Operative Techniques in Liver Resection
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Contents:
The liver serves many critical functions including metabolism of drugs and toxins, removing degradation products of normal body metabolism for example clearance of ammonia and bilirubin from the blood , and synthesis of many important proteins and enzymes such as factors necessary for blood to clot. Blood enters the liver from two channels, the hepatic artery and the portal vein, bringing nutrients and oxygen to liver cells, also known as hepatocytes, and bile ducts. Blood leaves the liver via the hepatic veins which drain into the inferior vena cava which immediately enters the heart.
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The liver makes bile, a liquid that helps dissolve fat and eliminate metabolic waste and toxins via the intestine. Each hepatocyte creates bile and excretes it into microscopic channels that join to form bile ducts. Like tributaries joining to form a river, the bile ducts join to form a single "hepatic duct" that brings bile into the intestine.
Liver Anatomy and Function The liver is a vital organ, meaning that one cannot live without it. Clinical Team Nancy L. Ascher, M. Transplant Surgeon Carlos U. Corvera, M. Preoperative selective portal vein embolization PVE is an effective means of inducing ipsilateral atrophy and contralateral hypertrophy of the liver remnant in these patients, thus allowing safe resection without postoperative liver failure.
Liver Resection
The portal vein is usually accessed percutaneously via a transhepatic route through tumour-free liver under ultrasound and fluoroscopic guidance. Adam et al. This strategy is usually applied to multinodular bilobar metastases. The first-stage resection is intended to remove the highest possible number of tumour lesions. This is followed by a liver regeneration period. During this period the patient is usually treated with chemotherapy to limit disease growth.
It is recommended that this chemotherapy should start 3 weeks after surgery so that it does not interfere with initial regeneration and continue for 2—3 months, when a further set of assessment tests are performed in order to evaluate the patient for the second curative stage. The second stage is only performed if it is potentially curative and only if enough parenchymal hypertrophy has occurred to reduce the risk of postoperative liver failure. Furthermore, in order for the patient to be eligible for two-stage hepatectomy, the tumour should be downstaged or stabilized by initial neoadjuvant chemotherapy.
The objective of this technique is to avoid post-hepatectomy liver failure. Inferior vena cava IVC involvement can often be dealt with by simple venous side-clamping, but in more extensive cases hepatic vascular exclusion and veno-venous bypass may be required.
Operative Techniques in Liver Resection | Lunan Yan | Springer
IVC resection accounts for 4. Tumours involving all the major hepatic veins with or without IVC invasion, and particularly tumours involving the hepatocaval confluence and needing IVC replacement, continue to pose a surgical challenge. In situ hypothermic perfusion and ex vivo resection offer a potential lifeline for this group. For this purpose, the portal triad structures and the IVC are clamped and cooling is achieved by infusion of a preservation solution into the portal vein or hepatic artery. The IVC is clamped above and below the liver and the infrahepatic IVC is incised above the clamp, from where the venous effluent is actively sucked to prevent body cooling.
In the ex vivo method the liver resection is carried out on the bench and the liver is then reimplanted. Liver transplant techniques, including veno-venous bypass, are usually required in these types of case. Patients with liver-only metastasis who are not candidates for liver resection may be offered one of the in situ destruction methods such as cryotherapy or radiofrequency ablation RFA. These techniques can be used on their own or as an adjunct to surgery.
These techniques may be used through a laparotomy incision, laparoscopy port or percutaneously. RFA has been more widely adopted. One of the limitations of these techniques is the size of the liver lesion. If RFA is applied incorrectly, it may cause peripheral burns in the vicinity of the necessary external electrical earthing plates.
It includes preoperative assessment, hepatic vascular occlusion, live parenchyma transection, various liver resection techniques, liver transplantation, ex situ ex. This book presents the latest knowledge in liver resection. It includes preoperative assessment, hepatic vascular occlusion, live parenchyma transection, various.
However, it has a significantly lower survival rate than surgical resection alone. However, there may be a place for this modality in recurrent CRLM after hepatectomy. New randomized trials are needed with inclusion of newer agents including oxaliplatin or irinotecan. Our current practice is to start all post-hepatectomy patients on a systemic 5-FU-based regimen unless they have received chemotherapy for their primary disease within the previous 12 months.
Perioperative blood loss is a major determinant of operative mortality and morbidity. Our median survival is 51 months.
It describes 21 resection techniques in the same style. The role of robotic surgery in pediatric surgery remains controversial partly because of the lack of pediatric-sized robotic instruments and equipment, the elevated cost and the need for robotic-trained pediatric surgeons. PRETEXT risk factors include invasion of the tumor into one or more hepatic veins abbreviated by the letter V or portal vein P and extrahepatic tumor invasion E , tumor rupture R or multifocality of the tumor F. It should be used at the beginning of the procedure to confirm and precisely locate the tumors, to exclude undetected tumors, and to map the vascular and biliary anatomy. Among the procedures that did not undergo conversion, the blood loss exceeded mL in 24 cases Asian J Urol ; The authors declare that data supporting the findings of this study are available within the article.
Several studies have attempted to define prognostic indicators for patients with CRLM. The stage of primary tumour and volume of liver metastases are the main indicators of outcome.
INTRODUCTION
However, patients with multiple hepatic metastases can achieve long-term survival and the number of metastases should not be used as a contraindication to surgery. Hilar or coeliac lymph node involvement with tumour is associated with adverse outcome, and biopsy of a suspicious lymph node is highly recommended but should not always exclude patients from curative resection.
Synchronous metastases have been presumed to represent a more aggressive tumour and therefore to be associated with lower survival. Clinical scoring systems may be used to predict outcome but not to exclude patients from surgery. We advocate an aggressive follow-up surveillance policy with regular imaging to detect recurrence in these patients.
At this visit, in addition to physical examination, liver function and tumour markers are tested. A return of tumour markers to normal if previously elevated serves to confirm that the goal of resection has been achieved. If they do not return to normal, a meticulous search for treatable tumour should be performed.
Following this postoperative check, patients are seen at 3, 6, 12, 18 and 24 months after surgery, and then annually up to 10 years. During each of these visits liver function and tumour markers are assessed and a CT scan of the chest, abdomen and pelvis is performed. In our practice, colonoscopy is also performed regularly to check for colorectal recurrence. Repeat hepatectomy can provide a significant survival benefit. It is safe and appears to be as effective as initial resection with similar postoperative morbidity and mortality risks. The same indications for primary resection should apply for repeat resection.
Therefore hepatic recurrence should be resected whenever possible. In this series, the interval between initial resection and diagnosis of recurrence appeared to be an important predictor of outcome. This is because patients with a shorter disease-free interval have adverse tumour characteristics and therefore a higher potential for spread and recurrence. These patients should be considered for resection as a good long-term survival can be achieved.
These should be treated with further resection, according to emerging data. Surgical resection is the only hope for patients with liver metastases. Rapid referral and assessment are required to improve outcome. New technologies and neoadjuvant therapies should allow more patients to become candidates for resection. Recent progress in molecular and cell biology has opened the way to novel therapies based on immunotherapy, anti-angiogenesis and gene therapy, but clinical application does not appear to be imminent.
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