What are the techniques of liver resection?

Techniques of Liver Resection

Primary Surgical Approaches

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 compared to open surgery. 1

Laparoscopic Indications and Applications

• Left lateral sectionectomy is now considered standard practice for laparoscopic approach 1
• Resections of lesions in anterior segments are suitable for laparoscopic technique 1
• Minor liver resections for both benign and malignant tumors can be performed laparoscopically 1
• Major hepatectomies can be performed laparoscopically in trained teams, demonstrating lower bleeding and shorter hospital stays 1
• Laparoscopic anatomical hepatectomy using indocyanine green fluorescence imaging facilitates precise anatomic resection 2
• Robotic liver resection should be avoided outside clinical trials, as there is no proven advantage in enhanced recovery protocols 1

Open Surgical Incisions

When open resection is necessary, incision selection depends on patient body habitus and tumor location 1:

• Mercedes-type incision should be avoided due to unacceptably high incisional hernia risk 1
• Right subcostal incision with midline extension is an acceptable option 1
• Inverted "L" incision (modified Makuuchi) is an acceptable option 1
• Incision tailored to lesion location is recommended 1

Parenchymal Transection Techniques

Ultrasonic Dissection

• Ultrasonic dissection (USD) significantly reduces intraoperative blood loss compared to finger fracture technique 3
• USD reduces the number of intraoperative transfusions required (p = 0.002) 3
• USD decreases the incidence of postoperative hepatic bleeding (p = 0.03) 3
• USD reduces postoperative length of stay (p = 0.009) 3
• Liver-related complications occur in 29.8% with USD versus 44.4% with finger fracture technique 3

Clamp Crushing Technique

• Clamp crushing remains one of the two most frequently used techniques for liver transection 4
• This technique is widely employed alongside ultrasonic dissection in contemporary practice 4

Intraoperative Ultrasound Guidance

Intraoperative ultrasound (IOUS) should be routinely employed in all patients undergoing liver resection, as it provides critical information that could obviate oncologically useless resections. 3

Diagnostic Capabilities

• IOUS is the most accurate diagnostic technique for detecting focal liver lesions, with 99% sensitivity and 98% specificity 2, 3
• IOUS detects lesions missed in preoperative imaging or during visual inspection 2
• IOUS identifies tumor vessel invasion and satellite lesions 2
• IOUS changes preoperative surgical plans in 17.2% of cases: 8 abandoned and 3 revised 3

Surgical Guidance Applications

• IOUS is mandatory for planning surgical strategy and deciding the exact resection plane 5
• IOUS guides parenchymal transection to respect surrounding vessels and biliary structures 5
• IOUS should be carried out by the surgeon himself for optimal surgical guidance 5
• Laparoscopic ultrasound (LUS) enables real-time observation of internal liver structures to avoid main blood vessels 6
• LUS detects tumor boundaries and extent of tumor thrombi during minimally invasive surgery 6
• Contrast-enhanced intraoperative ultrasound and real-time virtual sonography enhance laparoscopic surgical performance 6

Vascular Control and Hemostasis

Central Venous Pressure Management

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

Pringle Maneuver

• Hepatic pedicle clamping (Pringle maneuver) serves as a fundamental initial maneuver for vascular control 7
• This technique is particularly important in trauma settings and during significant hemorrhage 7

Use of Vascular Staplers

• Vascular staplers represent an important advance contributing to improved perioperative outcomes 4
• These devices facilitate safe division of major hepatic vessels during resection 4

Anatomic Versus Non-Anatomic Resection

Anatomic Resection Indications

Anatomic resection is recommended when the tumor invades segmental portal branches or has satellite lesions, as it is associated with better recurrence-free survival than non-anatomic resection. 2

Non-Anatomic Resection

• In unstable patients and during damage control surgery, anatomic resection should be avoided 2
• Non-anatomic resection is safer and easier in emergency settings 2
• For staged liver procedures, either anatomic or non-anatomic resections may be safely performed by experienced surgeons 2

Perioperative Management

Preoperative Assessment

Indications for resection should be based on multi-parametric composite assessment of liver function, portal hypertension, extent of hepatectomy, expected volume of future liver remnant, performance status and comorbidities to ensure perioperative mortality is lower than 3% and morbidity is lower than 20%. 2

Risk assessment should include 2:

• Volumetry of future liver remnant
• Indocyanine green liver retention test
• Laboratory value-based tests (Child-Pugh, MELD, ALBI, or aspartate aminotransferase-to-platelet ratio index)
• For major hepatectomy, scintigraphy should be considered 2

Future Liver Remnant Requirements

• The minimum safe amount of remaining liver parenchyma ranges from 20% to 40% of total liver volume 2
• In patients with normal liver, the safe limit ranges from 20% to 30% future remnant liver of total liver volume 8
• In patients with injured liver (cirrhosis, cholestasis, steatosis), higher remnant volumes are required 8
• Portal vein embolization can safely induce hypertrophy of the remnant liver without causing liver dysfunction 2, 1

Antibiotic Prophylaxis and Skin Preparation

• Single-dose antibiotic prophylaxis (e.g., cefazolin) should be administered within 60 minutes before incision 1
• Skin preparation with chlorhexidine-alcoholic solution is superior to povidone-iodine 1

Temperature Management

• Maintaining normothermia (>36°C) using multimodal temperature management is essential 1

Nasogastric Intubation

Routine nasogastric intubation is not recommended as it increases pulmonary complications. 1

Abdominal Drainage

Routine abdominal drainage after hepatectomy without biliary reconstruction is not indicated. 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

Alternative approaches include 1:

• Continuous local anesthetic wound infiltration combined with multimodal analgesia
• Intrathecal opiates combined with multimodal analgesia
• Transversus abdominis plane (TAP) blocks as a supplement to standard analgesia

Advanced Surgical Strategies

Portal Vein Embolization

• Portal vein embolization can increase future liver remnant in borderline resectable disease 1
• This technique is safer than combining liver partition and portal vein ligation for staged hepatectomy (ALPPS), which is associated with high morbidity and mortality 2

Two-Stage Hepatectomy

• Two-stage hepatectomy can be used for bilobar disease 1
• This approach allows for liver regeneration between procedures 1

Combination Strategies

• Combination of resection and ablation can be used for borderline resectable disease 1
• Thermal ablative technologies have been adapted for liver transection 4
• Radiofrequency ablation poses competition to liver resection but also expands indications for patients with bilobar tumors 4

Critical Pitfalls to Avoid

Biopsy of hepatic lesions should not be performed without discussion with a regional hepatobiliary unit. 1

Additional contraindications include 1:

• Mercedes incision should be avoided due to unacceptably high hernia rates
• Synchronous colorectal and liver resection should not be performed routinely, except for small, accessible metastases after discussion with a liver center
• Robotic liver resection should be avoided outside clinical trials

Patient Selection Criteria

Child-Pugh Classification

• Child-Pugh class A is a good indication for partial liver resection 2
• Child-Pugh class C is not indicated due to the risk of liver failure after resection 2
• Varices, ascites, and portal hypertensive gastropathy serve as surrogate indices of portal hypertension 2

Contraindications

• Impaired hepatic function and significant portal hypertension are related to poor tolerability of resection 2
• Regional lymph node metastases are associated with decreased survival 2

Oncologic Outcomes

Survival and Recurrence

• The 5-year survival rate after resection for hepatocellular carcinoma is 50% to 68% in experienced centers 2
• The 5-year recurrence rate is approximately 50% to 70% 2
• Small HCC (<2 cm) without microvascular invasion is associated with a 5-year recurrence rate of 50% to 60% 2
• Recurrence follows a bimodal pattern: first peak around 1 year and second peak 4 to 5 years after resection 2

Risk Factors for Recurrence

Risk factors include 2:

• Macro and/or microvascular invasion
• Multifocal tumors
• High alpha fetoprotein levels preoperatively