Overview

Over a comparatively short period, partial hepatectomy has been transformed from a high-risk, resource-intensive procedure to one that is now performed routinely, often removing a large amount of liver tissue and/or combined with resection of other organs, with the expectation of an uncomplicated postoperative course and recovery in most patients. Although reports of hepatic resection date back to antiquity (see the Introduction to this text), it was Lortat-Jacob’s report of an elective right hepatectomy for malignancy in 1952 that ushered in the modern era of hepatobiliary surgery, suddenly creating new possibilities to treat a wide range of disorders (Lortat-Jacob & Robert, 1952); however, from that point forward, the initial experience with hepatic resection was far from promising. In 1977, James Foster and Berman published a multiinstitutional summary of hepatic resection surgery in the United States composed of 168 resections performed over the preceding 14 years. This report documented a marked and unacceptably high operative mortality rate, which was due primarily to two often related factors: inability to control hemorrhage in the operating room and postoperative liver failure (Foster & Berman, 1977).

Since that time, progressive advances in many different areas have led to the improvement in outcome required for hepatic resection to take its place as a mainstream procedure. These advances have come on several fronts, and it is therefore difficult to single out one for special mention. Perhaps the most noteworthy gain has been a greater appreciation of the segmental anatomy of the liver and the willingness and ability of surgeons to pursue resections based on anatomic principles (see Chapters 1B, 90B, and 92). This particular element has had a profound effect, not only improving the results of major resections but spurring greater use of parenchyma-sparing sublobar resections, such as posterior or anterior sectoral hepatectomy or central hepatectomy, rather than right or extended right hepatectomy, respectively. Equally important, this change fundamentally altered the approach to patients who require bilobar resections.

A number of studies have documented this trend over time, and it has been associated with, and is probably responsible for, decreases in blood loss and transfusion rates, reductions in hospital stays, and decreases in operative mortality (Fan et al, 1999; Jarnagin et al, 2002; Belghiti et al, 2000).

Practice changes in other areas, including intraoperative and perioperative management and patient selection, have clearly contributed to the overall improvement in outcomes (see Chapter 22). The use of low central venous pressure (CVP) anesthesia, now widely used, represented a notable change in the previous standard practice of fluid loading prior to resection. Despite concerns of possible risks of air embolization or disturbance of renal function, both unfounded, low-CVP anesthetic management has been shown to reduce blood loss during the resection because of decreased filling pressures and reduced distension of the hepatic veins, and it does so with no significant untoward effects (Cunningham et al, 1994; Melendez et al, 1998).

Beyond the technical aspects of partial hepatectomy, a greater understanding of the impact of resection on the natural history of many diseases, combined with a clearer delineation of perioperative risk, have allowed a much more informed patient-selection process, one that has increasingly targeted resection more effectively to those patients most likely to benefit (see Chapter 49, Chapter 50A, Chapter 50B, Chapter 50C, Chapter 50D, Chapter 79A