Interest and experience with surgical treatment of the liver has expanded dramatically over the past two decades. The size of the pool of surgeons who routinely perform liver-directed surgery has also increased. These changes and expansion have been fueled by improved description, understanding, and study of segmental liver anatomy and the numerous potential variations in hepatic arterial, portal venous, hepatic venous, and bile duct anatomy. A key example is the description of segmental hepatic anatomy by Couinaud with an appreciation of the vascular anatomy and associations with the eight segments of the liver (Fig. 46A-1).
The junctional division of the liver and the segments according to Couinaud's nomenclature.
As with many other types of potentially complex surgical procedures, operations on the liver now occur more commonly because of enhanced safety. Procedures and techniques have evolved to minimize blood loss which reduces the morbidity related to transfusion of multiple units of blood. Hepatobiliary surgeons can be as idiosyncratic as any other group of surgical specialists; each individual surgeon has his or her own favorite technique or techniques for hepatic transection. The number of possible techniques to perform liver transection safely has grown based on the interest from medical device manufacturers to produce novel equipment to permit liver parenchymal transection while minimizing blood loss. It is not unusual for there to be an array of equipment in the operating room of the modern hepatobiliary surgeon with the goal being to perform the operation with maximum safety and improved patient outcome.
The liver is unusual in the human body as it has a dual blood supply, the portal vein and the hepatic artery. It has been known for almost a 100 years that occlusion of the portal vein and hepatic artery during operation on the liver, be it for a traumatic injury to the liver or for elective resection of a portion of the liver, can reduce blood loss. Advances in our understanding using this technique have led to the realization that inflow occlusion of the hepatic blood supply can be performed safely for carefully controlled periods even in patients with cirrhotic livers. Furthermore, intermittent occlusion followed by brief periods of reperfusion of the liver will increase the total time of inflow occlusion that can be achieved while still successfully limiting blood loss and reducing the risk for ischemic liver injury.
Despite an ever expanding selection of antibiotic agents, pyogenic liver abscess is as common a problem today as it was in the preceding century. If anything, treatment of pyogenic liver abscess with antibiotic therapy is more difficult and has been complicated by the indiscriminate use of antibiotics over the past several decades. Iatrogenic etiologies of liver abscess may have also been increased by the more invasive and aggressive ...