resection between the right and left liver. Greater exposure of the superior aspect of the hepatic hilum

and exposure of a high or intraparenchymal bifurcation of a portal triad structure may be aided by

exposing the hilar plate (Fig. 57-22) and dividing the Glisson capsule at the most inferior border of

segment IV. Inflow control to the liver can also be obtained by pedicle ligations in which small

hepatotomies are made around the main right pedicle, main left pedicle, right anterior pedicle, or right

posterior pedicle after identification with ultrasound (Fig. 57-23).10 The pedicle of interest can be

dissected out bluntly with a right angle or by palpation. The pedicle can then be clamped to confirm

that it does indeed supply the area of liver of interest (i.e., right half, left half, right anterior section, or

right posterior section). Once confirmed, the pedicle can be divided. Alternatively, the inflow pedicles

can be divided as they are encountered while transecting hepatic parenchyma. With this technique,

hemorrhage can be minimized by intermittent portal inflow occlusion, which is accomplished by gently

clamping the main portal triad within the hepatoduodenal ligament (“Pringle maneuver”).

Outflow control of the hepatic veins can be obtained before or after hepatic transection and should be

decided on a case-by-case basis. When there is a significant extraparenchymal component to the hepatic

vein(s), often it is easier to divide the hepatic vein(s) early and before parenchymal transection (but

after inflow control) (Fig. 57-24). When the extraparenchymal component to the hepatic vein(s) is very

short or absent and when the tumor margin is not near the junction of the hepatic vein(s) and IVC, it

may be easier and safer to divide the hepatic vein(s) within the hepatic parenchyma after most of the

parenchymal transection has been performed. The use of endoscopic vascular stapling devices has made

the ligation of hepatic veins, whether extra- or intraparenchymally, much quicker and safer (Fig. 57-

25).10 It is often useful to keep the central venous pressure (CVP) of the patient low (<5 mm Hg) until

after parenchymal transection as this will decrease bleeding from the IVC and hepatic vein branches.11

Figure 57-23. Hepatotomies to access pedicles for ligation: right hepatectomy, 1 and 2; left hepatectomy, 3 and 5; right anterior

sectorectomy, 2 and 4; and right posterior sectorectomy, 1 and 4.

During live donor hepatectomy, a meticulous dissection of the portal triad is done isolating the main

bifurcations of the hepatic artery, bile duct, and portal vein on the side that will be recovered. A

cholecystectomy and trans-cystic intraoperative cholangiogram is performed to confirm the biliary

anatomy. Outflow control is obtained by dissection of the extrahepatic portion of the hepatic veins as

previously described. After the graft hemiliver has been dissected off the IVC, the parenchyma is

transected while ensuring continued inflow and outflow to both sides limiting any ischemia to the graft

and remnant liver. The portal triad structures and the hepatic vein are divided and the graft is removed

in coordination with the recipient operation.

Over the last decade there has been significant advances in minimally invasive liver resection. In

large volume hepatobiliary centers with advanced laparoscopic skills both benign and malignant tumors

in the peripheral segments (II to VI) are safely resected with good results. With more experience,

formal hemihepatectomies are becoming more common. As with other laparoscopic operations,

advantages include decreased postoperative pain, decreased length of stay, and earlier return to normal

activity. A minimally invasive liver resection should proceed with the same indications and

intraoperative steps employed in an open resection. The indications to resect benign tumors should not

be broadened because an operation with potentially less associated morbidity can be offered to the

patient. As with open resections, major minimally invasive liver resections include optimal exposure,

vascular inflow and outflow control prior to parenchymal transection. Options for minimally invasive

liver resection include a purely laparoscopic approach that does not employ the planned use of a hand

port or mini-laparotomy incision. The specimen is removed through an extension of one of the

laparoscopic port incisions or a small Pfannenstiel incision. The planned use of a hand port is an option

for resections that require more manual control. Hybrid procedures that utilize the laparoscope to

mobilize the liver and then proceed with a mini-laparotomy for the portal triad dissection and

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parenchymal are use by many for major resections. As centers gain more experience the trend is to

perform more resections with the purely laparoscopic approach. Minimally invasive liver resection will

progressively be used for more complex cases including live donor hepatectomies.

Figure 57-24. Caudal retraction of the left hepatic lobe with division of middle and left hepatic veins during left hepatic

lobectomy. Often, the division of the middle and left hepatic veins is intraparenchymal.

Figure 57-25. A vascular endoscopic stapling device is used to divide the right hepatic vein after the right side of the liver has been

mobilized.

MAJOR HEPATECTOMIES

To develop a uniform nomenclature understood by all, the American and International HepatoPancreato-Biliary Associations (AHPBA and IHPBA) have adopted the Brisbane 2000 terminology of

hepatic anatomy and resections. Right hepatectomy or right hemihepatectomy involves the resection of

segments V through VIII. Left hepatectomy or hemihepatectomy involves the resection of segments II

through IV. Either of these resections may or may not include resection of segment I, which should be

stated. Extended right hepatectomy involves the resection of segments IV through VIII. Extended left

hepatectomy involves the resection of segments II through V plus VIII. Again, either of these extended

resections may or may not include resection of segment I, which should be stipulated.

Right anterior sectorectomy includes segments V and VIII. Right posterior sectorectomy includes

segments VI and VII. Left medial sectionectomy removes segment IV. Left lateral sectionectomy

includes segments II and III. A segmentectomy involves the resection of a single segment and a

bisegmentectomy involves the resection of two contiguous segments.

The steps involved in each of these major hepatectomies include optimal exposure of the liver,

vascular inflow control, vascular outflow control, and parenchymal transection. Vascular inflow control

can be obtained by directly ligating the main right or left branches of the hepatic artery and portal vein

in the hilum or by intermittent 10- to 20-minute intervals of a Pringle maneuver with 3 minutes in

between to reestablish blood flow (or both). It is the authors’ preference to encircle the hepatoduodenal

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ligament twice with a quarter-inch Penrose drain that is tightened and clamped for a Pringle maneuver.

Pedicle ligation can also be performed, as described previously, or the pedicles can be controlled as they

are encountered during parenchymal transection. It is the authors’ preference to obtain vascular inflow

by ligating the appropriate vessels in the hilum or by pedicle ligations and to supplement this with

intermittent Pringle maneuvers, as necessary, during parenchymal transection. Often the Pringle

maneuver is not required, but if bleeding from inflow vessels becomes significant, then it should be

performed. Vascular outflow to the right or left liver can be obtained by exposing and ligating the

hepatic veins, as previously described, or by ligating the vessels intraparenchymally during transection

of the liver tissue. Parenchymal transection can be performed using a multitude of techniques including

finger fracture, using a Kelly clamp to fracture, Cavitron Ultrasonic Surgical Aspirator (CUSA),

harmonic scalpel, stapling devices, electrocautery devices with or without saline perfusion, highpressure water jets, and radiofrequency planar arrays. The superiority of any one of these techniques

has not been established, and all are used. With these techniques, individual blood vessels and bile ducts

are cauterized, clipped, or sutured in rapid succession as they are encountered. Constant reevaluation of

the direction of transection is important both to not injure vital structures to the remnant liver and to

maintain a negative margin. After parenchymal transection and removal of the specimen, the raw

surface of the liver is carefully inspected for bleeding and bile leakage, which can then be controlled by

suture ligation and the use of argon beam coagulation. The authors’ preferences are to selectively use

closed suction drains near resected liver surfaces to monitor and drain unrecognized postoperative bile

leaks. Some centers have decreased the use of closed suction drains in favor of radiologic intervention

when necessary, because they often clog or do not actually drain the fluid collections that form.

SEGMENTAL RESECTIONS

To maximize functional reserve, (multi)segmental or subsegmental (or nonanatomic) hepatectomies can

be performed. For example, left lateral sectionectomy (segments II and III), central hepatectomy to

remove the right anterior section (segments V and VIII) and left medial section (segment IV), right

posterior sectionectomy (segments VI and VII), or caudate resection (segment I) are examples in which

one, two, or three contiguous segments are removed to eradicate tumors within those regions of the

liver. These resections are often done with intermittent Pringle maneuvers until the specific pedicles

supplying these areas are controlled.

References

1. McIndoe AH, Counseller VX. A report on the bilaterality of the liver. Arch Surg 1927;15:589.

2. Hjörtsjö CH. The topography of the intrahepatic duct systems. Acta Anat (Basel) 1931;11:599–615.

3. Tung TT. La vascularixation veineuse du foie et ses applications aux resections hepatiques. Thèse

Hanoi 1939.

4. Healy JE, Schroy PC. Anatomy of the biliary ducts within the human liver. Analysis of the

prevailing pattern of branchings and the major variations of the biliary ducts. AMA Arch Surg

1953;66:599–616.

5. Goldsmith NA, Woodvurne RT. Surgical anatomy pertaining to liver resection. Surg Gynecol Obstet

1957;195:310–318.

6. Couinaud C. Le Foi: Etudes anatomogiques et chirurgicales. Paris: Masson; 1957.

7. Bismuth J, Houssin D, Castaing D. Major and minor segmentectomies–réglées–in liver surgery.

World J Surg 1982;6:10–24.

8. Blumgart LH, Hann LE. Surgical and radiologic anatomy of the liver and biliary tract. In: Blumgart

LH, Fong Y, eds. Surgery of the Liver and Biliary Tract, 3rd ed. New York, NY: WB Saunders; 2000.

9. Michels NA. Newer anatomy of the liver and its variant blood supply and collateral circulation. Am

J Surg 1966;112:337.

10. Fong Y, Blumgart LH. Useful stapling techniques in liver surgery. J Am Coll Surg 1997;185:93–100.

11. Melendez JA, Arslan V, Fischer ME, et al. Perioperative outcomes of major hepatic resections under

low central venous pressure anesthesia: blood loss, blood transfusion, and the risk of postoperative

renal dysfunction. J Am Coll Surg 1998;187:620–625.

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Chapter 58

Hepatic Infection and Acute Liver Failure

Andrew M. Cameron and Christine Durand

Key Points

1 Pyogenic abscess is increasing due to the rise of invasive procedures involving the liver, biliary tree,

and pancreas.

2 The treatment for hydatid cysts is surgical resection after the introduction of antiparasitic

medication.

3 Viral hepatitis due to hepatitis B and C represents a principal cause of chronic liver disease in the

United States and worldwide, newer antiviral agents have made these diseases treatable or curable.

4 Liver transplant is the treatment of choice for decompensated cirrhosis or early hepatocellular cancer

in a cirrhotic liver.

5 One-third of acute liver failure patients will die without a liver transplant. Results after liver

transplant show greatly improved survival, though still inferior to that seen with transplantation for

chronic disease.

PYOGENIC LIVER ABSCESS

Abscess in the liver due to bacteria is known as pyogenic abscess. Pyogenic liver abscess occurs

relatively infrequently (incidence of 2.3 cases per 100,000 population) but still represents around 13%

of abdominal abscesses. It most frequently occurs in the setting of bowel compromise in which spread to

the liver is via the portal circulation or in the setting of direct spread from the biliary tree. Pyogenic

abscess may also occur as a result of seeding in the setting of systemic infection.1 Lastly, hepatic abscess

is seen in liver transplant recipients and when observed suggests hepatic artery compromise (Fig. 58-1).

1 Over the past 20 years the increase in invasive procedures involving the liver, biliary tree, and

pancreas has resulted in an increase in the rate of pyogenic abscess. Most pyogenic abscesses are

solitary and polymicrobial and involve the right lobe of the liver. Individuals over 50 years of age,

diabetics, liver transplant recipients, and those with malignancy are at the highest risk for pyogenic

abscess.

Fever is the most frequent presenting symptom of pyogenic liver abscess, sometimes without other

localizing signs. Right upper quadrant pain, chills, anorexia, weight loss, malaise, weakness, and

jaundice are frequently present. Laboratory studies show elevated white blood cell count in most cases,

though not always. Abnormal liver function tests, including elevated bilirubin or transaminases are seen

in about half of the cases.2,3

Though a chest x-ray may reveal a right pleural effusion or elevated hemidiaphragm in 50% of cases,

the radiographic test of choice is ultrasound (US) or CT scan. US will reveal abscess in 90% of cases and

can guide drainage. CT is even more sensitive and will reveal small abscesses and differentiate these

lesions from other pathology.4

Causative agents in hepatic abscess are gram-negative aerobes in two-thirds of patients, most

commonly Escherichia coli, Klebsiella pneumonia, and Proteus species. Enterococci may also be present if

the cause of the abscess is biliary; anaerobes may be isolated if the source is colonic. Streptococci

species are frequently found as well. These microbes will be isolated from the lesion and the blood in

most patients and it is helpful to draw blood cultures prior to the administration of antibiotics.

Coverage should be broad and its duration is based on clinical response. A typical course is 14 days of

IV antibiotics followed by oral medication for a total of 6 weeks.5–7

Percutaneous drainage is standard at this time and is almost always easily accomplished. A drainage

catheter should be left in place until output is minimal, often around 7 days. If attempt at percutaneous

drainage is complicated by ascites, multiple abscesses, transpleural approach, large size, or other

consideration, an open approach may be required. Adequate drainage and prompt initiation of

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