Figure 57-18. A,B: Intraoperative ultrasound images of liver demonstrating right hepatic pedicle (RHP), right anterior sector

pedicle (RASP), right posterior sector pedicle (RPSP), left hepatic pedicle (LHP), segment II pedicle (SIIP), segment IV pedicle

(SIVP), segment I (SI), and inferior vena cava (IVC). C,D: Intraoperative ultrasound images of liver demonstrating inferior vena

cava (IVC), right hepatic vein (RHV), middle hepatic vein (MHV), left hepatic vein (LHV), segment I (SI), and a metastatic

gastrointestinal stromal tumor lesion straddling segments IV and V of the liver.

Figure 57-19. Positron emission tomography and computed tomography (PET-CT) scan images of patient in Figure 57-18B and C

with solitary gastrointestinal stromal tumor metastasis straddling segments IV and V. Noncontrast CT images (left). PET images

(center). Fusion images (right).

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Figure 57-20. Computed tomography scan demonstrating segmental anatomy of the liver with cuts through the dome (A), just

above the portal bifurcation (B), and below the portal bifurcation (C).

Table 57-1 Strategies to Predict Hepatic Reserve

ONCOLOGIC CONSIDERATIONS IN HEPATIC RESECTION

The decision of when and whether to operate is often just as important as the technical details of

successfully removing a liver lesion(s) identified in a patient. It is very important to consider the likely

diagnosis in making the decision of whether to operate. For example, a solitary liver lesion presenting

in an elderly patient with a rising carcinoembryonic antigen (CEA) and a recent history of a resected

colon cancer should be treated differently from a young woman with a solitary lesion with radiologic

characteristics of a focal nodular hyperplasia lesion. It is important to consider the biology of the tumor

within the patient. For example, a patient who represents with a solitary hepatic colorectal cancer

metastasis 4 years after resection of the primary tumor will more likely benefit from hepatic resection

than another patient who presents with eight synchronous lesions in the liver at the time of diagnosis of

the primary tumor. It is important to consider whether the goal of resection is curative or palliative. For

example, patients with neuroendocrine tumor metastases of the liver may be debulked of hepatic

metastases, but they are rarely totally eradicated of disease. If the tumor is functional and difficult to

control medically, then there may be a benefit to debulking. Even if the tumor is not functional, some

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evidence indicates that surgical debulking of liver metastases in carefully selected patients may benefit

long-term survival. It is important to exclude other distant extrahepatic disease with a reasonable

number of preoperative tests. For example, before performing hepatic resection for colorectal cancer

metastases, it is often helpful to obtain a PET scan to exclude extrahepatic metastases. This will allow

better selection of patients most likely to benefit from hepatic resection and will allow patients with

previously unsuspected systemic disease to get systemic therapy sooner.

Table 57-2 Child–Pugh Classification

Table 57-3 MELD Score

The comorbid status of the patient is also important. Extended hepatic resections with or without

biliary reconstruction can exert a toll on even very fit patients. It is important to identify patients who

may have difficulties with hepatic regeneration (e.g., those with a history of hepatitis, cirrhosis, or

metabolic disorders). Patients with suspected cardiopulmonary disease should undergo appropriate

preoperative evaluation and treatment before hepatic resection. Finally, other effective treatments and

the optimal sequence of treatments should be considered. For example, in the treatment of

hepatocellular carcinoma the possibilities include liver transplantation, liver resection, radiofrequency

or microwave ablation, transarterial chemoembolization, and systemic chemotherapies. A patient with

limited hepatocellular carcinoma and poor hepatic reserve due to chronic liver disease, cirrhosis, and

portal hypertension is best treated with liver transplant, whereas a patient with normal liver

parenchyma, minimal portal hypertension, and a resectable lesion may be best treated with liver

resection. Additionally, some patients may best be treated with ablative techniques, especially if they

have very small lesions that are easily approached percutaneously. Many patients are treated with a

combination of these modalities. For example, most transplant centers will first treat hepatocellular

carcinoma patients with chemoembolization to provide locoregional control while the patient is

upgraded on the waiting list. Whether the patient is a candidate for liver transplantation or resection,

this combination can give insight into the biology of the disease prior to definitive treatment.

INTRAOPERATIVE ASSESSMENT

Incisions for open hepatic resections usually involve a right subcostal incision. Significant exposure can

be obtained with a trifurcated incision as shown in Figure 57-21. In the majority of cases, however, all

that is needed is an extended right subcostal incision with a vertical extension to the base of the xiphoid.

The xiphoid can be resected for better exposure. For bulky lesions on the left or if the left half of the

liver extends significantly to the left upper quadrant, a left subcostal component can be added. In rare

circumstances, especially for lesions high on the dome, an intercostal extension or even median

sternotomy may improve exposure. This is especially true for lesions involving the hepatic vein and IVC

confluences.

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Several versions of self-retaining costal margin retractors or ringed retractors are available that

provide good access to the subdiaphragmatic surface. For complete intraoperative ultrasonography and

for major resections, complete mobilization of the involved side of the liver is required. The round

ligament is divided and the falciform ligament divided. The right and/or left triangular ligaments are

then divided to expose the bare areas of the liver. During exposure of the bare areas of the liver, care

should be taken to avoid entering the right or left chest through the ligamentous portions of the

diaphragm because this will cause excessive bellowing of the diaphragm and poor exposure until a chest

tube is placed on that side or the hemithorax is “bubbled out” to remove the air and the diaphragm

repaired. Additionally, the right and left phrenic veins are very superficial on the hemidiaphragm and

can be injured. The right colon can be mobilized out of the field by dividing Gerota fascia over the right

kidney and pulling the hepatic flexure inferiorly. To completely assess the caudate lobe, the overlying

lesser omentum should be divided. Care should be taken to avoid inadvertently dividing a replaced or

accessory left hepatic artery running in this space. After mobilization, a thorough bimanual examination

should be performed and intraoperative ultrasonography used as previously described.

Figure 57-21. Incisions used for open hepatic resection.

Figure 57-22. Lowering the hilar plate. A: The inferior border of segment IV overlies the hepatic duct confluence. B: Division of

the connective tissue investment allows elevation of segment IV, which results in a “lower” hilar plate and surgical exposure to the

hepatic duct confluence.

10 The porta hepatis is often dissected to identify the main bifurcations of the hepatic artery and

portal vein and the confluence of the bile ducts. This allows individual ligation of the branches of these

structures supplying one side of the liver while preserving the branches to the other side. Ligation of the

hepatic artery and portal vein to one side also allows the liver parenchyma to demarcate a line of

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