Surgical resection is the primary treatment for hepatic malignancies. Resection may be indicated for a variety of benign and malignant liver tumors. 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 critical to 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.
Formal right hepatectomy is indicated for tumors that involve the proximal right inflow and/or outflow in which lesser resections (nonanatomic, segmentectomy, anterior or posterior sectionectomy) are not possible. Attention must be paid to the future liver remnant. The remaining left liver should comprise at least 20% of standardized total liver volume for patients with normal liver function, 30% in those with compromised liver function (e.g., patients with extensive systemic chemotherapy or hepatic steatosis), and 40%–50% if cirrhosis is present.
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 anesthetic that has minimal potential to harm the liver is required.
Patients are placed flat on the table with the arms extended.
The skin of the thorax and abdomen is prepared because the incision may extend from over the lower sternum to below the umbilicus. Bilateral large-bore intravenous lines are mandatory in anticipation of substantial blood loss. With experienced anesthesiologists, central venous catheters are no longer placed routinely but can be considered in appropriate cases. Avoiding significant intravenous resuscitation to maintain a low central venous pressure is critical to minimize intraoperative blood loss. Once parenchymal transection is complete and hemostasis is ensured, fluid resuscitation can be undertaken. Continuous arterial pressure monitoring is recommended. Then a time-out is performed.
Either a liberal bilateral subcostal incision or a midline incision from over the xiphoid to below the umbilicus is made.
The extent of tumor involvement in the right lobe is verified by inspection, palpation, and intraoperative ultrasound (FIGURE 1). The extent and location of all tumors are noted using ultrasound directly on the liver surface. Understanding the relationship of lesions in question with major vascular structures is essential to minimizing blood loss.
The liver is mobilized by dividing the falciform and ...