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KEY POINTS

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  1. When operating on the liver, gallbladder, pancreas, or ­adjacent organs, recognition of the normal or variant vascular and biliary anatomy is essential to avoiding surgical ­complications.

  2. The liver is the largest gland in the body and performs a diverse spectrum of functions.

  3. Computed tomography and magnetic resonance imaging with contrast enhancement constitute the mainstays for the radiologic evaluation of the liver.

  4. Acute liver failure rapidly progresses to hepatic coma and death even with maximal medical therapy. The only definitive treatment is orthotopic liver transplantation.

  5. Cirrhosis is the end result of chronic hepatic insult, and further deterioration can lead to the development of end-stage liver disease, which carries a high mortality rate.

  6. Acute variceal bleeding should be managed with aggressive resuscitation and prompt endoscopic diagnosis with hemorrhage control. The transjugular intrahepatic portosystemic shunt procedure can be considered for cases refractory to medical treatment.

  7. Common benign lesions of the liver include cysts, hemangiomas, focal nodular hyperplasia, and hepatocellular ­adenomas. In most instances, these lesions can be reliably diagnosed by their characteristic features on imaging.

  8. Many options exist for the treatment of hepatocellular carcinomas, and these cases are best managed by a multidisciplinary liver transplant team.

  9. Surgical resection is the treatment of choice for hilar cholangiocarcinoma. Under a protocol with strict eligibility criteria, patients with unresectable tumors can be considered for liver transplantation following neoadjuvant chemoradiation, with survival rates that compare favorably with the rates for resection.

  10. The resectability of colorectal cancer metastases to the liver is primarily determined by the volume of the future liver remnant and the health of the background liver and not actual tumor number.

  11. Laparoscopic liver resections can be performed safely by experienced surgeons in selected patients and have been shown to produce comparable morbidity and mortality rates to open resections.

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HISTORY OF LIVER SURGERY

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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 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 folklore, 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, h¯epar, derives from the verb h¯epaomai, which means “mend” or “repair.” Hence h¯epar 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 ...

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