Liver Surgery

The Operation

The aim of liver resection surgery is to successfully remove part of the liver, most usually because of the presence of a tumour. For liver tumour resection, it is important to achieve clear margins, but also leaving an adequate future liver remnant in terms of volume and quality, adequate blood inflow and outflow, and adequate bile drainage. To compromise on margins may result in tumour recurrence but to compromise on any of the other aspects will be associated with catastrophe due to post-operative liver failure, which can result in death. Liver resection techniques continue to advance rapidly, with improved immediate safety and long-term outcomes. Thus, liver resection should only be performed in expert centres.

Liver resection patients are at risk of postoperative liver insufficiency if the liver remnant is small or otherwise inadequate. One way to combat this is consideration of pre-operative portal vein embolization (PVE), which increases both future liver remnant volume and function.

The use of ultrasonic dissection or alternative appropriate liver tissue dissection techniques reduces blood loss and post-operative bile leakage by allowing identification of significant structures during liver resection surgery. During the parenchymal transection, these vessels and ducts are divided and clipped or ligated. There are many new technologies available to make liver surgery as safe as possible.

In patients with extensive liver disease and a potentially too small future liver remnant, multi stage resection strategies offer the chance for potential cure. These concepts use the unique feature of the liver to regenerate. Existing approaches for multi- stage liver resections are the classical two-stage hepatectomy approach and the more recently described ALPPS (Associating Liver Partition and Portal vein ligation for Staged hepatectomy). As well as clearing the future liver remnant of tumours, the classical two-stage approach contains portal vein ligation or portal vein embolization of the diseased side in the first step followed by resection in the second step. The second step normally takes place after 4-8 weeks after the initial treatment. On the contrary, part of the first step in ALPPS besides portal vein ligation is liver transection. This additional element triggers an acceleration of liver growth permitting the second step within 7-14 days.

Outcomes for liver surgery are almost entirely tumour specific: biological factors are of more impact than surgical technique. Having said that, surgeon and centre effect data is accumulating: liver resection should only be done in expert centres in order to optimise immediate outcomes and to reduce complication rates and blood transfusion, both of which affect cancer specific survival.