The successful local excision of benign liver tumors has fostered a more aggressive surgical approach to the excision of hepatic metastases of colorectal malignancies. During the first 2 or more years after the removal of a colorectal tumor, carcinoembryonic antigen (CEA) levels are measured every 3 months. When the CEA level begins to rise, recurrence must be considered. In the absence of proof of metastasis or recurrence in the rectum, colon, lung, or peritoneal cavity, a search is made for hepatic metastases. Imaging by CT, MRI, or PET scans is performed. Hepatic angiography is usually not necessary and has been replaced by CT or MRI with coronal reconstruction to define regional anatomy. Any evidence of liver metastases requires an evaluation of the number, size, and location of the metastases. It is hoped that none or only one or two solitary metastases will be verified in locations easily accessible to the surgeon. The age and general condition of the patient, as well as the size, number, and locations of metastases, are considered in making a decision to attempt curative resection. Given the sensitivity of modern imaging, “blind” abdominal exploration for rising CEA in the absence of radiographic abnormalities is discouraged. The patient should be fully informed and should participate in making a decision to reoperate. The patient should be made aware that a major portion of the liver may need to be excised. A residual of 20 percent or more of normal liver tissue remaining in the left lobe is essential for survival.
Perioperative antibiotics are given, and any blood deficiency is corrected. Studies should have ruled out metastases to the lungs and general peritoneal cavity insofar as possible.
A general anesthetic that has minimal potential to harm the liver is required.
The patient is placed flat on the table in a modest reverse Trendelenburg position.
The skin of the thorax and abdomen is prepared, since the incision may extend from over the lower sternum to below the umbilicus. Appropriate catheters are placed to provide ready access for the administration of blood, fluids, and medications and central venous pressures should be monitored.
A long right subcostal incision that extends across the midline as a bilateral subcostal incision with a midline extension to the xiphoid provides excellent exposure. Alternatively, a liberal midline incision extending from well above the xiphoid to or below the umbilicus ...