What is the recommended technique for liver resection?

Technique of Liver Resection

Primary Surgical Goal and Approach

The fundamental aim of liver resection is to remove all macroscopic disease with clear (negative) margins while preserving sufficient functioning liver—approximately one-third of standard liver volume or a minimum of two segments. 1

Minimally Invasive vs. Open Approach

Laparoscopic liver resection should be the preferred approach when clinically appropriate and performed by trained hepatobiliary surgeons, as it reduces postoperative length of stay, complication rates, blood loss, and improves recovery. 1

Specific Indications for Laparoscopic Approach:

• Left lateral sectionectomy (now considered standard practice) 1
• Resections of lesions in anterior segments 1
• Minor liver resections for both benign and malignant tumors 1
• Major hepatectomies in trained teams, showing lower bleeding and shorter hospital stays 1

When Open Surgery is Necessary:

• Complex resections requiring extensive vascular reconstruction 2
• Lesions near major vessels where laparoscopic control is unsafe 3
• Surgeon inexperience with advanced laparoscopic techniques 1

Surgical Incision for Open Resection

The choice of incision depends on patient body habitus and tumor location, but Mercedes-type incision should be avoided due to higher incisional hernia risk. 1

Acceptable Incision Options:

• Right subcostal incision with midline extension 1
• Inverted "L" incision (modified Makuuchi) 1
• Incision tailored to lesion location 1

Vascular Control Techniques

Low central venous pressure (CVP below 5 cmH₂O) should be maintained during hepatic parenchymal transection to minimize blood loss. 1

Inflow Control:

• Pringle maneuver (intermittent portal triad clamping) remains the standard method for vascular control 4
• Allows ischemic demarcation of segmental boundaries 4
• Combined with selective vascular clamping when appropriate 2

Parenchymal Transection Methods

Multiple techniques are available for parenchymal transection, with ultrasonic dissection and clamp-crushing being most commonly employed. 5, 4

Primary Transection Techniques:

• Ultrasonic dissector (CUSA): Allows precise dissection with identification of vascular and biliary structures 5, 4
• Clamp-crushing technique: Traditional method with proven safety 5
• Vascular staplers: For major vascular structures 5

Role of Intraoperative Ultrasound:

• Mandatory for identifying tumor location and vascular anatomy 5
• Guides resection planes and identifies additional lesions 5

Perioperative Technical Considerations

Prophylactic Measures NOT Recommended:

• Routine nasogastric intubation (increases pulmonary complications and should be avoided) 1
• Routine abdominal drainage after hepatectomy without biliary reconstruction (evidence is non-conclusive, but routine use not indicated) 1

Essential Perioperative Measures:

• Maintain normothermia (>36°C) using multimodal temperature management 1
• Single-dose antibiotic prophylaxis (e.g., cefazolin) within 60 minutes before incision 1
• Skin preparation with chlorhexidine-alcoholic solution (superior to povidone-iodine) 1

Analgesia Strategy

For open liver surgery, multimodal analgesia is recommended over routine thoracic epidural analgesia (TEA), as TEA can cause hypotension and mobility issues detrimental to rapid recovery. 1

Recommended Analgesic Approach:

• Continuous local anesthetic wound infiltration or intrathecal opiates combined with multimodal analgesia 1
• Transversus abdominis plane (TAP) blocks as supplement to standard analgesia 1
• For laparoscopic surgery: No regional anesthesia needed; multimodal analgesia with judicious IV opiates provides adequate pain control 1

Anatomic vs. Non-Anatomic Resection

The decision between anatomic and non-anatomic resection should prioritize achieving R0 (margin-negative) resection while preserving adequate liver function. 1

• Anatomic resections follow segmental boundaries defined by vascular territories 2, 4
• Non-anatomic (wedge) resections appropriate for peripheral lesions when clear margins achievable 2, 3

Special Surgical Strategies

For Borderline Resectable Disease:

• Portal vein embolization to increase future liver remnant 1
• Two-stage hepatectomy for bilobar disease 1
• Combination of resection and ablation 1

For Intrahepatic Cholangiocarcinoma:

• Portal lymphadenectomy is mandatory at time of hepatectomy for staging 6

Critical Pitfalls to Avoid

• Never perform biopsy of hepatic lesions without discussion with regional hepatobiliary unit 1
• Avoid Mercedes incision due to unacceptably high hernia rates 1
• Do not perform synchronous colorectal and liver resection routinely (except for small, accessible metastases after discussion with liver center) 1
• Avoid robotic liver resection outside clinical trials (no proven advantage in ERAS protocols) 1