Chapter 59 - Major hepatic resection

Summary

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

The availability of MRI and CT scans is leading to earlier detection of hepatocellular carcinoma or hepatic metastases from colorectal cancer. Other biochemical measurements such as elevated alpha-fetoprotein (AFP) and carcinoembryonic antigen (CEA) may prompt earlier imaging.

Preoperative screening with MRI for major hepatic resections is very sensitive in detecting small nodules, showing the relationship between tumor nodules and major intrahepatic and retrohepatic blood vessels, and determining resectability. MRI can also be used to assess volume reserve in patients with cirrhosis who need major hepatic resection.

Major hepatic resection is performed under general anesthesia through an upper abdominal incision for left lobe resection, and a right subcostal resection for right lobe resection. In skilled centers, minimally invasive techniques have been used successfully for major resections. The general stages of major lobectomy include 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. Division of the hepatic parenchyma is accomplished using finger fracture techniques, blunt knife handle dissection, cutting staplers, and ultrasonic vibrating-suction device or ultrasonic shears. Blood loss depends on the extent of the resection and involvement of the retrohepatic vena cava. The median blood loss was 600 mL in one recent large series, and only 49% of patients were transfused at any time. In general, intraoperative fluid restriction reduces back-pressure bleeding during major hepatic resection. The operative time is 3–4 hours in experienced hands, and the stress of a major hepatic resection is moderate to severe.