Hepatectomy - Types, Indications, Procedure, and Complications

What Is Hepatectomy?

The surgery to remove all or part of the liver is called Hepatectomy or Liver resection. It can be a partial or complete Hepatectomy depending upon the portion removed. 'Hepat' refers to the liver, and 'ectomy' refers to removal.

Why Is the Liver an Essential Organ?

The liver is the largest internal organ in the body, located in the upper right portion of the abdomen. A yellow-green fluid called bile is produced by the liver that helps in digestion. The other vital functions of the liver are:

• It helps convert excess glucose to glycogen which can later be used as glucose when needed.

• Iron is stored in the liver that is used for the production of hemoglobin.

• Helps synthesize fibrinogen and clotting factors II, V, VII, IX, X, XI, and XII needed for coagulation (blood clotting).

• Takes part in detoxification.

• Resists the infection by increasing immunity.

• Removes the excess bilirubin from the body failing, which gets accumulates in the eyes and skin, seen as yellow pigmentation (e.g., Jaundice)

The factors mentioned above are some of the important functions. It plays a major role in the metabolism of protein, fat, and carbohydrate, which are essential to our body in providing energy. Since it has a central role in many vital processes, any dysfunction in the liver will lead to the failure of various mechanisms in our body.

When Is a Hepatectomy Required?

Liver resection is done for the following reasons,

• Cancer or a benign tumor (non-cancerous) in the liver.

• Formation of Secondary cancer in the liver, wherein the primary origin is from a different organ.

• Presence of bile stones in the liver.

• Liver failure, acute or chronic, requires complete removal followed by its transplantation.

• Parasites like tapeworms can cause cystic disease in the liver. Fluid-filled swellings are called cysts. This condition is called hydatid cyst disease.

• Large hemangiomas ( blood-filled cavities) in the symptomatic liver are also removed.

• Any liver disorders present from birth (congenital condition).

Apart from these conditions, there are situations where a healthy liver is removed from a living donor for transplantation.

What Are the Investigations to Be Done Before the Surgery?

For a proper diagnosis and to find out the severity of the condition, the following investigations are performed:

• CT scan to find out the extent of the disease.

• An MRI scan is done to visualize the relationship of major hepatic veins to the diseased portion.

• Ultrasound helps visualize the tumor size and the degree of involvement. It also helps in differentiating between a tumor and a cystic mass.

• Duplex ultrasound also shows the relation of the hepatic vessels to the tumor.

• CT Angiography is rarely used to know information regarding vascular invasion.

• A preoperative liver biopsy may also be performed for a proper treatment plan.

What Are the Types of Hepatectomy?

Before performing the surgery, a clear understanding of the anatomy of the liver is essential. The umbilical fissure divides the liver into the right and left lobes. The liver has eight segments and thousands of small lobules. These lobules are connected to the small duct followed by the larger duct to form the common hepatic duct that transports the bile to the gall bladder and duodenum.

• Anatomic resection is a procedure where the tumor and the associated veins are removed.

• Non-anatomic resection is when the tumor and its margin are removed, and a major portion of the liver is left behind.

• Two-stage liver resection is performed when the whole tumor mass is difficult or harmful to be removed in one operation. A few weeks later, the liver regenerates, and the second surgery removes the remaining diseased portion. This ensures that enough liver is left in place and not removed fully.

The liver resection procedure is named after the portion being removed.

• Right hepatectomy or Hemi-Hepatectomy involves removing segments five to eight.

• Left hepatectomy or Hemi-hepatectomy involves removing segments two to four.

• Removal of the right lobe (right Lobectomy) includes removing segments four to eight and sometimes segment one.

• Removal of the left lobe (left Lobectomy) includes removing segments two and three.

• Extended left lobectomy is another procedure where segments two, three, four, five, eight, and sometimes segment one are removed.

What Are the Steps Involved in Hepatectomy?

Various techniques are available for hepatectomy. The most common are the open and the laparoscopic method.

1. The patient is advised not to have food or drinks 6 to 8 hours before the operation. General anesthesia is given to make the patient unconscious and not feel any pain during the procedure.

2. In open surgery, a long incision is made in the middle of the abdomen, and the liver is mobilized.

3. The portion affected is identified and removed carefully without damaging the surrounding blood vessels and the bile duct.

4. An ultrasonic surgical aspirator, laser, or diathermy is used to cut the diseased part of the liver.

5. If the surrounding organs are also affected by the disease, they are removed simultaneously.

6. After successful completion of the surgery, sutures are placed to close the site of operation.

What Is Laparoscopic Hepatectomy?

A laparoscope is used for the surgery. A small incision is made on the abdomen to introduce a camera; if required, additional incisions can be made for the instruments to pass through. Laparoscopic surgery is preferred as it is painless, causes less blood loss, and a faster recovery. If any complications occur during laparoscopic operation, it can be converted to open surgery.

What Are the Postoperative Instructions to Be Followed?

• About 24-48 hours post-surgery, the patient is in the intensive care unit under a ventilator to keep the vitals stable. IV (intravenous)fluids, a draining tube for urine, and a nasogastric tube is attached.

• Liver function tests are performed to check if it is normal.

• From 3 to10 days, the ventilator and the draining tubes are removed once the flatus is passed and the condition is stable.

• The patient is shifted to a general ward and under painkillers.

• The sutures are removed two weeks after surgery.

• All necessary drugs prescribed should be consumed regularly by the patient after discharge.

• Post-discharge, stay hydrated and do gentle exercises like walking.

What Are the Complications of Hepatectomy?

Any surgery has complications associated with it if not performed correctly.

• Damage to the surrounding organs.

• Excessive bleeding.

• Jaundice may develop due to excess bile not being removed by the liver.

• Infection at the incision site can be venous-catheter-related.

• Ascites can occur due to the accumulation of fluid in the abdomen.

• Pleural effusion occurs due to the accumulation of fluid in the pleural space.

• Bile leakage into the abdomen.

• Liver failure.

• Kidney failure.

• Pulmonary embolism is wherein a blood clot reaches the lung.

• Complications related to general anesthesia, like a chest infection.

What Are the Alternative Treatment Options Available?

Other than surgery, the alternate treatment options include:

• Chemotherapy.

• Microwave ablation.

• Selective internal radiation therapy.

• Stereotactic body radiotherapy.

• Portal vein embolisation.

Conclusion:

Hepatectomy is a procedure on the liver, a vital organ in our body. Various complications that occur during or after the procedure is managed effectively at the right time. Even if the whole liver is removed, a transplant from a donor can be done to increase the patient's survival. Only a professional with good expertise is recommended to perform this surgery for a successful outcome.