraw-Hill; 1964:254.)

LEFT LATERAL SECTIONECTOMY Left lateral sectionectomy can usually be performed through an upper midline incision and involves resection of segments II and III of the liver. However, if unexpected findings in the right liver are discovered during exploration, a midline incision may be limiting. Alternatively, a bilateral subcostal incision can be used. The bridge of liver parenchyma between segment III and IV over the round ligament is divided either with electrocautery or with an endoscopic stapler with a vascular load. The left bare area is next exposed by dissecting the left triangular ligament. For resection of tumor, the surface of the liver is then scored 1 cm to the left of the falciform ligament and to the left of the umbilical fissure (provided that the margin is adequate). This preserves the blood supply and biliary drainage to segment IV of the remnant liver. For donor hepatectomy, the anterior surface of the liver is scored 1 cm to the right of the falciform ligament and to the right of the umbilical fissure. This preserves the blood supply and biliary drainage to segments II and III of the

donor liver. Parenchymal transection is then performed by any of the previously described techniques. Intermittent portal inflow clamping is usually not required for left lateral sectionectomy. As the main portal pedicles to the segments are encountered within the parenchyma, they are controlled with clamps, divided, and ligated or stapled with an endoscopic stapler with a vascular load. The left hepatic vein can then be finally controlled within the hepatic parenchyma either with ligatures or a stapler.

EXTENDED RIGHT AND LEFT HEPATECTOMIES Extended right and left hepatectomies are perhaps the most difficult and complicated types of liver resections and are covered in classic manuscripts.39,40 The initial maneuvers for the extended right hepatectomy are similar to right hepatectomy. The cystic artery and duct are ligated and divided, but the gallbladder can be left attached to the specimen because segment IV, V, VI, VII, and VIII are to be resected in continuity. The portal structures are dissected and divided as before. The right hepatic vein is controlled and divided, if possible as before. Because the line of parenchymal transection is just to the right of

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the umbilical fissure and falciform ligament, the feedback structure to segment IV must be controlled. The bridge of liver parenchyma between segment III and IV is divided. The liver parenchyma is scored with the electrocautery device along the plane of transection. Parenchymal transection is then performed by any of the previously described techniques. As the main portal pedicles to segment IV are encountered within the parenchyma, they are controlled with clamps, divided, and ligated or stapled with an endoscopic stapler with a vascular load. This dissection is carried to the base of the umbilical fissure (Fig. 124.13). Parenchymal transection is continued posteriorly ligating the middle hepatic vein and/or its branches. Great care is taken to preserve the left hepatic vein (Fig. 124.14). Intermittent portal inflow clamping as described previously can be used to help decrease blood loss if this is a problem during parenchymal transection. The caudate is either preserved or resected with the specimen. Because of the risk of torsion of the liver remnant, it should be attached back to the falciform ligament. The initial maneuvers for an extended left hepatectomy are similar to left hepatectomy. The cystic artery and duct are ligated and divided, but the gallbladder can be left attached to the specimen as segments II, III, IV, V, and VIII are to be resected in continuity. The right triangular ligament, in addition to the left, is also divided. The portal structures are dissected and divided as before. The left hepatic vein (with the middle hepatic veins) is controlled and divided, if possible, as before. The difficulty with extended left hepatectomy is performing the parenchymal transection to preserve the right posterior pedicle and the right hepatic vein while taking the right anterior section of the liver (segments V and VIII). Intraoperative ultrasound is useful in locating and protecting these structures. Intermittent portal inflow clamping as described previously is usually required because of the magnitude of parenchymal transection and difficulty in early control

of the right anterior pedicle. Parenchymal transection is then performed by any of the previously described techniques (Figs. 124.15 and 124.16).

SEGMENTAL RESECTIONS To maximize functional reserve, (multi)segmental or subsegmental (or nonanatomic) hepatectomies can be Feedback structures Teres ligament

Structures to lateral segment of left lobe

FIGURE 124.13  Right extended hepatectomy. Control of the feedback vessels to segment IV. Blunt dissection in liver substance just to the right of the umbilical fissure exposes these vessels. Each vascular and biliary structure is ligated individually to complete devascularization of segment IV. (From Starzl TE, Bell RH, Baert RW. Hepatic trisegmentectomy and other liver resections. Surg Gynecol Obstet. 1975;141:429.)

Medial segment of left lobe IVC

Ligature on middle hepatic vein Left hepatic vein Lateral segment of left lobe Falciform ligament

FIGURE 124.14  Right extended hepatectomy. Parenchymal transection is nearly complete. The main trunk of the middle hepatic vein is exposed, with a ligature around it. At this juncture, the caudate still may be left in situ. IVC, Inferior vena cava. (From Starzl TE, Bell RH, Baert RW. Hepatic trisegmentectomy and other liver resections. Surg Gynecol Obstet. 1975;141:429.)

IVC

Feedback structures Hepatic artery Common Portal vein duct

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Right hepatic vein Middle hepatic vein Left hepatic vein

FIGURE 124.15  Left extended hepatectomy: superior-to-inferior dissection between the right anterior section and the right posterior section. The dissecting finger is kept anterior to the right hepatic vein. The left and middle hepatic veins have been ligated or sutured. (From Starzl TE, Iwatsuki S, Shaw BW Jr, et al. Left hepatic trisegmentectomy. Surg Gynecol Obstet. 1982;155:25.)

FIGURE 124.17  Wedge biopsy of the free margin of the liver. The two mattress sutures of heavy absorbable material actually should be placed as a V shape and should intersect at the apex, not run parallel as shown. (From Grewe HE, Kremer K. Atlas of Surgical Operations. Vol. 2. Philadelphia: Saunders; 1980:321.)

The two mattress sutures are placed in the form of a V intersecting at the apex. After the wedge resection is performed, the mattress sutures can be tied to each other to approximate the two opposing raw liver surfaces.

LAPAROSCOPIC LIVER RESECTION

FIGURE 124.16  Left extended hepatectomy. Further development of the plane between the anterior and posterior sections of the right liver. (From Starzl TE, Iwatsuki S, Shaw BW Jr, et al. Left hepatic trisegmentectomy. Surg Gynecol Obstet. 1982;155:25.)

performed. For example, left lateral sectionectomy (segments II and III), central hepatectomy to remove the right anterior section (segments V and VIII) and left medial section (segment IV), right posterior sectionectomy (segments VI and VII), or caudate resection (segment I) are examples in which one, two, or three contiguous segments are removed to eradicate tumors within those regions of the liver. These resections are often done with intermittent Pringle maneuvers until the specific pedicles supplying these areas are controlled.

WEDGE RESECTIONS When a simple wedge resection of the liver is appropriate, the area to be resected is isolated between two interlocking mattress sutures of heavy absorbable material (Fig. 124.17).

Since the first laparoscopic liver resection, performed by Reich in 1991, minimally invasive approaches to liver resection have been popularized, ranging from minor procedures such as wedge resections, to more extensive segmentectomies, sectionectomies, and even hemihepatectomies.41,42 Several minimally invasive techniques have been reported, such as pure laparoscopy, hand-assisted laparoscopy, and a hybrid technique in which both laparoscopic and open approaches are used during the procedure. The Second International Consensus Conference on Laparoscopic Liver Resection ( Japan 2014) issued a recommendation statement, based mainly on observational studies, suggesting that laparoscopic liver resection is associated with decreased wound complications, postoperative pain, and length of stay.43 Furthermore, laparoscopic liver resection is neither associated with increased mortality nor increased rate of positive margin in the setting of neoplastic diseases, making it an attractive approach in liver surgery. However, in interpreting the available literature, one must be cautious because no randomized clinical trials exist comparing open versus laparoscopic liver resection, and the available data consist mainly of small cohort studies with short follow-up and significant selection bias. Proper patient selection appears to be of critical importance for a safe and successful outcome of the minimally invasive approach.

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12

Laparoscopic Right Hepatectomy Surgical Technique Intraoperative ultrasound provides significant assistance in the setting of laparoscopic liver resection and allows for the identification of tumor location and inflow and outflow vessels and can serve as guidance during parenchymal liver transection. After appropriate peritoneal exploration for evidence of extrahepatic disease, the falciform ligament is first separated from the anterior abdominal wall; this is followed by transection of the right triangular and coronary ligaments. The liver is then freed from its retroperitoneal attachments, and the right hemiliver is elevated to expose the IVC; this allows for the identification of the retrohepatic vessels (draining directly into the IVC), which are carefully ligated with surgical clips proceeding from the inferior liver edge cranially toward the right hepatic vein. Visualization of the liver hilum can be facilitated by cranial retraction of the round ligament, this is accomplished using a transcutaneously placed Endoloop (loaded on a Carter-Thomason needle suture passer) around the round ligament. The gallbladder is then dissected from the gallbladder fossa (proceeding from the fundus to the level of the hilum) with attachment to the cystic duct maintained; this can be used as a handle to facilitate liver retraction and exposure of the hilar structures. The right hepatic artery is dissected free from the surrounding tissues and transected with the use of a stapling device. This is followed by the dissection and transection of the right hepatic vein in a similar fashion. Parenchymal transection can be performed using an energy device along the demarcation line visible on the liver surface. The small hepatic vessels encountered during parenchymal transection can be controlled with the application of an energy device; alternatively, larger vessels (i.e., branches of the right hepatic vein, middle hepatic vein, and the right bile duct) are controlled with the use of a stapling device. It is paramount to inspect the cut edge of the liver surface for any evidence of bleeding or bile leakage. These can often be controlled with the use of additional clips or with the application of the argon beam coagulator, as needed. The liver specimen can be positioned in a laparoscopic extraction bag and retrieved through the supraumbilical incision; this incision can be extended as needed to allow safe retrieval of the specimen. The authors routinely reattach the falciform ligament to the anterior abdominal wall to minimize the risk of liver torsion; this can be easily accomplished with the use of an endoscopic suture device. Of note, control of the liver hilum is occasionally necessary; therefore a vascular loop or an umbilical tape should be positioned around the portal triad to allow for a prompt Pringle maneuver as needed. This maneuver can easily be accomplished by tightening the umbilical tape or the vessel loop and securing it with the use of a bulldog clamp.

hepatectomy. For hand-assist access, the supraumbilical port can be extended.

Laparoscopic Left Hepatectomy, Port Placement and Surgical Technique Access to the abdominal cavity is obtained with a 10-mm port placed approximately 2 cm above the umbilicus through which CO2 insufflation is delivered. First, the peritoneal cavity is explored for evidence of extrahepatic

PORT PLACEMENT AND PATIENT POSITIONING FOR THE LAPAROSCOPIC APPROACH Proper visualization and easy access to the surgical resection bed is mandatory, especially considering the limitations added by the laparoscopic approach, such as loss of tactile sensation, and increased complexity of the maneuvers of liver mobilization and retraction. The patient is positioned supine on the operating table; care should be taken to elevate the right side of the patient, which can be easily accomplished with placement of padding underneath the right flank. Four to five laparoscopic ports are used, and the port position varies slightly based on the type of procedure performed (i.e., left vs. right liver resection). Laparoscopic Right Hepatectomy, Port Placement Access to the abdominal cavity is obtained with a 10-mm port placed approximately 2 cm above the umbilicus through which CO2 insufflation is delivered. First, the peritoneal cavity is explored for evidence of extrahepatic disease; this can be promptly accomplished with the use of a 30-degree laparoscope. A 12-mm port is placed along the right midclavicular line; this port will be used for the insertion of stapling devices and energy-based devices. Two 5-mm ports are positioned laterally, along the right subcostal margin. These two ports are of the utmost importance because they will be used to achieve optimal retraction. In addition, a 5-mm port can be inserted in the epigastrium/subxiphoid region to facilitate visualization and mobilization of the liver dome (Fig. 124.18). If a hybrid approach is used, the supraumbilcal port access site can be extended to allow for the placement of a hand port.

5

10

5

FIGURE 124.18  Optimal port placement for laparoscopic right

Diagnostic Operation of the Liver and Techniques of Hepatic Resection  CHAPTER 124 

10

5 12

FIGURE 124.19  Optimal port placement for laparoscopic left hepatectomy. For hand-assist access, the supraumbilical port can be extended.

disease; this can be promptly accomplished with the use of a 30-degree laparoscope. A 12-mm port is placed along the left midclavicular line; this port will be used for the insertion of stapling devices and energy-based devices, and a second 12-mm port is placed along the right midclavicular line. Two 5-mm ports are positioned laterally, along the left subcostal margin. Once again, if a hybrid approach is used, the supraumbilical port access site can be extended to allow for the placement of a hand port (Fig. 124.19). Attention is first turned to the identification of the left hepatic artery and left portal vein, which are usually ligated at the level of the umbilical fissure. Parenchymal transection can proceed in a similar fashion to the one described during a laparoscopic right hepatectomy (see earlier). The left hepatic vein, as well as branches from the middle hepatic vein and the left bile duct, can be controlled with a stapling device as they are encountered during the parenchymal transection. The liver specimen is retrieved as described previously, and the falciform ligament is secured to the abdominal wall.

POSTOPERATIVE MANAGEMENT Liver resection has evolved into a safe and reproducible procedure with an estimated perioperative mortality of less than 5% when performed for metastatic disease and less than 10% for primary hepatocellular carcinoma.44 However, metabolic derangements can still occur, especially when large portions of liver parenchyma are resected, and this must be expected and anticipated. Characteristic of the initial perioperative phase is a transient hyperbilirubinemia (occasionally manifested as frank jaundice), a transient elevation of serum transaminase

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(aspartate transaminase/alanine transaminase), hypophosphatemia, and prolonged international normalized ratio (INR). The serum bilirubin level usually peaks around the third or fourth postoperative day and quickly resolves as the liver remnant recovers and regenerates. This phenomenon is not uncommon and is usually driven by loss of hepatic parenchyma and sporadically by blood transfusion, when used. Serum transaminases elevations are expected and usually plateau at less than 1000 units/L, and are not usually ominous in the absence of severe prolongation in INR, decreased fibrinogen, hepatic encephalopathy, acidosis, and elevated serum ammonia level. Hypophosphatemia is to be expected and is a sign of liver regeneration; phosphate is consumed during hepatocyte DNA regeneration and serum phosphate level should be monitored closely. In addition, hypokalemia, hypoglycemia, and hypoalbuminemia commonly occur, and again careful monitoring should be implemented and appropriate replacement instituted. Particular attention should be given to any evidence of coagulopathy, often characterized by a prolonged INR; this can arise as a result of a combination of intraoperative blood loss, dilution of clotting factors, blood product transfusion, or as an ominous sign of inadequate liver function.

POSTOPERATIVE COMPLICATIONS The rate and specific type of complications that can be expected following liver resection is highly influenced by the type of operation performed (i.e., open vs. laparoscopic; major vs. minor resection; with or without biliary duct reconstruction), by the status of the liver parenchyma (cirrhotic vs. not cirrhotic), and by the quality of the FLR. Intraabdominal fluid collections are not uncommon and are often seen along the transected edge of the liver. The significance of these collections can vary; if symptomatic (i.e., pain, compression of the hilar structures) or in the setting of clinical signs of infection, they often need to be percutaneously drained; however, if asymptomatic, they can be left alone.26 In case of persistent biliary leakage, an endoscopic retrograde cholangiopancreatogram can be both diagnostic and therapeutic as it might allow for the identification of the site of leakage and for decompression of the biliary duct via sphincterotomy. Perhaps, one of the most severe complications following hepatectomy is the development of progressive and refractory postoperative hepatic failure (POHF). This complication has been described in the literature to occur in approximately 1.2% to 32% of cases and has an associated mortality estimated between 1.6% and 2.8% of cases.45,46 It is important to note that POHF can manifest as early as a few days to many weeks after the initial liver resection, and its presentation can range from acute fulminant liver failure to a progressive insidious deterioration over weeks to months.

SUMMARY The indications for liver resection are a myriad and cover both primary and secondary conditions of the liver.

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Nonetheless, the hepatobiliary surgeon needs to adhere to a few surgical principles to ensure a successful outcome: first, intimate knowledge of the conventional liver anatomy and its common variants; second, development of an appropriate operative plan based on the understanding of the preoperative functional status of the liver parenchyma. The ultimate goal is to obtain appropriate parenchymal transection while maintaining an adequate liver remnant with good vascular inflow, vascular outflow, and biliary drainage in continuity with the enteric tract. The third principle is knowledge and anticipation of the most common complications known to arise after hepatic resections and familiarity with the available treatment strategies.

ACKNOWLEDGMENT This chapter is a combination and update of a previous chapter on diagnostic operation of the liver and techniques of hepatic resection. The authors acknowledge Aram N. Demirjian, MD for his contribution to the previous chapter on which this update is based.

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