Surgical resection is the primary treatment for hepatic malignancies. Resection also may be indicated for a variety of benign lesions, especially those with malignant potential or those that are causing symptoms. The most common malignant tumors include hepatocellular carcinoma, intrahepatic cholangiocarcinoma, and metastatic colorectal cancer. In the Western world, liver metastases are more common than primary liver tumors. A comprehensive evaluation of the overall health status, oncologic appropriateness, and anatomic resectability is required for appropriate patient selection. A lesion is considered resectable if negative margins can be obtained while leaving an adequate amount of functional liver parenchyma with hepatic arterial and portal venous inflow, venous outflow, and biliary drainage. Although the advantages and disadvantages of anatomic versus nonanatomic resection for various tumor types is beyond the scope of this chapter, in general, nonanatomic liver resections are appropriate for peripherally located small liver lesions.
Patients should be assessed for evidence of liver dysfunction, including evaluation of liver function tests, history of hepatitis, alcohol use, and extensive systemic chemotherapy, as well as radiographic evidence of cirrhosis and/or portal hypertension. Nutrition should be optimized. Preoperative antibiotics are given.
A general endotracheal anesthetic is given. Catheters are placed in both arms for replacement of fluid and blood products, if required.
Patients are placed supine on the operating table in a slightly reverse Trendelenburg position.
The skin is prepared over the chest and abdomen down to the pubis. Then a time-out is performed.
An extended or bilateral subcostal incision can provide excellent exposure. Alternatively, a liberal midline incision beginning over the xiphoid may be used.
The peritoneum, the small and large intestines, and the cul-de-sac, mesentery, and omentum are all inspected for evidence of metastases. The liver is carefully inspected and palpated bimanually. In addition, the use of handheld intraoperative ultrasound is mandatory for assessment of tumor location, to rule out the presence of other hepatic tumors, and to evaluate vascular anatomy. Depending on the location of the tumor being excised, the liver should be adequately mobilized. This may involve division of the falciform, coronary, and triangular ligaments. Fixation of the liver with tumor invading into the diaphragm posteriorly complicates the resection and should only be undertaken in experienced hands.
Using a combination of ultrasound and visual inspection, a 1- to 2-cm margin is marked around the peripheral tumor in order to perform a nonanatomic resection (FIGURE 1). Distal to the cautery line and parallel to it, a series of deeply placed chromic mattress sutures on slightly curved large, thin needles is placed in the liver tissue to provide hemostasis ...