54 - Major hepatic resection

Summary

In addition to treating critical injuries, major hepatic resection is performed to remove malignant neoplasms (hepatoma, cholangiocarcinoma, metastases), benign neoplasms (liver cell adenoma, focal nodular hyperplasia, cavernous hemangioma), and cysts (congenital, multicystic disease, echinococcal). If the remaining hepatic tissue is normal, as much as 80% to 90% of the liver can be removed in children and adults.

Screening of high-risk individuals allows for earlier detection of hepatocellular carcinoma or hepatic metastases from colorectal cancer. In the former group, cirrhotics, hepatitis B carriers, and family members of patients with hepatocellular carcinoma should undergo yearly measurements of alpha-fetoprotein (AFP) and hepatic ultrasonography. In the latter group, measurements of carcinoembryonic antigen (CEA) and hepatic ultrasonography are indicated every 3–6 months in the first 3 years after resection of a colorectal cancer.

Preoperative screening before major resection is performed using MRI, which is very sensitive in detecting small nodules, showing the relationship between tumor nodules and major intrahepatic and retrohepatic blood vessels, and determining resectability. An indocyanine green clearance test is still used to assess functional reserve in patients with cirrhosis who need major hepatic resection.

Major hepatic resection is performed under general anesthesia through an upper abdominal incision using either vascular inflow occlusion (Pringle maneuver or clamping of the porta hepatis) or individual ligation of the lobar hepatic artery, portal vein, and right or left branch of the hepatic duct when lobectomy is planned.