• Liver resections are performed to remove diseased liver parenchyma: Tumors (primary and secondary), cysts, and adenomas. It is not suitable for severely cirrhotic livers because of the risk of postoperative hepatic failure.
• Outcome and, hence, the decision to resect, are dependent on the location, number, and distribution of the mass, as well as the amount of liver that will remain. The liver has significant reserve capacity that allows a large portion to be excised. Additionally, it has the capability to regenerate; occasionally portal vein embolization may be performed to facilitate this.
• Modalities prior to resection:
  • Tumor shrinkage may be achieved with chemotherapy; it can either be systemic or directed. Intra-arterial therapies can be utilized to decrease whole-body adverse effects. It involves threading a catheter through the femoral artery in the groin to the feeding vessels.
  • Radiofrequency ablation (RFA): May be performed percutaneously with the aid of imaging modalities or direct visualization during open procedures (or laparoscopic surgery). The tip of a needle probe is heated utilizing alternating electric current to destroy tumors. Alternatively, microwave ablation may be performed, particularly for tumors near large-diameter vessels.
  • Portal vein embolization: Blood vessels to the tumor are embolized, and nutrients and flow are diverted to the other side with the goal of facilitating growth/regeneration. Repeat imaging to assess hypertrophy is recommended 3–4 weeks after embolization.
• Following dissection, hepatic resection is either:
  • Anatomic: Margins defined by segmental liver anatomy
  • Non-anatomic: Margins defined by tumor
• Surgical maneuvers to decrease bleeding include portal triad clamping (Pringle's maneuver) and selective hepatic venous occlusion. Pringle's maneuver is generally without hemodynamic consequence to the patient. Hepatic tolerance of this maneuver is enhanced by intermittent clamping for 15 minutes followed by unclamping for 5 minutes. Selective hepatic venous occlusion (occlusion of the hepatic venous branches without caval compromise) has been shown to be as effective as a low CVP (central venous pressure) technique for reducing blood loss in patients who are unable to tolerate a CVP <5 mm Hg (1).
• Laparoscopic resection may or may not be hand-assisted. Transection is accomplished via repeated, layered application of endovascular staplers.

Supine, bilateral upper extremities abducted to <90°

Bilateral subcostal incisions ± midline extension

1.5–5 hours depending on the extent of resection

100–1,500 mL, depending on extent of resection and use of cell saver

3–10 days

• Ultrasonic dissector
• Vascular stapler
• Tissue sealer

Incidence

• 7,000 resections performed in 2004 (2)
• 18,920 new cases of hepatic/biliary cancer in US in 2004

Prevalence

Liver cancer is considered a "rare disease" by the National Institutes of Health (NIH); there are <200,000 cases in the US.

23–56% depending on the extent of resection, and indication for surgery (3)

2.6% among high-volume centers (3)

History

• Resection candidates are usually screened for significant hepatic dysfunction.
• Liver cancer is commonly a metastatic disease from the colon.

Signs/Physical Exam

May have stigmata of cirrhosis and/or portal hypertension

Labs/Studies

• Standard labs are dictated by age and comorbidities.
• In chronic hepatic disease, use the INR, creatinine, and bilirubin values to calculate the MELD score.

No absolute contraindications. Titrate carefully in the presence of known underlying hepatic dysfunction, especially benzodiazepines.

• Epidural catheter placement for postoperative pain
• Potential need for invasive monitors such as arterial or central line
• Blood consent

• Biliary penetration/concentration requires Gram-negative coverage.
• Ceftriaxone, ampicillin/sulbactam, and piperacillin/tazobactam can provide broader Gram-negative coverage.

• General endotracheal anesthesia
• Regional techniques for postoperative pain management are acceptable in patients with normal preoperative coagulation parameters. Postoperative coagulopathy correlates with the extent of resection and blood loss. INR peaks on POD #1, ranging from a mean of 1.3 in left lateral segmentectomy to 1.6 in right hepatic lobectomy. Platelet count nadir is POD #3, with a mean of 110–160 K in hepatic lobectomy (major resection). Thus, although continuous epidural analgesia can be used for postoperative pain, the catheter will remain in place for a few days (generally 2–5) until coagulation abnormalities have corrected (ASRA recommendation: INR <1.5) (4,5).

• Standard ASA monitors
• Consider arterial line for larger procedures (e.g., hepatic lobectomy).
• Consider central line placement for larger procedures. There is literature to support the use of peripheral venous pressures (PVP) in lieu of CVP for monitoring (6,7).

Consider a rapid sequence or modified rapid sequence induction in patients with portal hypertension.

• Minimize and avoid agents that require hepatic metabolism to terminate their effects, if possible.
• Consider cisatracurium if hepatic function is a concern.
• Isoflurane has an excellent track record; however, sevoflurane and desflurane are also acceptable.
• Maintain a CVP <5 mm Hg until parenchymal division is complete, if possible. This can minimize blood loss; the liver has multiple caval communications and elevated caval pressures cause increased back-bleeding from the hepatic surface (8).
• Temperature: Implement warming measures early; hypothermia contributes to coagulopathy.

Plan to extubate, unless there were large fluid shifts or blood loss during the surgery