Liver Resection: Indications, Procedure, and Complications

What Is Hepatectomy?

Also known as liver resection, it is a procedure designed to remove part (partial hepatectomy) or complete liver (total hepatectomy). It is done in patients with liver diseases and in healthy individuals who are donating for a liver transplant.

The remarkable feature of the liver is that it can grow back to its normal size even after two-thirds of it is removed. Surgeons take advantage of the regeneration aspect of the liver and often perform living donor liver transplantations in patients who have had total hepatectomy.

Who Needs Hepatectomy?

The liver is the largest gland in the body with both endocrine and exocrine functions, the endocrine functions include the secretion of hormones like somatomedin, angiotensinogen, etc., and the exocrine functions of the liver involve the secretion of bile juice which is necessary for digestion. This makes it susceptible to many pathologies. Patients in whom conventional medical therapy does not resolve the underlying disease need hepatectomy.

Below are a few conditions for which the patient will need a liver resection-

• Liver Cancer- They can be of two types; when cancer originates in the liver itself, it is known as primary cancer, and when cancer spreads to the liver from a different organ, it is known as metastatic or secondary cancer.

• Primary Cancer- Hepatocellular carcinoma, cholangiocarcinoma are a few examples.

• Metastatic or Secondary Cancer- Colorectal cancer is an example.

• Liver Tumors- Benign tumors are masses of abnormal tissue that are not life-threatening but can cause pain and risk becoming cancerous. A couple of examples of benign liver tumors are focal nodular hyperplasias and hepatocellular adenomas.

• Hepatolithiasis- It is the medical term for gallstones that form in the bile duct adjacent to the hepatic ducts.

• Parasitic Cysts- Usually seen in a tapeworm infection, the fluid-filled cyst that is formed as a result is known as a hydatid cyst.

• Hemangiomas- These are abnormal growths of the blood vessels supplying the liver, which cause it to enlarge and compress the adjacent organs.

• Acute or Chronic Liver Failure- If the loss of liver function is rapid, it is known as acute, and if it happens over a long period of time, it is known as chronic liver failure. Most commonly seen in hepatitis virus, prolonged use of certain medication, chronic alcoholism.

• Congenital Condition- Biliary atresia, neonatal hepatitis syndrome are a few conditions present at birth that will need hepatectomy.

Along with the above-mentioned pathological conditions, a surgeon will also perform a partial hepatectomy on healthy individuals to transplant it in patients who have had total hepatectomy.

How Does the Doctor Diagnose a Liver Disease?

History and investigations play a major role in diagnosing a liver dysfunction; abdominal examination may show signs of abdominal distension due to an enlarged liver but does not confirm the condition.

Based on the initial diagnosis, the clinician will request any of the below tests for a definitive diagnosis-

• Blood Tests- The routine blood test will measure hemoglobin, white and red blood cells, platelets, etc., but there are specific blood tests that are done to diagnose liver diseases. They are-

• Alpha- Fetoprotein Blood Test- It is a protein and is found in high amounts in unborns (that is normal), and after birth, it goes down. If it is present in the blood of the patient who has a solid tumor, that indicates the tumor has become malignant (cancerous).

• Liver Function Tests- This is a relatively familiar test that the clinician does to check the functionality of the liver. Specific substances like bilirubin, globulin, alkaline phosphatase help to evaluate liver function.

• Blood Clotting Test- The liver is a storage house for a lot of vitamins and minerals, out of which potassium is one; this mineral plays an important role in forming a blood clot when an injury happens. The longer the body takes to form a clot, the more damaged the liver is. This is measured with a test called prothrombin time.

• Radiology Tests- The usual ultrasound, computed tomographic (CT) scan, and magnetic resonance imaging (MRI) are also done to diagnose liver abnormality, but they are more or less done in a sequence.

The first to be done is an ultrasound. It gives the clinician an understanding of the blood flow, size, and shape of the liver. Liver fibrosis and tumors can be diagnosed using ultrasound.

If the clinician needs further info, an MRI might be requested, which is highly sensitive for liver stenosis and fat. In radiology, the more sensitive the machine, the more accurate the diagnosis is. An MRI can also differentiate between benign and malignant tumors.

Sometimes, the clinician will ask for a positron emission tomography (PET) scan; this gives a three-dimensional image of the liver and, when combined with CT, provides accurate pictures of the liver.

• Angiography- It is an X-ray of the liver but done under a contrast medium- which is a dye injected into an artery. This dye travels to the liver and outlines the extent of the tumor, which is essential before planning surgery.

• Radionuclide Scan- Can be further divided into a bone scan and a radiolabeled meta-iodo benzyl-guanidine (MIBG). Both are not routine tests, but the doctors will ask for them if they suspect the spread of cancer to the bones and visualize carcinoid tumors and neuroblastoma of the liver.

How Is a Hepatectomy Done?

After careful evaluation and meticulous pre-planning, the surgeon will decide on the amount of liver to be removed and the resection technique. The general procedure goes as follows-

• If the surgeon is performing open surgery, after anesthesia, a long incision is made across the abdomen to open the abdominal cavity. The underlying ligaments that hold the liver in place are carefully mobilized.

• The surgeon will identify the section of the liver that needs to be resected and then isolate the associated blood vessels and the ducts, followed by resection of the liver. Different tools are available to resect, for example- ultrasonic surgical aspirator, laser, cautery or diathermy, etc.

• If a laparoscopic hepatectomy is performed, the surgeon will make multiple small incisions through which a laparoscope (an instrument with an in-built camera) is introduced through one and surgical instruments through the others. The laparoscope will be connected to an image-guidance system which will guide the surgeon through the resection.

• Sometimes a planned laparoscopic hepatectomy might be changed to open surgery if any complications arise.

Based on the underlying pathology and the amount of liver transplanted, the surgeon might do different types of resections-

• Minor or wedge resection when only the superficial lesion along with the surrounding tissue is removed.
• Major resection is when the entire right or left lobe of the liver is resected.
• Multiple resections involve the removal of multiple tumors at the same time.
• Two-stage resection is when the resection is done in two stages on account of the complexity of the underlying tumors.

• Apart from the open and laparoscopic hepatectomies, a few techniques for liver resection are parenchymal transection, crushing technique, ultrasonic dissection, radio-frequency assisted liver resection, water-jet dissection, vascular stapler technique, and Loma Linda approach for liver resections.

What Are the Complications of Hepatectomy?

Hepatectomy is a widely performed surgical procedure, in spite of being a challenging one due to its unique structure and vital functions. A few of the noted complications are-

• Post-Operative Hemorrhage- It is commonly seen after hepatectomy and can be due to coagulation disorder, gastrointestinal tract bleeding, biliary tract, and intraperitoneal hemorrhage.

• Bile- It is a liquid that aids in digestion and is produced from the liver. After hepatectomy, it can leak into the abdomen due to damage to the bile duct.

• Infection- This may occur at the site of the incision or can be catheter-related.

• Ascites- It is defined as the swelling of the abdominal cavity due to the accumulation of fluid and may be seen due to the damage to the underlying lymphatic vessels.

• Pleural Effusion- It is the accumulation of fluid in the lungs that happens if the diaphragm gets injured during the surgery.

• Liver Failure- This can happen if the remaining liver does not function well.

Hepatectomy is an excellent treatment for patients suffering from cancer; with proper post-operative care, many patients recover completely with the best survival rate.

Conclusion-

Hepatectomy takes around four to eight weeks to recover, good nutrition plays an important role in a speedy recovery, and pain is common after the surgery and can be managed with medication. The initial regeneration happens in a few weeks, but it takes several months for complete regeneration. If open surgery is performed, the patient will be left with a “L” shaped scar measuring around 6 to 12 inches. This is a considerably lower price to pay for life-saving surgery.