Hepatectomy
Encyclopedia
Hepatectomy consists on the surgical resection of the liver
. While the term is often employed for the removal of the liver from a liver transplant recipient, this article will focus on partial resections of hepatic tissue.
) in 1949, and Jean-Louis Lortat-Jacob in 1952, the patient being a 58-year-old woman diagnosed with colorectal cancer
which had metastasized to the liver.
Benign neoplasms include hepatocellular adenoma
, hepatic hemangioma
and focal nodular hyperplasia
.
The most common malignant neoplasms (cancers) of the liver are metastases; those arising from colorectal cancer are among the most common, and the most amenable to surgical resection. The most common primary malignant tumour of the liver is the hepatocellular carcinoma
.
Hepatectomy may also be the procedure of choice to treat intrahepatic gallstones or parasitic cysts of the liver.
, typically by a bilateral subcostal ("chevron") incision, possibly with midline extension (Calne or "Mercedes-Benz" incision).
Hepatectomies may be anatomic, i.e. the lines of resection match the limits of one or more functional segments of the liver as defined by the Couinaud classification (cf. liver#Functional anatomy); or they may be non-anatomic, irregular or "wedge" hepatectomies.
Anatomic resections are generally preferred because of the smaller risk of bleeding and biliary fistula; however, non-anatomic resections can be performed safely as well in selected cases.
For details on the variety of anatomic hepatectomies and the specific nomenclature, cf. the International Hepato-Pancreatico-Biliary Association (IHPBA) Terminology for Liver Resections
is the most feared technical complication and may be grounds for urgent reoperation. Biliary fistula
is also a possible complication, albeit one more amenable to nonsurgical management. Pulmonary complications such as atelectasis
and pleural effusion
are commonplace, and dangerous in patients with underlying lung disease. Infection
is relatively rare.
Liver failure
poses a significant hazard to patients with underlying hepatic disease; this is a major deterrent in the surgical resection of hepatocellular carcinoma in patients with cirrhosis
. It is also a problem, to a lesser degree, in patients with previous hepatectomies (e.g. repeat resections for reincident colorectal cancer
metastases).
For optimal results, combination treatment with systemic or regionally infused chemo or biological therapy should be considered. Prior to surgery, cytotoxic agents such as oxaliplatin given systemically for colorectal metastasis, or chemoembolization for hepatocellular carcinoma can significantly decrease the size of the tumor bulk, allowing then for resections which would remove a segment or wedge portion of the liver only. These procedures can also be aided by application of liver clamp (Lin or Chu liver clamp; Pilling no.604113-61995) in order to minimize blood loss.
Liver
The liver is a vital organ present in vertebrates and some other animals. It has a wide range of functions, including detoxification, protein synthesis, and production of biochemicals necessary for digestion...
. While the term is often employed for the removal of the liver from a liver transplant recipient, this article will focus on partial resections of hepatic tissue.
History
The first hepatectomy was reported by Ichio honjo (Kyoto UniversityKyoto University
, or is a national university located in Kyoto, Japan. It is the second oldest Japanese university, and formerly one of Japan's Imperial Universities.- History :...
) in 1949, and Jean-Louis Lortat-Jacob in 1952, the patient being a 58-year-old woman diagnosed with colorectal cancer
Colorectal cancer
Colorectal cancer, commonly known as bowel cancer, is a cancer caused by uncontrolled cell growth , in the colon, rectum, or vermiform appendix. Colorectal cancer is clinically distinct from anal cancer, which affects the anus....
which had metastasized to the liver.
Indications
Most hepatectomies are performed for the treatment of hepatic neoplasms, both benign or malignant.Benign neoplasms include hepatocellular adenoma
Hepatocellular adenoma
Hepatocellular adenoma, also hepatic adenoma, or rarely hepadenoma, is an uncommon benign liver tumor which is associated with the use of hormonal contraception with a high estrogen content...
, hepatic hemangioma
Hemangioma
A hemangioma of infancy is a benign self-involuting tumor of endothelial cells, the cells that line blood vessels. It usually appears during the first weeks of life and sometimes resolves by age 10. In more severe case hemangioma may have permanency, if not treated by a physician...
and focal nodular hyperplasia
Focal nodular hyperplasia
Focal nodular hyperplasia is a benign tumour of the liver , which is the second most prevalent tumour of the liver . It is usually asymptomatic, rarely grows or bleeds, and has no malignant potential...
.
The most common malignant neoplasms (cancers) of the liver are metastases; those arising from colorectal cancer are among the most common, and the most amenable to surgical resection. The most common primary malignant tumour of the liver is the hepatocellular carcinoma
Hepatocellular carcinoma
Hepatocellular carcinoma is the most common type of liver cancer. Most cases of HCC are secondary to either a viral hepatitide infection or cirrhosis .Compared to other cancers, HCC is quite a rare tumor in the United States...
.
Hepatectomy may also be the procedure of choice to treat intrahepatic gallstones or parasitic cysts of the liver.
Technique
Access is accomplished by laparotomyLaparotomy
A laparotomy is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity. It is also known as coeliotomy.- Terminology :...
, typically by a bilateral subcostal ("chevron") incision, possibly with midline extension (Calne or "Mercedes-Benz" incision).
Hepatectomies may be anatomic, i.e. the lines of resection match the limits of one or more functional segments of the liver as defined by the Couinaud classification (cf. liver#Functional anatomy); or they may be non-anatomic, irregular or "wedge" hepatectomies.
Anatomic resections are generally preferred because of the smaller risk of bleeding and biliary fistula; however, non-anatomic resections can be performed safely as well in selected cases.
For details on the variety of anatomic hepatectomies and the specific nomenclature, cf. the International Hepato-Pancreatico-Biliary Association (IHPBA) Terminology for Liver Resections
Complications
BleedingBleeding
Bleeding, technically known as hemorrhaging or haemorrhaging is the loss of blood or blood escape from the circulatory system...
is the most feared technical complication and may be grounds for urgent reoperation. Biliary fistula
Fistula
In medicine, a fistula is an abnormal connection or passageway between two epithelium-lined organs or vessels that normally do not connect. It is generally a disease condition, but a fistula may be surgically created for therapeutic reasons.-Locations:Fistulas can develop in various parts of the...
is also a possible complication, albeit one more amenable to nonsurgical management. Pulmonary complications such as atelectasis
Atelectasis
Atelectasis is defined as the collapse or closure of alveoli resulting in reduced or absent gas exchange. It may affect part or all of one lung. It is a condition where the alveoli are deflated, as distinct from pulmonary consolidation.It is a very common finding in chest x-rays and other...
and pleural effusion
Pleural effusion
Pleural effusion is excess fluid that accumulates between the two pleural layers, the fluid-filled space that surrounds the lungs. Excessive amounts of such fluid can impair breathing by limiting the expansion of the lungs during ventilation.-Pathophysiology:...
are commonplace, and dangerous in patients with underlying lung disease. Infection
Infection
An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...
is relatively rare.
Liver failure
Liver failure
Acute liver failure is the appearance of severe complications rapidly after the first signs of liver disease , and indicates that the liver has sustained severe damage . The complications are hepatic encephalopathy and impaired protein synthesis...
poses a significant hazard to patients with underlying hepatic disease; this is a major deterrent in the surgical resection of hepatocellular carcinoma in patients with cirrhosis
Cirrhosis
Cirrhosis is a consequence of chronic liver disease characterized by replacement of liver tissue by fibrosis, scar tissue and regenerative nodules , leading to loss of liver function...
. It is also a problem, to a lesser degree, in patients with previous hepatectomies (e.g. repeat resections for reincident colorectal cancer
Colorectal cancer
Colorectal cancer, commonly known as bowel cancer, is a cancer caused by uncontrolled cell growth , in the colon, rectum, or vermiform appendix. Colorectal cancer is clinically distinct from anal cancer, which affects the anus....
metastases).
Results
Liver surgery is safe when performed by experienced surgeons with appropriate technological and institutional support. As with most major surgical procedures, there is a marked tendency towards optimal results at the hands of surgeons with high caseloads in selected centres (typically cancer centres and transplantation centres).For optimal results, combination treatment with systemic or regionally infused chemo or biological therapy should be considered. Prior to surgery, cytotoxic agents such as oxaliplatin given systemically for colorectal metastasis, or chemoembolization for hepatocellular carcinoma can significantly decrease the size of the tumor bulk, allowing then for resections which would remove a segment or wedge portion of the liver only. These procedures can also be aided by application of liver clamp (Lin or Chu liver clamp; Pilling no.604113-61995) in order to minimize blood loss.