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INDICATIONS

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There are a number of indications for removal of all or part of the left lobe of the liver. The most common indication is evidence of one or more metastases from a previously resected colorectal cancer. The diagnosis is supported by a rising carcinoembryonic antigen (CEA) level during repeated postoperative evaluations. Liver function studies are performed and evaluated. Imaging scans verify the location, size, and probable number of metastases. The initial operative notes and the pathologist’s report should be carefully studied for evidence of metastasis at the time of the initial operation. Studies to identify abdominal and lung metastases, including colonoscopy, must be negative. A period of delay may be chosen to reassess the trend of the CEA levels and CT scans, as well as to evaluate the risk of a second-look procedure in an elderly patient. PET/CT to identify occult intra- and extrahepatic disease should be undertaken.

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PREOPERATIVE PREPARATION

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An informative discussion with the patient and the family is part of the preoperative preparation. Antibiotics are given and cross-matched blood is made available.

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ANESTHESIA

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A general anesthetic agent with the minimum of potential for injuring the liver is administered.

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OPERATIVE PREPARATION

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The skin is prepared over the entire abdomen and the chest. Bilateral large bore IVs are mandatory in anticipation of substantial blood loss. Central venous catheters should be considered standard for major liver surgery and intraoperative monitoring of central venous pressure is helpful. Resistance to large volume resuscitation so as to maintain a CVP <6 greatly reduces blood loss. Once parenchymal transection is complete and large bleeding points addressed, aggressive fluid resuscitation should be undertaken. Continuous arterial pressure monitoring is mandatory.

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INCISION AND EXPOSURE

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Various incisions have been used, but the bilateral subcostal incision provides excellent exposure. Extra assistants may be needed, unless special self-retaining retractors are available to retract the left costal margin. Alternatively, a long midline incision that can be extended can be used.

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DETAILS OF PROCEDURE

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The abdominal cavity is carefully inspected for evidence of pinpoint or large metastases in the pouch of Douglas, colon, mesentery, small bowel, omentum, or peritoneum. Any suspicious areas are excised for frozen section examination. The liver surface is inspected for evidence of metastases, followed by bimanual palpation to verify the diagnostic procedures suggesting metastasis in the left lobe of the liver. Metastases deep within the left lobe rather than superficially are best evaluated with a hand-held ultrasound probe. Metastases readily seen on the surface of the left lobe can be locally excised with a 1-cm margin. Metastases near the inferior liver margin can be removed by wedge incision.

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The line of transection is outlined extending into the bed of the gallbladder. The left hepatic vein is the major vessel in the dome of the left lobe (figure 1). When the tumor is located deep in the left lobe, the left lobe is mobilized by division of the falciform ...

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