What Is Hepatectomy

Liver resection or Hepatectomy is a surgical technique involving the removal of small, non-anatomical superficial tissue or large segments of tissue in the liver because of any disorder or disease condition. It is divided into two types based on the amount of liver segment removed.

•  Major hepatectomy (75% of tissue is removed)
•  Minor hepatectomy (Superficial tissue is removed)

Liver resection stands as the most efficacious curative approach for primary liver cancers, such as cholangiocarcinoma and hepatocellular carcinoma (HCC), as well as metastatic illness, such as colorectal liver metastases.¹

Techniques of liver resection

Crushing technique

Crushing the liver parenchyma between the surgeon's fingers exposes and isolates tiny arteries and biliary radicals, which can subsequently be separated. This fundamental technique can be improved further by using basic surgical clamps to crush the hepatic parenchyma (so-called "crush-clamp" technique).

Sealing devices

By sealing tiny arteries before division, sealing devices help in liver parenchymal transection. These devices may be useful in laparoscopic or nonanatomic liver resections.

Saline-linked radiofrequency sealer

It is a dissecting sealer that uses radiofrequency radiation as a conductor at the device's cone-shaped tip to enable blunt parenchymal dissection and hemostatic sealing of tiny arteries at the liver surface. Larger vessels can be easily isolated, ligated, and divided as required.

Water-jet dissection

A high-pressure water jet is used to break apart the liver tissue and selectively isolate minor vascular and biliary systems, potentially reducing blood loss. These vessels and ducts must then be ligated and split individually as needed.

Radiofrequency-assisted liver resection

Radiofrequency energy is used to pre-thermocoagulate the liver parenchyma prior to division.

Challenges in hepatectomy

Understanding the various hepatic vascular occlusion strategies is crucial for successfully performing liver resections, minimising blood loss, and reducing the need for blood transfusions.

 The sort of resection to be done, the location and size of the tumour, and the liver function prior to surgery should all be taken into consideration when applying each specific approach.²

Complications following surgery

It is important to look after these complications after the liver resection and follow its management.

Post-hepatectomy haemorrhage

Is severe blood loss after surgery. But you need not worry, the advanced imaging and operative technique has recently reduced postoperative blood loss in recent times. The focus is now to reduce the morbidity due to postoperative blood transfusion.

Post-hepatectomy venous thrombosis

It is an obstruction of blood outflow from the liver, which mainly happens after complete liver transplantation. This complication is rarely reported in hepatectomy.

Bile leak

It is the draining of bile from the abdomen wound post-surgery. Bile leak seems to be one of the major complications post-surgery. Bile leaks could require a longer hospital stay, further imaging, and more methods.

Post-hepatectomy liver failure

The most serious consequence following liver resection is probably hepatic failure. Although temporary support devices are being developed, other than thorough supportive care, there is limited treatment for this potentially fatal condition. Because of the varying patient groups and depth of resection, the incidence of post-hepatectomy liver failure (PHLF) ranges from 4% to 19%. 

The incidence is less than 10% in recent research, owing to improved preoperative assessment and intraoperative and postoperative management. Liver failure is still a major cause of death after hepatectomy, accounting for 18% to 75% of fatalities in certain cases and up to 60% to 100% of deaths in others.¹

Open vs laparoscopic hepatectomy

One long incision(cut) called a laparotomy opens up your abdominal cavity during an open hepatectomy. Surgeons can see your abdomen in real-time. It works better for more complex treatments.

Laparoscopic surgery involves the entire operation through small "keyhole" incisions while your surgeon examines images from the camera on a screen. They complete your liver resection using specially specialised, lengthy instruments. Surgeons can also utilize robotic arms. Due to limited mobility, laparoscopic or robotic techniques have traditionally been preferred for less complex liver resections. Yet, with the advancement of surgical techniques, laparoscopic or robotic methods have made it feasible to perform more intricate surgeries such as extensive liver resections or living donor liver resections.

Procedure in hepatectomy

The method varies based on how much the liver physician removes and the surgical technique used. In general, a hepatectomy consists of the following steps:

1). Before the procedure, the patient will be put to sleep with general anaesthesia. If it is open surgery, there might also be a transversus abdominis plane (TAP) nerve block, which will help to manage pain once you wake up.

2). In case of open surgery, the surgeon will make a single lengthy incision across the belly to access your abdominal cavity. In case of having laparoscopic surgery, the surgeon will create 4 to 6 "keyhole" incisions to insert the camera (laparoscope) and surgical equipment. The surgeon will determine which part of the liver has to be removed. 

3). An intraoperative ultrasound may be used to map the liver. If the portion to be removed is near the gallbladder, they may need to remove that as well. The surgeon will delicately dissect the liver tissue, separating and regulating the blood vessels and bile ducts with metallic clips or staplers. 

4). To dissect the liver and stop bleeding, they use ultrasonic energy equipment or electrocautery instruments. If having laparoscopic or robotic surgery, the surgeon may make a second 2- to 5-inch incision to remove the resected liver. The size of the incision is determined by the size of the tumour and the amount of liver removed.³

Summary

In conclusion, liver resection is a significant surgical intervention primarily chosen for cases of hepatic cancer or liver cirrhosis, requiring specialized techniques and expertise for successful completion. Despite its effectiveness, there are numerous post-surgical complications that must be carefully managed to facilitate patient recovery. However, advancements in laparoscopic and robotic-assisted techniques have emerged in recent years, aiming to enhance patient care by reducing both morbidity and mortality associated with the procedure.