What are the recommended methods for liver resection?

Methods of Liver Resection

Laparoscopic liver resection should be the preferred approach when clinically appropriate and performed by trained hepatobiliary surgeons, as it reduces postoperative complications, hospital stay, blood loss, and improves quality of life compared to open surgery. 1

Minimally Invasive Approach: The Current Standard

Minor Liver Resections

• Laparoscopic resection is strongly recommended for minor resections (≤2 segments), particularly for lesions in anterolateral and superficial locations, as RCTs demonstrate lower morbidity, shorter hospital stays, reduced morphine consumption, and better quality of life compared to open surgery. 1
• Left lateral sectionectomy via laparoscopy has become standard practice and should be performed routinely by experienced hepatobiliary surgeons. 1, 2
• Resections of lesions in anterior segments are particularly suitable for the laparoscopic approach. 1, 2

Major Hepatectomies

• Major hepatectomies (≥3 segments) can be safely performed laparoscopically in trained teams, with meta-analyses and propensity score studies showing lower bleeding, shorter hospital stays, and reduced postoperative morbidity for both left and right hemihepatectomies. 1
• While RCTs for major laparoscopic hepatectomies are lacking, the evidence from high-volume European centers supports their use in experienced hands. 1
• Complex procedures including staged hepatectomies show not only short-term advantages but also shorter delays between surgery and chemotherapy restart. 1

Robotic Approach: Limited Current Role

• Robotic liver resection should be reserved for clinical trials only, as there is currently no proven advantage over laparoscopic techniques and RCT data are lacking. 1, 2
• The robotic approach may facilitate certain complex procedures but remains more costly without demonstrated superior clinical outcomes. 3

Open Surgical Approach: When and How

Incision Selection

• The choice of incision depends on patient body habitus and tumor location, but Mercedes-type incision must be avoided due to unacceptably high incisional hernia risk. 1, 2
• Acceptable alternatives include right subcostal incision with midline extension or inverted "L" incision (modified Makuuchi). 2

Vascular Control During Transection

• Maintain low central venous pressure (CVP below 5 cmH₂O) during hepatic parenchymal transection to minimize blood loss, using restrictive fluid management and close hemodynamic monitoring. 1, 2, 4
• The Glissonian approach enables safe portal pedicle control without extensive dissection, reducing risk from anatomical variations and facilitating vascular stapling. 4

Essential Perioperative Technical Elements

Prophylaxis and Preparation

• Administer single-dose antibiotic prophylaxis (such as cefazolin) within 60 minutes before skin incision; extending antibiotics into the postoperative period provides no benefit. 1, 2
• Use chlorhexidine-alcoholic solution for skin preparation rather than povidone-iodine, as it significantly reduces surgical site infection rates. 1, 2

Intraoperative Management

• Maintain perioperative normothermia (>36°C) using multimodal temperature management to reduce blood loss, transfusion requirements, and cardiac complications. 1, 2
• Do not use routine prophylactic nasogastric intubation, as it increases pulmonary complications and delays return of bowel function. 1, 2

Drainage Considerations

• Routine prophylactic abdominal drainage after hepatectomy without biliary reconstruction is not indicated, though the evidence remains non-conclusive and surgeon discretion is reasonable. 1, 2

Analgesia Strategy for Open Resection

For open liver surgery, use multimodal analgesia rather than routine thoracic epidural analgesia (TEA), as TEA can cause hypotension requiring vasopressors and complicate fluid management, while providing only marginally better pain control. 1, 2

Recommended Alternatives

• Continuous local anesthetic wound infiltration catheters combined with multimodal analgesia provide effective pain control without hemodynamic instability. 2
• Intrathecal opiates combined with multimodal analgesia show similar results to TEA but with lower likelihood of postoperative hypotension and reduced length of stay. 1, 2
• Transversus abdominis plane (TAP) blocks can supplement standard analgesia regimens. 2

Special Surgical Strategies for Complex Cases

• Portal vein embolization can increase future liver remnant in patients with borderline resectable disease and insufficient remnant volume. 2
• Two-stage hepatectomy is an option for bilobar disease requiring extensive resection. 2
• Combination of resection and ablation can be employed for borderline resectable disease with multiple lesions. 2

Critical Pitfalls to Avoid

• Never perform biopsy of hepatic lesions without discussion with a regional hepatobiliary unit, as this can compromise subsequent surgical options. 2
• Avoid Mercedes incision due to unacceptably high hernia rates documented in multiple studies. 1, 2
• Do not routinely perform synchronous colorectal and liver resection except for small, accessible metastases after discussion with a liver center. 2

Patient Selection Considerations

For Cirrhotic Patients

• Laparoscopic resection is particularly beneficial in cirrhotic patients with small HCC (<2 cm), where it competes favorably with thermal ablation while avoiding collateral vessel ligation and reducing postoperative adhesions. 1, 5
• Clinically significant portal hypertension (HVPG >10 mmHg) and Child-Pugh class B cirrhosis are not absolute contraindications for limited resections with minimally invasive techniques, though risks must be carefully weighed. 1

Surgical Goal

• The fundamental aim is to remove all macroscopic disease with clear margins while preserving sufficient functioning liver (approximately one-third of standard liver volume or minimum of two segments). 2