Hepatectomy


Hepatectomy is the surgical resection of the liver. While the term is often employed for the removal of the liver from a liver transplant donor, this article will focus on partial resections of hepatic tissue and hepatoportoenterostomy.

History

The first hepatectomies were reported by Dr. Ichio Honjo of in 1949, and Dr. Jean-Louis Lortat-Jacob of France in 1952. In the latter case, the patient was a 58-year-old woman diagnosed with colorectal cancer 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, hepatic hemangioma and focal nodular hyperplasia. The most common malignant neoplasms 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. Partial hepatectomies are also performed to remove a portion of a liver from a live donor for transplantation.

Technique

A hepatectomy is considered a major surgery done under general anesthesia. Access is accomplished by laparotomy, typically by a bilateral subcostal incision, possibly with midline extension. An anterior approach, one of the most innovative, is made simpler by the liver hanging maneuver.
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 ; 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.
The Pringle manoeuvre is usually performed during a hepatectomy to minimize blood loss - however this can lead to reperfusion injury in the liver due to Ischemia.

Complications

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.

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.
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 in order to minimize blood loss.

Etymology

The word "hepatectomy" is derived from Greek. In Greek liver is hepar and -ectomy comes from the Greek ektomē, "to remove."