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INDICATIONS

Surgical resection is the primary treatment for hepatic malignancies. Resection may be indicated for a variety of benign and malignant liver tumors. A comprehensive evaluation of the overall health status, oncologic appropriateness, and anatomic resectability is critical to appropriate patient selection. In general, 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 left hepatectomy is indicated for tumors that involve the proximal left inflow and/or outflow in which lesser resections (e.g., nonanatomic, monosegmentectomy, and left lateral sectionectomy) are not possible. Attention must be paid to the future liver remnant. The remaining right 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. In reality, for most patients without cirrhosis, the remaining right liver volume should be sufficient to safely proceed with left hepatectomy.

PREOPERATIVE PREPARATION

Patients should be assessed for evidence of liver dysfunction, including evaluation of liver function tests, history of hepatitis, alcohol use, or extensive systemic chemotherapy, as well as radiographic evidence of cirrhosis and/or portal hypertension. Nutrition should be optimized. Antibiotics are given, and cross-matched blood is made available.

ANESTHESIA

General anesthesia with low central venous pressure is recommended.

OPERATIVE PREPARATION

The skin is prepped over the entire abdomen and chest. Bilateral large-bore intravenous lines 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 (CVP) is helpful. Resistance to large-volume resuscitation so as to maintain a CVP of less than 6 mm Hg greatly reduces blood loss. Once parenchymal transection is complete and large bleeding points addressed, fluid resuscitation can ensure. Continuous arterial pressure monitoring is recommended. Then a time-out is performed.

INCISION AND EXPOSURE

Either a liberal bilateral subcostal incision or a midline incision from over the xiphoid to below the umbilicus is made.

DETAILS OF THE PROCEDURE

The abdominal cavity is carefully inspected for evidence of extrahepatic disease. Any suspicious areas are excised for frozen-section examination. The liver surface is visually inspected and manually palpated for evidence of tumors and liver quality. Comprehensive liver ultrasound is then performed to document the location of the tumor(s) as well as their relation to the vasculature (FIGURE 1).

The liver is mobilized by dividing the falciform ligament as well as the left coronary and triangular ligaments (FIGURE 2). While not mandatory, a cholecystectomy is typically performed prior to proceeding ...

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