This document provides information on liver resection techniques and methods. It discusses the history and indications for liver resection, preoperative assessment including future liver remnant assessment, portal vein embolization to augment the liver volume, and surgical techniques for vascular control and parenchymal transection including the Pringle maneuver, water jet dissection, CUSA, and radiofrequency devices. The key steps in liver resection are preoperative planning, intraoperative assessment, inflow and outflow control, low central venous pressure, and parenchymal transection using various techniques and instruments.

1. LIVER
RESECTION
Indications
&
Methods
Dr Harsh Shah
MS, FMAS, DNB, MCh (GI)
Kaizen Hospital, Ahmedabad

2. INTRODUCTION
• First successful elective liver resection - 1888 (Langenbuch)
• True anatomical right hepatectomy in 1952 (Lortat-Jacob)
• Subsequent experience
• Not encouraging till 20 years back
• Morbidity (30%) & mortality (5%)
• Most common complications being bleeding and bile leak
• Techniques and Instruments
• Large, non-anatomical wedge resections
• Possible due to development of new instruments and techniques

3. ANATOMY

4. BLOOD SUPPLY
• 1-1.5 litres per minute
• Portal vein – 75%
• Hepatic artery – 25%
• Bile duct
• Three hepatic veins

5. INDICATIONS FOR LIVER RESECTION
• Benign liver tumours
• Hemangioma
• Adenoma
• Cystadenoma
• Malignant liver tumours
• HCC
• Cholangiocarcinoma
• Metastasis
• Carcinoma GB
• Benign conditions
• Intrahepatic stones
• RPC
• Caroli’s disease
• Hydatid cyst
• Liver cysts
• Liver trauma
• LDLT (Living donor liver
transplantation)

6. HEPATOCELLULAR CARCINOMA

7. HILAR CHOLANGIOCARCINOMA

8. INTRAHEPATIC
CHOLANGIOCARCINOMA

9. LIVER METASTASIS
• COLORECTAL
• NET
• BREAST
• GIST

10. RIGHT LOBE LEFT LOBE
Hemangioma

11. HEMANGIOMA
• Giant hemangioma - > 10cm
• Pain
• Signs of inflammatory process – fever, ESR, thrombocytosis
• Compression – bile duct, stomach
• Thrombocytopenia (KMS)
• Rupture

12. HEPATIC ADENOMA
• Hemorrhage - >5cm size
• Malignant transformation (5%)

13. CYSTADENOMA
• Contains ovarian like stroma
• High risk of
cystadenocarcinoma

14. CARCINOMA GALL BLADDER

15. IHPBA BRISBANE 2000

20. LIVER RESECTION : STEPS
• Pre-op planning
• Intra-op assessment
• Inflow control
• Outflow control
• Maintenance of low central
venous pressure
• Parenchymal transection

21. PRE-OPERATIVE
ASSESSMENT

24. QUESTIONS
• Is it amenable to surgical resection ?
• Portal vein
• Hepatic vein
• Is the future liver remnant sufficient ?
• Quality of future liver remnant ?
• Alcohol
• Hep B & Hep C
• Fatty liver
• Cholestatic

25. Future liver remnant
Normal - >20%
Cholestatic - >30%
Cirrhotic - >40%

26. LIVER FAILURE
• Liver is unique in its ability to ‘regenerate’
• Post hepatectomy liver failure
• Incidence – 2-10%
• cirrhotic liver – 10-30%

27. LIVER VOLUME ASSESSMENT
• Right liver (segments V to VIII) contributes two thirds of the total
liver volume (TLV)
• The left liver (segments II to IV) represents a third of the TLV
• Left lateral section (bisegment II/III) contributes approximately half
the volume of the left liver or 16% of the TLV

28. CT VOLUMETRY
• Indications
• Extended liver resections
• Right hepatectomy in
cirrhotics
• LDLT
• Softwares
• LiverAnalyzer (Mevis)
• Osiri X

30. FUNCTIONAL LIVER VOLUME

31. INDOCYANINE GREEN ELIMINATION TEST
• Indocyanine green (ICG) is an anionic organic dye selectively taken up
by hepatocytes and excreted unchanged via the bile
• Plasma extraction of ICG by the liver is an active process
• Values extrapolated to reflect hepatocyte blood flow and functional
hepatocyte mass
• ICG retention values above 15% at 15 minutes are considered
abnormal

32. MEGX & GALACTOSE ELIMINATION TEST
• Lidocaine is metabolized by hepatocytes and converted to
monoethylglycinexylide (MEGX)
• Galactose is actively phosphorylated to glucose by hepatocyte
• Both tests require uptake and metabolism by the liver to quantify
hepatic function

33. HEPATOBILIARY SCINTIGRAPHY
• Liver uptake and excretion imaging of aminodiacetic acid derivatives
(HIDA, DISIDA) with radiolabeled
• Reduction in receptor numbers is seen in patients with chronic liver
disease
• Receptors absent from the surface of hepatocellular carcinoma cells

34. HEPATOBILIARY SCINTIGRAPHY
• Scintigraphic imaging of the liver has the added advantage of
providing an assessment of liver volume
• Volumetric analysis is better than that obtained with CT volumetry,
because it measures only the functional volume ( kwon et al ,2006)
• Stromal and fibrous tissues are excluded because of the lack of the
asialoglycoprotein receptors

35. Low FLR ??

36. METHODS OF LIVER VOLUME
AUGMENTATION
• Portal Vein Embolization (PVE)
• PVE + TACE (Trans Arterial Chemo Embolization)
• Staged Hepatic Resection

37. WHAT IS PVE ?
Embolization of PV on the side to be resected
Concept – atrophy hypertrophy complex
Leads to hypertrophy of future liver remnant (FLR)
Allows major resection without post op liver failure

38. PORTAL VEIN EMBOLIZATION
Indications
1. Normal liver (ICG retention rate at 15 minutes [ICG R15] <10%) if
FLRV/TLV is less than 40%
2. Injured liver (10% < ICG R15 < 20%), if FLRV/TLV is less than 50%
If ICG R15 exceeds 20%, major hepatectomy is Contraindicated even
after PVE

39. TECHNIQUE
Three approaches –
1. Laparotomy and through ileocolic vein
2. Transhepatic ipsilateral approach
3. Transhepatic contralateral approach

41. EMBOLIZATION MATERIALS
No ideal embolization material
1. Gelfoam (gelatin sponge with thrombin)
2. Fibrin glue (fibrinogen + thrombin)
3. Synthetic glue (n-butyl-2-cyanoacrylate)
Permanent, massive perivascular fibrosis, difficult dissection
4. Polyvinyl alcohol
5. Coils
6. Iodized oil
7. Absolute ethanol (significant more hypertrophy, increase enzymes)
All – similar hypertrophy 2-4 weeks after PVE

42. PRE-EMBOLIZATION POST EMBOLIZATION

43. RESULTS OF PVE
• PVE leads to an increment of segmental volume in non embolized
hemiliver and a decrement of segmental volume in embolized hemiliver
maintaining a constant TLV
• In case of right hemiliver PVE, regeneration rate of the
• Non cirrhotic liver - 12 cm2/day at 2 weeks
11 cm2/day at 4 weeks
6 cm2/day at 32 days
• in cirrhotic patients regeneration is slower

44. PVE
• Volume increase in the non-embolized lobe accompanied by a parallel
increment in liver function
• Improvement in FLR function apparent from an increase in biliary
excretion
• Embolized hemiliver atrophy through apoptosis and subsequent cell
deletion
• Volume increase in non-embolized hemiliver is by hyperplasia rather
than cellular hypertrophy

45. FACTORS AFFECTING REGENERATION
• Regeneration rate depends on embolized hemiliver volume, the greater the
FLRV before PVE, the smaller the volume increase after PVE
• Hypertrophy modest when biologic materials such as gelfoam and fibrin glue
used as a result of the progressive recanalization
• Absolute ethanol achieve the highest degree of regeneration but at the
expense of marked increases in AST and ALT levels secondary to liver necrosis

46. Complications Of PVE

47. TRANSARTERIAL
CHEMOEMBOLIZATION
(TACE)

48. MECHANISM OF ACTION
• Embolization  Ischemia  Necrosis
• Ischemia  blocks transmembrane pumps  limits
chemotherapy from washing out of tumor cells (Ramsey D et al,
2002)
• Concentration of chemotherapy drug in tumor is 10-100 times
greater than given systemically (Konno T et al,1990)
• Chemotherapy + lipiodol traps chemotherapy & concentrates in
HCC (Ramsey D)
• Because most of the drugs is retained in the liver, systemic
toxicity is reduced (Daniels JR, 1988)

49. TACE
Exclusion criteria
• Hepatic encephalopathy
• PV thrombosis
• Serum bilirubin >5mg/dl; serum creatinine >2mg/dl

50. PROCEDURE
• 7-10ml of chemotherapy solution infused (100mg cisplatin, 50mg
doxorubicin & 10mg mitomycin C in a 1:1 or 2:1 volume ratio with
ethiodol / lipiodol)
• Followed by infusion of 1-2ml of gelfoam / PVA particles (300-500
micron) to slow down arterial inflow & prevent washout of
chemotherapeutic agents
• End point - entire amount is delivered & slowed arterial flow as
compared to initial flow
• Forward flow in the HA is to be maintained to preserve patency for
re-treatment and minimize theoretical risk of ischemia or infarction

53. COMPLICATIONS
• Post-embolization syndrome (fever, pain, vomiting, ALT) – 32-80%
• Ascites, GI bleed, leucopenia, worsening hepatic function -- <10%
• Rare – cholecystitis, ischemic hepatitis, abscess, bacteremia,
hepatic, renal failure, death

54. RADIOLOGY
PRE-OP ASSESSMENT

55. CT ANGIOGRAPHY- HEPATIC ARTERY

56. PORTAL VEIN ANATOMY

57. HEPATIC VENOUS ANATOMY

58. MRCP

59. SURGERY

60. VASCULAR CONTROL
• Inflow Vascular Occlusion
• Total Vascular Exclusion

61. INFLOW VASCULAR OCCLUSION
Pringle Maneuver
• Oldest and simplest way
• Hepatoduodenal ligament
encircled with tape
• Until pulse in hepatic artery
disappears
Pringle JH et al, ann surg 1909

62. INFLOW VASCULAR OCCLUSION
Pringle Maneuver
• Advantages
• Little general hemodynamic effect
• No specific anesthetic management
• Disadvantages
• Backflow from hepatic veins
• Ischaemic-reperfusion injury to the liver parenchyma
• Splanchnic congestion
Kim YI et al, J hepatobiliary pancreat surg 2003

63. INFLOW VASCULAR OCCLUSION
Continuous Pringle Maneuver
• Up to 60 minutes in normal liver (normothermic conditions)
• Up to 30 minutes in pathological (fatty or cirrhotic) livers

64. INFLOW VASCULAR OCCLUSION
Intermittent Pringle Maneuver
• 15-20 minutes clamping, 5 minutes unclamping
• 5 minutes clamping, 1 minute unclamping
• Advantages
• Doubling of ischaemia time
• Better tolerated by pathological liver
• Disadvantages
• Bleeding during unclamping period
• Increased overall transection time
Torzilli G et al, arch surg 1999
Belghiti J et al, ann surg 1999

65. INFLOW VASCULAR OCCLUSION
Ischaemic Preconditioning
• Endogenous self-protective mechanism
Hypothesis:
• 10 minutes of ischaemia followed by 10 minutes of reperfusion 
protection against subsequent transection with complete inflow occlusion
Advantage:
• Lower serum transaminase levels after surgery
• Longer inflow occlusion in steatotic livers
Clavien et al, ann surg 2000

66. Hemi-hepatic clamping (Half-Pringle maneuver)
• Interrupts arterial and portal inflow
selectively one lobe
• Advantage
• Avoids ischaemia in the remnant
liver
• Avoids splanchnic congestion
• Clear demarcation of the resection
margin
• Disadvantage
• Bleeding from the parenchymal cut
surface
Horgan PG et al, am J surg 2001

67. Total vascular exclusion
• Complete mobilization of the
liver
• Encircling of suprahepatic
and infrahepatic IVC
• Pringle maneuver
• Clamping the infrahepatic
IVC & suprahepatic IVC

68. Total vascular exclusion
• Hemodynamic changes
• Marked reduction of venous return and cardiac output
• Trial clamping of two to five minutes
• Ischemia time
• 60 minutes in normal liver
• 30 minutes in diseased liver
• Extended with hypothermic perfusion of the liver
Azoulay D et al, ann surg 2005

69. Total vascular exclusion
• Disadvantages
• Hemodynamic intolerance
• Post-operative abdominal collections/ abscesses and
pulmonary complications
• Venovenous bypass if hemodynamic intolerance
• Infrahepatic IVC clamp alone with inflow occlusion
• Reduce back bleeding
Abdalla et al, surg clin north am 2004

70. SELECTIVE VASCULAR CONTROL
• Inflow occlusion with extraparenchymal control of
hepatic veins
• Trunks of major hepatic veins can be safely looped in
90% of patients
• Loops tightened or vessels clamped after inflow
occlusion
• Continuous or intermittent
• Advantages
• Liver lobe isolated from systemic circulation
• Caval flow un-interrupted
Elias D wt al, hepatogastroenterology 1998
Smyrniotis VE et al, world J surg 2003

71. PARENCHYMAL
TRANSECTION

72. INSTRUMENTS
• CUSA
• WATER-JET
• HABIB PROBE
• HARMONIC FOCUS
• LIGASURE
• VASCULAR STAPLERS

73. Cavitron Ultrasonic Surgical Aspirator(CUSA)
Pencil-grip surgical hand piece contains a transducer
Oscillates longitudinally at 23 KHz
Explosion of cells with a high water content
(hepatocytes) and fragmentation of parenchyma,
sparing blood and bile vessel

74. Cavitron ultrasonic surgical
aspirator, CUSA (Valleylab)

75. Cavitron ultrasonic surgical aspirator,
CUSA (Valleylab)
• Constant water irrigation
• Cools the titanium tip
• Washes blood
• Suction – in built
• Clears the transection plane
• No need for vascular control
• Non-anatomical resection possible
• Less operative time

77. WATER-JET
‘Intelligent knife’
• Consists of pressure generating pump connected to a hand-piece
• Jet nozzle with a pinhole 0.1 mm
• Projects physiologic saline
• Suction line connected to a transparent hollow tip
• Separates ducts & blood vessels from parenchyma
• Splashing (source infection) avoided by
• Keep hollow tip into direct contact with liver

78. WATER-JET

79. WATER-JET
• Intrahepatic vessels and bile ducts (>0.2mm) not injured with
water jet pressure
• 10 kgf/cm2 in normal liver parenchyma
• 15-18 kgf/cm2 in cirrhotic patients
• Compared with CUSA
• Less blood loss
• Similar operating time
• Less positive margins

81. Multiprobe Bipolar Radiofrequency
Device (Habib)

82. Multiprobe bipolar radiofrequency device
(Habib)
‘Bloodless liver surgery’
• The radiofrequency handheld device 2x2 array of 4 needles
spaced at the corners of a 6 mm rectangle
• 2 variants
• Long (120-mm) and short (60-mm) needles
• Needles made of stainless steel with a polished titanium
nitride nonstick coating
• Active portion of long needles is distal 40 mm
Ahmet et al, arch surg 2008

84. Multiprobe bipolar radiofrequency
device (Habib)
• Without reduction of central venous pressure
• Mark resection line before starting the radiofrequency
energy
• Radiofrequency power set
• 125 W for small vessel coagulation
• 75 W around large vessels
• Series of coagulations made
• Create a band of coagulation

85. Multiprobe Bipolar Radiofrequency
Device (Habib)
The surface of the liver parenchyma left behind
• Homogeneous
• Without visible bile duct structures or blood vessel
Advantages
• Less blood loss
• No major post-operative morbidity/ mortality
Ahmet et al, arch surg 2008

86. Harmonic ‘Focus’
• Ultrasonically activated shear
• Causes protein denaturation and coagulation by high frequency
ultrasound vibration
• Ultrasonic generator, foot switch, hand piece
• Vibration frequency 55,500 Hz
• Simultaneous coagulation (3mm) & cutting
• No smoke & minimal lateral spread (0.5mm)
• Only for superficial parenchymal transection
Kim J et al, am surg 2003

87. Harmonic scalpel
• Comparison with clamp crush technique
• Reduce operative time
• Reduce blood loss
• Increases biliary fistulae

88. BIPOLAR VESSEL SEALING DEVICE,
BVSD (LIGASURE)
• Bipolar electrothermal energy
• Seals off vessels up to 7mm in diameter
• Liver tissue crushed between blades
• Coagulation energy applied to seal vessels
• Lateral thermal spreading is minimal (1mm)
• No bile leak
• Does not produce smoke interfering with field
Strasberg SM et al, J gastrointest surg 2002
Romano F et al, world J surg 2005

89. VASCULAR STAPLERS
• Inflow & outflow vessel control
• Reduced operative time
• Use when in trouble !

90. LAPAROSCOPY
• First anatomical laparoscopic liver resection
• 1996 by Azagra
• Left lateral sectionectomy for hepatic adenoma
• Small and localized tumors on anterolateral segments
• Oncological principal has to be followed
• Need of intra-operative ultrasound

91. LAPAROSCOPY
• Laparoscopic assisted hepatectomy (LAH)
• Total laparoscopic liver resection (TLLR)

92. LAPAROSCOPY
• Pneumoperitoneum
• Carbon dioxide
• Pressure aiming for 6–8 mmHg during transection
• 300 laparoscope
• Hepatic transection
• Harmonic scalpel/ CUSA/Ligasure
• Bleeder control
• Bipolar coagulation for minor bleeding
• Endoclips/ endo GIA staplers for larger structures
Gagner et al, surg clin N am 2004

93. LAPAROSCOPY
• TLLR
• Usually possible in patients with tumor size < 5 cm
• Wedge resection
• Left lateral sectionectomy
• Safe procedure in antero-inferior segments
Meta analysis by simillis et al, surgery 2007
Sasaki et al, BJS 2009
• Few reports of right hepatectomy
Ibrahim et al, J am coll surg 2005
• Can be performed safely in cirrhotic patients
Buell et al, J am coll surg 2005

94. LAPAROSCOPY
Advantages
• Decreased operating time
• Lower overall cost
Francesco et al, surg endosc 2008
• Less pain, early discharge, faster recovery
• Less adhesions
Topal et al, surg endosc 2008
Sasaki et al, BJS 2009

95. LAPAROSCOPY
Disadvantages
• Chance of gas embolism
• Tumor dissemination
• Tumor margin

96. LIVER RESECTION- COMPLICATIONS
• Blood loss
• Bile leakage
• Post-operative liver failure

97. Associating Liver Partition & Portal
Vein Ligation For Staged Hepatectomy
(ALPPS)
Indications
• Marginally resectable or primarily non-resectable locally advanced liver
tumors of any origin with an insufficient FLR either in volume or quality
• Need to perform major liver resections combined with synchronous
resection of other organs (i.e. Colorectal cancer and liver metastases,
neuroendocrine pancreatic, or intestinal tumors with massive liver
metastases)

102. CONCLUSION
• Tumours & LDLT are major indications for liver resections
• PVE, TACE & ALPPS may help us resect tumours previously
considered unresectable
• Intermittent Pringle maneuver is still the widely used method
for inflow control
• Surgery without vascular occlusion possible with aid of new
instruments – CUSA, Waterjet
• Harmonic & Ligasure - for superficial parenchymal transection