Hepatectomy

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CHAPTER 13 Hepatectomy

BACKGROUND

Although once associated with significant morbidity and high mortality rates, improvements in surgical technique, anesthetic management, and postoperative care have made liver resection a viable treatment option for a variety of benign and malignant processes. At centers specializing in hepatobiliary surgery, overall mortality and morbidity rates are now estimated at 1% to 5% and 30% to 40%, respectively.

A variety of liver resections are commonly performed, including limited resections (e.g., tumor enucleation or wedge resection) and anatomic resections (i.e., removal of a segment or lobe of the liver). The extent of hepatic resection undertaken is, in part, dictated by the type of pathology and its anatomic location. Additionally, the choice of operation depends on the patient’s hepatic reserve. Up to 80% of the liver parenchyma can be removed from a normal liver because the remaining segment will hypertrophy and hepatic function will be restored within days to weeks. In the presence of underlying liver disease, however, significantly less liver parenchyma can be safely removed. The Child’s classification and its modifications are commonly used to assess a patient’s hepatic functional reserve (Table 13-1). In patients classified as Child’s class C, hepatic resection should not be attempted because of the very high risk of postoperative liver failure. Even in patients with well-compensated cirrhosis who are classified as Child’s class A, only limited hepatic resection should be performed.

INDICATIONS FOR HEPATECTOMY

There are three primary indications for partial hepatectomy in adults: neoplasm, infection, and to provide a liver lobe for transplantation.

I. Neoplasm: The majority of liver resections in the United States are performed for malignant disease, most commonly for metastatic cancer. Additionally, the increasing burden of hepatocellular carcinoma (HCC) in the United States because of chronic hepatitis C virus infection and cirrhosis has made liver resection and transplantation for HCC more common. In contrast, hepatic resection for cholangiocarcinoma remains relatively uncommon because the majority of patients with this malignancy present with advanced, unresectable disease.

A. Malignant Neoplasms

PREOPERATIVE EVALUATION

The preoperative evaluation for partial hepatectomy focuses on determining: (1) the amount and location of hepatic parenchyma that should be resected and (2) whether the remaining liver will be sufficient to sustain the patient physiologically.

COMPONENTS OF THE PROCEDURE AND APPLIED ANATOMY

Resection Nomenclature

Cantlie’s line divides the liver into the right hemiliver (segments V–VIII) and the left hemiliver (segments II–IV), which are the segments that are commonly resected during right and left hepatectomy, respectively. Resection of the hepatic parenchyma to the left of the falciform ligament (segments II and III) is called left lateral segmentectomy. Resection of the hepatic parenchyma to the right of the falciform ligament (segments IV–VIII) has multiple names, including extended right hepatectomy, right trisegmentectomy, and right lobectomy, depending on which nomenclature system is used (Fig. 13-3 and Box 13-1). Other limited anatomic resections, including specific segmental resections that follow the segmental anatomy of the liver, can be performed as well. During nonanatomic wedge resections, the parenchyma and vessels are divided without consideration of the internal hepatic anatomy. Wedge resections are most commonly used for small peripheral tumors in patients with benign disease or in patients with malignant disease who cannot tolerate a formal lobectomy.

BOX 13-1

Nomenclature of Hepatic Resections

Couinaud (1957) Goldsmith and Woodburne (1957)
Right hepatectomy (segments V, VI, VII, VIII) Right hepatic lobectomy
Left hepatectomy (segments II, III, IV) Left hepatic lobectomy
Right lobectomy* (segments IV, V, VI, VII, VIII) Extended right hepatic lobectomy*
Left lobectomy (segments II, III) Left lateral segmentectomy
Extended left hepatectomy (segments II, III, IV, V, VIII) [see Fig. 13-3B] Extended left lobectomy

* Also referred to as a right trisegmentectomy (Starzl, 1975, 1980).

Also referred to as a left trisegmentectomy (Starzl, 1982).

Data from Blumgart LH [ed]: Surgery of the Liver, Biliary Tract, and Pancreas, 4th ed. Philadelphia, Saunders, 2007.

Incision and Exposure

Inflow and Outflow Control

IV. Total hepatic vascular exclusion is an alternative method by which vascular control is obtained. This technique is performed by clamping the IVC above and below the liver. The hepatic artery and the portal vein are controlled via Pringle’s maneuver (Fig. 13-10). Total vascular exclusion of the liver can be associated with significant hemodynamic changes. Therefore, this procedure is used only in select patients in whom more selective methods of inflow and outflow control are inadequate (e.g., patients with large tumors in close proximity to the major hepatic veins or IVC).

POSTOPERATIVE COURSE

II. Complications