What is the step-by-step process for hepatic resection?

Step-by-Step Guide for Hepatic Resection

Hepatic resection must be performed by specialized hepatobiliary surgeons in centers with expertise, following a systematic approach that ensures complete tumor removal while preserving adequate functioning liver volume.

Preoperative Assessment

Imaging and Staging

• Perform contrast-enhanced CT scan of abdomen and pelvis with maximum 5mm collimation 1
• Complete chest CT or chest X-ray to assess for pulmonary metastases 1
• For colorectal liver metastases, perform CT of chest, abdomen, and pelvis 1
• Consider PET scan and laparoscopy for high-risk patients (T4 perforated tumors, apical node involvement) 1
• Avoid biopsy of hepatic lesions without discussion with hepatobiliary unit 1

Liver Function Assessment

• Conduct multi-parametric assessment of liver function including:
  • Laboratory tests: Child-Pugh score, MELD, ALBI grade 1, 2
  • Indocyanine green retention test (ICG R15) 2
  • Volumetric assessment of future liver remnant (FLR) 1

Resectability Criteria

• Aim to remove all macroscopic disease with clear margins 1
• Ensure sufficient functioning liver remains (minimum one-third of standard liver volume or at least two segments) 1
• Assess ability to achieve R0 resection (negative margins) 1
• Perioperative mortality should be <3% and morbidity <20% 1

Optimization Strategies for Small Future Liver Remnant

• Portal vein embolization (PVE): Induces 40-60% FLR growth in 6 weeks 1
• Two-stage hepatectomy with portal vein ligation (PVL): 30-43% FLR growth in 6 weeks 1
• ALPPS (Associating Liver Partition and Portal vein ligation for Staged hepatectomy): Fastest growth (up to 80% in 1 week) 1

Preoperative Optimization

• Nutritional screening and supplementation for 7-14 days before surgery if malnourished 3
• Smoking cessation at least 4 weeks before surgery 3
• Alcohol cessation 4-8 weeks before surgery for heavy drinkers 3
• Prehabilitation for 4-6 weeks if possible 3

Intraoperative Procedure

Preparation and Positioning

• Administer single-dose intravenous antibiotics within 60 minutes before incision 3
• Prepare skin with chlorhexidine-alcoholic solution 3
• Position patient supine with arms extended

Incision and Exposure

• Tailor incision to patient's anatomy and tumor location 3
• Avoid Mercedes-type incision due to higher risk of incisional hernia 3
• Consider laparoscopic approach for appropriate cases (left lateral sectionectomy, anterior segment lesions) 3

Exploration

• Perform thorough abdominal exploration to confirm resectability
• Exclude extrahepatic disease
• Use intraoperative ultrasound to confirm tumor location and relationship to vascular structures

Vascular Control

• Consider temporary inflow occlusion (Pringle maneuver) to reduce blood loss
• Maintain low central venous pressure during resection 3
• Use balanced crystalloids rather than 0.9% saline or colloids 3

Parenchymal Transection

1. Mark resection line on liver surface based on intraoperative ultrasound findings
2. Divide liver capsule using electrocautery
3. Perform parenchymal transection using appropriate technique (CUSA, harmonic scalpel, clamp-crushing)
4. Identify, ligate, and divide intrahepatic vessels and bile ducts
5. Maintain hemostasis throughout procedure
6. Achieve negative margins (R0 resection) 1

Closure

• Ensure meticulous hemostasis
• Avoid routine prophylactic drainage after hepatectomy without biliary reconstruction 3
• Close abdomen in layers

Postoperative Management

Immediate Care

• Monitor vital signs, fluid balance, and laboratory parameters daily 3
• Start low molecular weight heparin and use intermittent pneumatic compression devices 3
• Implement early mobilization from the morning after surgery 3
• Maintain normothermia 3

Pain Management

• Use multimodal analgesia with judicious intravenous opiates 3
• Consider thoracic epidural analgesia for open surgery 3

Nutrition and Mobilization

• Implement early oral intake with normal diet from day one 3
• Avoid routine nasogastric tube placement 3
• Begin early mobilization protocol 3

Monitoring for Complications

• Monitor liver function tests (ALT, AST, bilirubin, albumin, INR) daily 3
• Maintain normoglycemia (<8.3 mmol/L) with insulin therapy 3
• Apply "50-50 criteria" on postoperative day 5 to predict mortality risk 3
• Use ultrasound with Doppler to assess vascular patency if complications suspected 3
• Consider hepatology consultation for persistent liver function test elevation beyond 7 days 3

Special Considerations

Colorectal Liver Metastases

• Ensure primary colorectal cancer has been resected for cure (R0) 1
• Verify no unresectable extrahepatic disease is present 1
• Consider synchronous or staged approach for resectable primary and metastatic disease 1

Borderline Resectable Disease

• Refer to regional hepatobiliary unit for discussion 1
• Consider portal vein embolization, two-stage hepatectomy, or ALPPS 1
• Re-evaluate for resection after 2 months of preoperative chemotherapy and every 2 months thereafter for potentially convertible disease 1

Cirrhotic Patients

• More stringent assessment of liver function required 3
• Higher FLR volume needed (>35% for mild disease) 1
• Consider ALICE grade to stratify postoperative prognosis in Child-Pugh A patients 4

Common Pitfalls to Avoid

• Underestimating extent of liver disease
• Inadequate future liver remnant volume assessment
• Failure to recognize portal hypertension
• Excessive blood loss during parenchymal transection
• Bile leaks from unrecognized biliary injuries
• Hepatotoxic medications in the postoperative period 3