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A
B
C
M anagement: M alignant P rimary Liver N eoplasms ............................................................................. 189
Types of hepatic resection
FIGURE 6.20. Hepatic resections. The type of liver resection performed depends on the type and extent of the pathology.
(Adapted with permission from Schwartz SI, ed. Principles of
Surgery. 6th ed. New York: McGraw-Hill, Inc., Health Professions
Division, 1994.)
requiring dissection along the main interlobar fissure in
the right and left segmental fissure.
Hepatic lobectomy. In hepatic lobectomy, all liver tissue
to one side of the main interlobar fissure is removed, either
all tissue to the left in a left hepatic lobectomy or all tissue to
the right in a right hepatic lobectomy. In either case, full
mobilization of the liver is required (see below).
Trisegmentectomy. Also known as extended right hepatectomy, trisegmentectomy involves removing the right
lobe as well as the medial segment of the left lobe. This
procedure can be considered only when the hepatic
parenchyma in the left lateral segment is normal.
ECHNIQUE OF LIVER RESECTION Several steps are
T
involved in performing liver resection:
1. Incision. Either a long midline incision or a large
right subcostal incision can be used. If necessary, either
can be extended into medial sternotomy (Figure 6.21).
2. Mobilization. Key to major liver resection is adequate mobilization of the liver by dividing ligamentous
attachments. The type of resection to be performed determines the degree of mobilization required (Figure 6.22).
3. Portal dissection. Dissection of the hepatoduodenal
ligament allows accurate application of a noncrushing
clamp, should the Pringle maneuver be required at any
time in the course of the operation (Figure 6.23).
4. Intraoperative ultrasound. Intraoperative ultrasound
provides precise identification of the size of the tumor and
its relationship to major ducts and vessels, particularly the
hepatic veins. Hence, resection margins and avoidance of
the unintended hepatic venous injury can be planned
before embarking on the parenchymal dissection.
mentectomy, lobectomy, and trisegmentectomy (Figure
6.20). The selection of one approach over another depends
on the type and extent of the pathology. The usual
operations performed for HCC are hepatic lobectomy or
trisegmentectomy:
Wedge resection. Benign tumors superficially located in
the liver are amenable to wedge resection that involves
removal of less than one segment of liver. The procedure
usually requires little mobilization of the liver and no
anatomic plane dissection. Resection is usually accomplished with electrocautery and bleeding controlled
by heavy mattress sutures using #1 absorbable suture.
Segmentectomy. This operation requires anatomic
plane dissection along the lines of Couinaud. The simplest
segmental resection is left lateral segmentectomy, also
known as left hepatic lobectomy. An alternate procedure,
left medial segmentectomy, is a more complicated approach
FIGURE 6.21. Surgical incision for liver resection. A modified
chevron incision is often used. If necessary, the incision can be
extended up into the chest, either as a median sternotomy or
right lateral thoracotomy.
190 ................................................................................................................................................. Liver
A
B
C
D
FIGURE 6.22. Mobilization of the liver. The extent to which the liver must be mobilized depends on
the type of resection to be performed. (A–C) Trisegmentectomy requires complete liver mobilization,
which involves division of the triangular and coronary ligaments, the ligamentum teres and the falciform ligament. (D) The liver is then rotated to the left and posterior attachments are dissected to
expose the inferior vena cava and hepatic veins as they enter it. (Adapted from Blumgart LH, ed.
Surgery of the Liver and Biliary Tract. 3rd ed. London: W.B. Saunders Company Ltd.; 2000.)
M anagement: M alignant P rimary Liver N eoplasms ............................................................................. 191
A
B
FIGURE 6.23. Portal dissection. (A) The hepatic artery, portal vein and bile duct are dissected in the
hepatoduodenal ligament. (B) Dissection is carried to the liver parenchyma so that the right and left
divisions of these structures can be identified and, if possible, encircled individually with tape before
subsequent division between ligatures.
192 ................................................................................................................................................. Liver
A
B
C
FIGURE 6.24. Parenchymal and hepatic vein dissection. (A) The relevant vascular structures in the
porta hepatis are clamped and the liver capsule incised along the surgical plane with scalpel or electrocautery. The surgical plane is developed by blunt dissection using the scalpel handle or by finger
fracture technique. Vessels and bile ductal structures are clamped as they are encountered and individually ligated (B). At the conclusion of the hepatic parenchymal division, the right, middle, and left
hepatic veins can be isolated and the appropriate vein divided between vascular clamps and (C) the
proximal end closed with continuous suture. (Adapted from Warren KW, Jenkins RL, Steele GD, Jr.
Atlas of Surgery of the Liver, Pancreas and Biliary Tract. Norwalk, CT.: Appleton & Lange; 1991.)
5. Parenchymal dissection (Figure 6.24). Several other
techniques may be used to aid in parenchymal dissection,
including electrocautery, water-jet dissection, and ultrasonic dissector. The procedure described above uses the
technique of selective inflow control. Total inflow control by
the Pringle maneuver may also be used but requires inflow
restoration for several minutes every half hour to avoid
warm ischemic injury to the liver.
6. Hepatic vein division. The intrahepatic dissection is
continued posteriorly until the major hepatic veins are
identified. Those draining the portion of the liver to be
removed are doubly ligated in continuity and divided; care
must be taken not to damage the venous drainage of the
portion of the liver that is to be left behind. Now, the
portion of liver to be excised is completely freed and
removed. At this point, any clamps previously applied on
M anagement: M alignant P rimary Liver N eoplasms ............................................................................. 193
the vessels in the porta hepatis are unclamped and the cut
surface of the liver examined for any bleeding. Bleeders
are individually controlled and ligated. When all bleeding
has stopped, the raw surface of liver is covered with
omentum.
Another technique used for major hepatic resection
is total vascular isolation of the liver, in which total
inflow is controlled and the inferior vena cava is clamped
below and above the liver. Total vascular isolation is
safe for up to 60 minutes and is appropriate only for
technically demanding cases in which hepatic vein dissection is complicated by pathology in that region of the
liver.
7. Drainage. Two large closed sump drains are inserted,
one posteriorly in the right subphrenic space and the other
more anteriorly, close to the porta hepatis.
194 ................................................................................................................................................. Liver
POSTOPERATIVE COMPLICATIONS
1. Functional complications. Patients who undergo 50%
or more resection may develop metabolic complications:
a. Hypoglycemia may occur when the remaining liver
cannot provide adequate glycogenolysis. It can be prevented by administering 10% glucose solution intravenously and frequently monitoring blood glucose levels.
b. Hypoalbuminemia may require administration of
albumin but is rarely serious.
c. Coagulopathy may occur because of inadequate
synthesis of prothrombin, fibrinogen, and factor ix. Prothrombin time should be monitored and vitamin K administered intravenously if prothrombin time is prolonged.
d. Hyperbilirubinemia and AST and LDH elevation
may occur but are temporary and resolve in 3 to 5 days.
2. Postoperative hemorrhage. The incidence of hemorrhage is significantly reduced by ensuring meticulous
hemostatis during the operation. Occasionally, significant
postoperative bleeding requires control angiographically
or with reoperation.
3. Sepsis. Subphrenic or perihepatic abscess may
develop, causing fever and leukocytosis. These abscesses
are usually successfully treated by percutaneous drainage.
4. Stress ulcer. Upper gastrointestinal bleeding from
stress ulcer is now very rare because of the prophylactic
use of histamine H
2
-receptor antagonists and antacids.
Total Hepatectomy and Liver Transplantation
Liver transplantation is emerging as a viable option in
patients with lesions of less than 5 cm in size, three or
fewer lesions, and with associated cirrhosis, which renders
partial hepatectomy risky. Recently reported studies indicate 5-year survival of 19% to 70%.
16
Favorable prognostic factors are tumor size of 5 cm or less, unicentric tumors,
absence of vascular invasions, presence of pseudocapsulae,
and low histologic grade. In one report by Mazzaferro et
al.,
17
the 4-year survival for single nodules less than 5 cm
or fewer than three nodules each less than 3cm in size was
92%.
Palliative Therapy
When curative resection or transplantation are not
possible a number of palliative therapeutic modalities are
available.
1. Transarterial chemoembolization with doxorubicin
may be helpful because the blood supply of HCC is
derived from the hepatic artery. A 1-year survival rate
of 40% to 50% has been achieved.
18
2. Hepatic artery ligation can be performed to produce
tumor necrosis and may be combined with
chemoembolization.
3. Percutaneous ethanol injection may lead to partial
regression.
4. Cryosurgery with liquid nitrogen may help shrink the
tumor.
5. Systemic chemotherapy is particularly useful in children with hepatoblastoma, in which subsequent resection might achieve very high cure rates of 80% to
90%.
19
CHOLANGIOCARCINOMA
The incidence of cholangiocarcinoma in patients is about
5% of the incidence of HCC. Its incidence is much higher
in areas of the world where chronic infestation of liver
flukes (Clonorchis sinensis and Opisthorchis viverrini)
occurs in the biliary tree (i.e., Thailand, Hong Kong, and
Canton Province of China). Other conditions associated
with cholangiocarcinoma are sclerosing cholangitis and
a
1
-antitrypsin deficiency. While the symptoms and signs
are similar to those of HCC, jaundice is more common
and more severe. The picture is one of progressive obstructive jaundice.
Investigations
Liver function studies show a mixture of obstructive and
hepatocellular abnormality. AFP is infrequently elevated.
CT and ultrasound show the tumor. Hepatic angiography
reveals a tumor that is not hypervascular,and the branches
of the hepatic artery are diminished in number and size
because of the associated fibrosis that occurs. Endoscopic
retrograde cholangiopancreatography (ERCP) or transhepatic cholangiography are useful localizing techniques.
Treatment
Resection is rarely possible because the lesion is diagnosed
late. Similarly, the tumor is unresponsive to radiotherapy
or chemotherapy. Resection of hilar tumors is discussed
separately in Chapter 7.
METASTATIC NEOPLASMS OF
THE LIVER
The liver is a common site for metastatic cancer. Metastatic cancer accounts for 95% of all neoplasms in the liver.
The liver represents the first hematogenous filter of tumor
cells spread from abdominal organs via the portal vein.
Thus, it is a frequent site of metastasis from the pancreas,
stomach, and small and large intestine. Secondary spread
to the liver can also occur via the systemic circulation, and
common primary tumors that metastasize there are breast,
lung, kidney, ovary, and uterus.
The clinical picture is usually dominated by that of
the primary neoplasm. Since liver metastasis represents
advanced malignancy, patients frequently exhibit weight
loss, anorexia, and fatigue. The liver lesions, however, may
be painful and become palpable on abdominal examination. Jaundice is a rare symptom.
Investigations
Abnormal liver function is seen in more than 50% of
patients. Elevated alkaline phosphatase is more common
than elevated bilirubin levels. CT, ultrasound, or MRI will
show the lesion. MRI is the superior imaging modality
because it provides information about venous invasion.
Needle biopsy can be obtained under CT or ultrasound
guidance, at laparoscopy, or laparotomy.
Treatment
In ninety percent of patients with liver metastases, the
disease will have spread to other organs. Only nonsurgical
palliative therapy can be offered to these patients. In
some, presence of multiple lesions precludes surgical treatment, and in others, the known aggressive biological
behavior of the primary makes consideration of surgical
treatment of liver secondaries futile. Hence, secondaries from the esophagus, stomach, pancreas, lung, and
usually breast and liver are not considered for surgical
extirpation.
Patients with colorectal primary neoplasms have been
shown to benefit most from resection of hepatic metastasis. Even here, fewer than 5% of patients are candidates for
liver resection. Patients who should be considered for
removal of hepatic secondaries include those with:
1. No extrahepatic disease.
2. A single metastatic tumor or not more than three or
four lesions.
3. A time lapse of 1 year from colectomy or proctectomy.
4. Duke B stage of primary tumor.
Other patients who may be candidates for resection of
hepatic metastases are those with carcinoid syndrome and
other neuroendocrine tumors. Hepatic resection may be
limited to wedge resection or may involve hepatic lobectomy (see Figure 6.20).
Outcome
Some 25% of patients with colorectal cancer who meet the
criteria for resection of hepatic metastasis will live 5 years
after resection.
20
Patients who undergo palliative liver
resection for the carcinoid syndrome or for other malignant neuroendocrine tumors (e.g., VIPoma, insulinoma)
experience significant improvement of their symptoms
and are more successfully managed postoperatively pharmacologically with octreotide.
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198 ...........................................................................................................................................................
The biliary tree and liver develop from a diverticulum of
the embryonic foregut at approximately 18 days of gestation. Between the fourth and fifth weeks, the diverticulum
consists of a solid cranial portion and a hollow caudal
portion. The solid cranial portion differentiates into the
liver with the development of hepatocytes and intrahepatic bile ducts, while the hollow caudal portion gives rise
to the gallbladder, the extrahepatic bile ducts, and the
ventral pancreas (Figure 7.1).
GALLBLADDER
In the adult, variability in the anatomy of the biliary tree
is more the norm than the exception.The gallbladder (GB)
is a pear-shaped organ (50ml volume) consisting of the
fundus, corpus, infundibulum, and neck, which tapers into
the cystic duct. Its wall is made up of smooth muscle
encased in fibrous tissue. The mucosa is made up of
columnar epithelial cells with tight junctions and microvilli suited for absorption. The cystic duct connects the GB
to the common bile duct (CBD) and contains the spiral
valve of Heuser, which provides a measure of resistance to
outward flow.
COMMON BILE DUCT
The left and right hepatic ducts form the common hepatic
duct. The cystic duct entrance into the common hepatic
7
Biliary Tract
EMBRYOLOGY AND ANATOMY
duct represents the beginning of the CBD, which then runs
inferiorly toward the duodenum in the free edge of the
lesser omentum to the right of the hepatic artery and anterior to the portal vein. The CBD passes behind the first
part of the duodenum and then courses within the pancreas to enter the second part of the duodenum. The CBD
is about 7 cm long and less than 1 cm wide when assessed
intraoperatively with the naked eye or with a choledochogram. When seen by ultrasonography, however,
normal CBD width should be less than 0.7 cm. The
mucosa is cuboidal epithelium, and the wall of the CBD is
fibrous tissue with small amounts of smooth muscle.
CHOLEDOCHAL SPHINCTER COMPLEX
OR SPHINCTER OF ODDI
The entrance of the CBD into the second portion of the
duodenum is oblique and surrounded by the choledochal
sphincter complex, which controls bile flow into the duodenum in a manner that is coordinated with GB contraction. The choledochal sphincter complex or sphincter of
Oddi (Figure 7.2) is composed of several portions:
1. The choledochal sphincter, comprised of a compact
area of circular muscle around the intramural part of
the duct.
2. The pancreatic duct sphincter, present in about onethird of individuals.
Management of biliary tract disease constitutes an important segment of gastrointestinal
surgery. Patients recovering from biliary tract surgery once accounted for a significant
number of inpatients on the surgical wards. The advent of minimally invasive surgery and
advances in both interventional endoscopy and interventional radiology has changed all this.
Following laparoscopic cholecystectomy and endoscopic sphincterotomy and removal of
common duct stones, most patients now are admitted for only 24 to 48 h or need not be
admitted at all. Nonetheless, the incidence of biliary tract surgery has not decreased.
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