Chapter 31

1. Understand extrahepatic and intrahepatic liver anatomy and physiology.

2. Understand hepatic molecular signaling pathways.

3. Know the features of acute liver failure and cirrhosis, along with treatment options.

4. Formulate a plan for the work-up of an incidental liver lesion.

5. Understand the current treatment options for primary and metastatic liver cancer.

6. Describe the nomenclature and steps in performing an anatomic right or left hepatic resection.

The ancient Greek myth of Prometheus reminds us that the liver is the only organ that regenerates. According to Greek mythology, Zeus was furious with the titan Prometheus because he gave fire to the mortals. In return, Zeus chained Prometheus to Mount Caucasus and sent his giant eagle to eat his liver during the day, only to have it regenerate at night. Although this is an exaggeration, the principles are correct that after hepatic resection, the remnant liver will hypertrophy over weeks to months to regain most of its original liver mass. It is interesting to note that the ancient Greeks seem to have been aware of this fact, because the Greek word for the liver, hēpar, derives from the verb hēpaomai, which means “mend” or “repair.” Hence hēpar roughly translates as “repairable.”1 The importance of the liver dates back to even biblical times, for the Babylonians (c. 2000 b.c.) considered the liver to be the seat of the soul. There are scattered reports of liver surgery for battlefield injuries, but the first recorded elective hepatic resection was done in 1888 in Germany by Langenbuch. There followed reports of liver resections in the United States (Tiffany, 1890) and Europe (Lucke, 1891), as well as the first large series of hepatic resections by Keen in 1899.2,3 In 1908, Pringle described in Annals of Surgery the “arrest of hepatic hemorrhage due to trauma” by compression of the porta hepatis, a maneuver that now bears his name.4 Possibly due to the potential for massive hemorrhage during liver surgery, very little progress in surgical techniques was recorded for the next half-century. Work by Rex, Cantlie, and others laid the groundwork for experimental and clinical reports in the 1950s by Couinaud, Hjortsjo, Healey, Lortat-Jacob, and Starzl.5,6 These seminal contributions paved the way for the modern era of hepatic resection surgery.

The liver is the largest organ in the body, weighing approximately 1500 g. It sits in the right upper abdominal cavity beneath the diaphragm and is protected by the rib cage. It is reddish brown and is surrounded by a fibrous sheath known as Glisson’s capsule. The liver is held in place by several ligaments (Fig. 31-1). The round ligament is the remnant of the obliterated umbilical vein and enters the left liver hilum at the front edge of the falciform ligament. The falciform ligament separates the left lateral and left ...

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