Laparoscopic Liver Resection

Overview

According to the American Society of Clinical Oncology, more than 42,000 Americans will be diagnosed with primary liver cancer (cancers that begin in the liver) in 2021, with more than 30,000 likely to die. Men are around three times as likely than women to be diagnosed with this condition.

If cancer is discovered in your liver, your doctor may advise you to have the affected organ removed. This treatment, known as a liver resection or partial hepatectomy, frequently prolongs the lives of patients with liver cancer.

The liver, unlike most of your other organs, may recover following surgery, even if up to 70% of it is removed. However, the rest must be healthy. It may take many weeks for regrowth to occur.

Cirrhosis, which is a developing concern in the United States, affects many persons with liver cancer. This liver scarring is frequently caused by excessive alcohol intake or a long-term infection with hepatitis B/C viruses. Cirrhosis can also be caused by an excess of fat in the liver. Patients with cirrhosis who have cancer may have their livers resected if their livers are not too damaged and the malignancy has not spread.

 

Liver Anatomy & Function

The liver is a crucial organ, which means it is required for survival. The liver performs a variety of critical processes, including drug and toxin metabolism, removal of breakdown products of normal body metabolism (for example, clearance of ammonia and bilirubin from the blood), and production of several important proteins and enzymes (such as factors necessary for blood clotting). 

The liver, which is positioned in the right upper quadrant of the abdominal cavity, is divided into eight (8) segments that correspond to the portal vein and bile ducts eight (8) main divisions.

The hepatic artery and portal vein supply nutrients and oxygen to liver cells, commonly known as hepatocytes, and bile ducts. Blood exits the liver via the hepatic veins and flows into the inferior vena cava before entering the heart. Bile is a liquid produced by the liver that aids in the digestion of fat and the elimination of metabolic waste and toxins through the gut.

Each hepatocyte produces bile, which is excreted into microscopic channels that connect to form bile ducts. The bile ducts, like streams combining to make a river, combine to form a single "hepatic duct" that transports bile into the gut.

The liver’s life-sustaining functions include:

• Controlling fat, carbohydrate, and protein levels by metabolizing and storing nutrients from meals.
• Making bile to aid with fat digestion.
• Filtering out toxins and processing alcohol and medications.
• Defending against potentially dangerous microorganisms and antigens.
• Making clotting factors to stop excessive bleeding.
• Removing old cells and waste materials from the blood.

 

Why Is Liver Resection Performed?

You may have a liver resection to treat liver disease, or when you want to donate part of your liver for living donor liver transplantation.

Causes of disease that may require hepatectomy:

A partial liver resection is often performed by a surgeon to remove a malignant, precancerous, or benign lesion such as cholecystolithiasis. Liver cancer can be primary, which means it starts in the liver, or secondary, which means it starts in another organ and spreads to the liver.

1. 1. liver cancers include:

• Hepatocellular carcinoma (primary liver cancer).
• Cholangiocarcinoma (primary liver cancer).
• Metastatic colorectal cancer (secondary liver cancer).

1. 2. Gallstones in the intrahepatic ducts — the bile ducts inside your liver.
   3. Adenoma (primary benign tumor).
   4. If they cause symptoms, liver cystadenoma or a cyst.

 

Liver resection for living donor liver transplant:

As a living liver donor, you may potentially have a partial liver resection. This procedure involves the removal of a part of your healthy liver in order to give it to someone in need of a liver transplant. Both your remaining liver and your transplanted liver will grow into full-sized liver.

 

How Serious Is Laparoscopic Liver Resection?

Liver resection is regarded as a technically difficult procedure. One reason is because your liver has numerous vessels and may bleed profusely, therefore liver surgeons must be trained in special techniques to avoid injuring the vessels and managing any bleeding. When your resection is less (less than half of your liver), it is less dangerous and can be performed using minimally invasive surgery techniques like laparoscopy or robotic surgery. 

It gets more hazardous and complicated when you require a large resection (more than half of your liver). Because of the complexity of the procedure, you should generally have your liver resection performed by experienced doctors.

 

Laparoscopic/Robotic Vs. Open Liver Resection

One long incision called a laparotomy opens up your abdominal cavity during open abdominal surgery. Surgeons can see your abdomen directly. It works better for more complex operations.

In laparoscopic surgery, your physician sees the pictures from the camera on a screen while performing the whole procedure through tiny "keyhole" incisions. They complete your liver resection using specially designed, long tools. They can also take use of robotic arms. Because movement is limited, surgeons have usually used a laparoscopic or robotic method for less difficult liver resections. 

However, as surgical methods have advanced, more complicated procedures such as massive liver resections or living donor liver resections are now possible using a laparoscopic or robotic approach.

 

Types of Liver Resections

Major and minor liver resections are the two types of liver resection. A large resection is when more than three segments are removed, whereas a minor resection is when only a few segments are removed. The following are some examples of common surgeries:

• Major liver resection. The right or left lobe is removed during a hepatectomy or lobectomy.
• Minor liver resection. Segmental or wedge resection removes a segment or portion of a segment with a tumor and a margin around it. The left lateral sectionectomy is a small liver resection that removes the lateral segment (section) of the left lobe.
• Multiple liver resections. Multiple tumors can be removed simultaneously. If your surgeon believes that any tumors will benefit from ablation, they may combine resection and ablation.
• Two-stage liver resection: If your surgeon believes that removing all of the tumors in one operation would be too dangerous, they may perform the resection in two phases. The initial procedure involves the removal of a portion of the tumor. The liver then regenerates for many weeks, ensuring that you have enough liver after the second surgery to remove the remaining tumors.

 

What Happens Before Laparoscopic Liver Resection?

Your healthcare professional must assess if surgery is the best treatment choice for your situation. This might be determined by:

• Whether you are in good enough health to have surgery.
• Whether or not your liver lesion is technically operable.
• Whether or not you have cancer in other places of your body in addition to your liver.

Your doctor will also have to decide whether you require a partial hepatectomy or a liver transplant. This might be determined by:

• How extensive the tumor is.
• How healthy your liver is.
• How much functional liver can be left after resection.
• Whether you qualify for a transplant.

Prior to surgery, you will most likely have imaging to establish the size and location of the tumor, as well as to detect whether cancer occurs outside of the liver. In addition to other testing, computed tomography (CT) scans or magnetic resonance imaging (MRI) scans with contrast may be employed. A CT scan can also be used to determine the size and volume of the remaining section of the liver following surgery.

If the portion of the liver that would remain after a resection is deemed inadequate, surgeons can use a procedure to wither the cancer-bearing region while encouraging the remaining to expand fast. The portal vein embolization procedure cuts off blood flow to the cancerous area of the liver. Some individuals get effects in three to four weeks. An extra three to four weeks may be required for patients with diabetes or cirrhosis. 

Because extensive courses of chemotherapy might harm the liver, a brief course may be delivered before surgery. Chemotherapy may also be given in individuals undergoing a two-stage hepatectomy who have metastatic cancers on both sides of the liver. In such circumstances, a brief course of chemotherapy is administered, followed by a restricted resection of the liver side with less malignancy. The blood flow to the opposite side is subsequently cut off to encourage the development of the resected side. Following recovery, the more affected side of the liver is resected more completely.

Before liver surgery, you'll meet with several members of your care team to go through the procedure's details and what kind of assistance you'll need. To better understand the technique, ask as many questions as you can during your consultations.

 

Surgical Steps for Laparoscopic Liver Resection Procedure

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

1. Before the procedure, you will be put to sleep with general anaesthetic. If you're undergoing open surgery, you could also have a transversus abdominis plane (TAP) nerve block, which can help you manage pain once you wake up.
2. If you are undergoing laparoscopic surgery, your surgeon will create 4 to 6 "keyhole" incisions to insert the camera (laparoscope) and surgical equipment.
3. Your surgeon will determine which part of your liver has to be removed. An intra-operative ultrasound may be used to map your liver. If the portion to be removed is near your gallbladder, doctors may need to remove that as well.
4. Your surgeon will delicately slice your liver tissue, separating and regulating the blood vessels and bile ducts with steel clips or staplers. To dissect your liver and stop bleeding, they employ ultrasonic energy equipment or electrocautery instruments.
5. If you're having laparoscopic or robotic surgery, your surgeon may create a second 2- to 5-inch incision to remove the resected liver. The size of the incision is determined by the size of the tumor and the amount of liver removed.

 

How Can You Care for Yourself at Home?

• Activity:

1. 1. When you're exhausted, take a break. Getting adequate sleep can assist you in healing.
   2. Make an effort to walk every day. Begin by walking a bit more than you did the previous day. Increase your walking distance gradually. Walking increases blood flow and aids in the prevention of pneumonia and constipation.
   3. Avoid intense activity like biking, running, weight lifting, or aerobic exercise until your doctor says it's safe.
   4. Avoid lifting anything that will cause you to strain for at least 8 weeks. A child, heavy shopping bags and milk containers, a heavy briefcase or backpack, cat litter or dog food bags, or a vacuum cleaner are all examples.
   5. When coughing or taking deep breaths, place a pillow over your incision. This will help to support your stomach and relieve discomfort.
   6. Do the breathing exercises prescribed by your doctor at home. This will aid in the prevention of pneumonia.
   7. Inquire with your doctor about when you will be able to drive again.
   8. You will most likely need to take 4 to 8 weeks off work. It depends on the nature of your work and how you feel.
   9. You might be able to shower (unless you have a drain near your incision). If you have a drain near your incision, empty it and care for it according to your doctor's instructions. Do not bathe for the first two weeks, or until your doctor says it is okay.
   10. Ask your doctor when it is okay for you to have sex.

 

• Diet:

1. 1. You can continue to eat your regular diet. Try bland, low-fat items such plain rice, broiled chicken, bread, and yogurt if your stomach is upset.
   2. Drink lots of water (unless your doctor tells you not to).
   3. Before using alcohol, see your doctor. The liver can be harmed by alcohol.
   4. You may notice that your bowel motions are irregular immediately following surgery. This is rather frequent. Constipation and bowel straining should be avoided. You should consider taking a fiber supplement every day. If you haven't had a bowel movement in a few days, consult your doctor about using a mild laxative.

 

• Medicines:

1. 1. Your doctor will inform you when and if you may resume taking your medications. He or she will also teach you on how to take any new medications.
   2. Talk to your doctor if you use blood thinners such warfarin (Coumadin), clopidogrel (Plavix), or aspirin. He or she will advise you on when and if you should resume taking such medications. Make sure you understand everything your doctor wants you to do.
   3. Take pain relievers exactly as prescribed.

• • • If your doctor ordered pain medication, use it exactly as directed.
    • Take an over-the-counter pain reliever recommended by your doctor if you are not taking a prescription pain reliever. Read and obey all label directions.
    • Take no more than two pain relievers at the same time unless directed by your doctor. Many pain relievers include Tylenol, often known as acetaminophen. You can become really ill if you take too much acetaminophen.
    • Unless your doctor has approved it, do not use aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve), or other nonsteroidal anti-inflammatory medicines (NSAIDs).

1. 4. If you think your pain medicine is making you sick to your stomach:

• • • After meals, take your medication (unless your doctor has told you not to).
    • Request a new type of pain medication from your doctor.

1. 5. Take antibiotics exactly as advised by your doctor. Do not stop taking them simply because you are feeling better. You must complete the entire course of antibiotics.

 

• Incision care:

1. 1. If you have tape strips on the incision, leave them on for a week or until they fall off.
   2. Every day, wash the area with warm, soapy water and pat it dry. Avoid using hydrogen peroxide or alcohol, both of which can slow recovery. If the wound weeps or scrapes against clothing, wrap it with a gauze bandage. Every day, change the bandage.
   3. Maintain a clean and dry area.

 

Can Your Liver Grow Back?

Healthy liver tissue may regenerate up to two-thirds of its volume in just a few weeks. However, it is not unusual for it to take many months. A more damaged liver may take longer to repair. The following factors may influence how quickly your liver regenerates:

• Prior chemotherapy.
• Excessive fat in your liver.
• Chronic liver disease or cirrhotic livers.

 

Is Laparoscopic Liver Resection Surgery Safe?

About 2% of people who have liver resection surgery die of complications. Cancer patients weigh these risks against the risks of cancer itself.

Complications may include:

1. Infection. Infections might occur in your incision area, urinary tract, or lungs (pneumonia). Antibiotics are used to treat such illnesses by your doctor.
2. Bleeding. Your liver has a large number of blood arteries and is also important for causing your blood clot to cease bleeding. Because liver surgery disrupts this mechanism, patients may bleed excessively. Some patients may require a blood transfusion following surgery.
3. Leakage of bile. Damage to any of your liver's bile ducts after surgery might cause bile to leak and gather inside your belly. This may need the placement of an additional drain.
4. Pleural effusion. Fluid can easily accumulate inside your chest cage following liver surgery. It might cause soreness in the chest and shortness of breath. It may need to be treated with medicine or drained.
5. Ascites. Fluid accumulation in your abdominal cavity might also result from liver surgery. It may need to be treated with medicine or drained.
6. Deep vein thrombosis (DVT). Being in bed for an extended period of time after surgery increases the risk of blood clots. Pay close attention to any areas of your arms or legs that appear swollen or painful.
7. Failure of the kidneys. Surgery can sometimes cause your kidneys to cease functioning. It is critical to remain hydrated.
8. Liver failure. If the remaining liver doesn’t have enough function left, you can go into liver failure. In this case, you may need an urgent liver transplant.

 

When to Call Your Healthcare Provider?

Contact your healthcare provider about any usual symptoms after your hepatectomy, including:

• Bleeding or discharge from your wound.
• Persistent fever.
• Vomiting or diarrhea.
• Persistent constipation (more than three days).
• Swollen, distended abdomen.
• Jaundice (yellow eyes and skin).

 

Conclusion

A laparoscopic liver resection, also known as a hepatectomy, is a surgical procedure that removes a portion of your liver through small incisions. As long as the remainder of your liver is healthy, you can have up to two-thirds of your liver removed. A lesser percentage may be eliminated if you have liver problems. Your liver can regenerate. If your remaining liver is healthy, it will regrow to its original size.

A liver resection may be performed to treat liver disease or to donate a portion of your liver for living donor liver transplantation.