Liver Anatomy & Function The liver is located in the upper right quadrant of the abdomen and is the largest organ weighing ~1.5 kilogram. It is a major metabolic organ regulating various bodily functions and supports the function of other organs as well. The liver has two major blood supply – Hepatic artery and portal vein. The artery carries oxygen-rich blood to the liver whereas the portal vein carries blood rich in nutrients from the gastrointestinal tract, spleen and pancreas. The majority of the blood supply to the liver is derived from the portal vein (70%) while the blood supply to the bile ducts are derived from the artery. The hepatic vein is the major outflow blood vessel from the liver into the inferior vena cava.
The most commonly used system to describe liver anatomy is the Couinaud system. The liver is divided into a right and left lobe. Within each lobe, the liver is further divided into segments, based on the division of the blood vessels within the liver. There are eight segments and are numbered in Roman numerals. The left lobe consists of segments II to IV, while the right lobe consists of segments V to VIII. The caudate lobe is labelled as Segment I.
From the surface, it is impossible to determine the boundaries between the segments. Pre-operative imaging (USS, CT, MRI) is used to delineate the anatomy, while intra-operative USS is used directly on the liver to aid in further defining the anatomy. The knowledge of the segmental anatomy determines the plane of transection during liver surgery.
Function
Helps in digestion of fat via production of bile
Conversion of carbohydrate (sugar) into energy
Produces blood clotting factors
Aids in excretion of waste product
Protects against infection
Regulates cholesterol level
Metabolism and elimination of drugs and toxins
What is Liver Surgery? Liver (hepatic) surgery involves surgical procedures on the liver for a variety of reasons. Liver resection is the most common procedure performed on the liver. The aim of liver surgery is to remove the diseased area (most commonly cancer) with preservation of as much normal liver as possible.
Indication for Liver Resection The most common indication for liver resection is for cancer. Liver resection is the main treatment option for primary liver cancer (HCC) and is only beneficial for secondary liver cancer if all of the cancer can be removed.
Depending on the distribution and number of liver metastases, liver resection can be performed on different lobes of the liver for multiple metastases with a high success rate. Liver resection may also be indicated for benign liver tumours such as hepatic adenoma or hepatic cyst. Liver resection may be performed by an open technique or laparoscopically (key-hole). Occasionally, liver resection can be performed simultaneously with other procedures within the abdomen, such as colon resection. Liver biopsy (to confirm diagnosis) is not usually recommended as there is a potential for bleeding and the rare theoretical risk of spreading the cancer.
Pre-Operative Assessment Initial Assessment Initial assessment will include blood tests and imaging of your liver (USS, CT, MRI and/or PET-CT) to assess the extent of the liver disease. These are performed to determine your suitability for liver surgery. The results of these investigations will be discussed with you and treatment options will be outlined.
Anaesthetic Assessment Once a decision has been made to proceed with surgery, you will be requested to fill out an anaesthetic questionnaire. This will be reviewed by the anaesthetist that will be responsible for your care and you may be required to see the anaesthetist in person or sent for additional tests. Once you have completed the anaesthetic review, the date of surgery will be confirmed with you.
Liver Resection Liver resection is commonly performed by an open procedure (laparotomy). In certain cases, it is feasible to perform liver resection laparoscopically (keyhole). The preferred approach for major liver resection is by a laparotomy, especially for tumours in difficult areas to access.
The principle of liver resections are:
Mobilisation of the liver
Intraoperative Ultrasound is performed to confirm the location of the cancer and the anatomy of the major blood vessels
The blood vessels to the planned resected liver are controlled.
The liver parenchyma (substance) is transected (cut) and meticulous care is taken to seal off the small blood vessels and bile ducts that traverses across the surgical plane of transection
Open Liver Resection An incision is made in the right upper quadrant of the abdomen and the abdominal cavity is entered into carefully. The incision can be a straight midline wound or more commonly, a “Reverse-L incision”.
Laparoscopic Liver Resection A laparoscope (camera) is introduced via a small incision and three further small wounds are used to allow utility of laparoscopic surgical instruments. Once the liver resection has been completed, the wound for the laparoscope is extended to allow removal of the resected liver.
Risk of Liver Resection There are risks with any surgery and can be divided into “General” or “Procedure-specific risks”. Complications occur in ~20-30% of all cases and are usually mild. If you are overweight or smoke, there is an increased risk of post-operative complications.
General Risks
Wound infection
Venous thromboembolism (VTE), e.g. deep vein thrombosis (DVT) or pulmonary embolism (PE)
Incisional hernia at the wound site
Respiratory complications such as pneumonia (infection) or atelectasis (collapse) can occur secondary to poor inspiratory effort in the post-operative period and from prolonged ventilator support. This can usually be treated with antibiotics. To reduce the risk of post-operative respiratory issues, it is important for early mobilisation to help expand the lungs and reduce the risk of atelectasis that can develop into pneumonia.
Procedure-Specific Risks for Liver Resection There are some rare but specific complications related to liver resection:
Liver failure
This is one of the most feared and severe complications following liver surgery. This occurs if the future liver remnant (remaining volume of liver tissue) is insufficient to maintain normal liver synthetic, excretory and detoxifying function.
The symptoms of liver failure include: Progressive jaundice Ascites (fluid build-up in abdominal cavity) Coagulopathy (abnormal blood clotting)
Liver failure can lead to death if the liver is unable to regenerate sufficiently post-liver resection. During the work-up for liver surgery, Dr. Michael Chu will estimate the volume of the future liver remnant and provide an approximate risk of liver failure post-liver resection. If pre-operative work-up was performed cautiously, post-liver resection liver failure is a rare complication.
Bile leak
There is a 5-10% chance of bile leak from the liver cut surface following liver resection. This can usually be treated with percutaneous aspiration under ultrasound guidance and is normally self-limiting. If the bile leak does not settle spontaneously, an endoscopic procedure (ERCP) may be required to decompress the bile ducts and encourage bile flow towards the duodenum rather than the cut surface. On rare occasions, a re-operation may be required to deal with the bile collection.
Post-Operative bleeding
The liver is a very vascular organ and bleeding may occur at the time of resection or post-operatively. In the majority of patients, it settles without requiring further intervention but some patients may need blood transfusion. Rarely, patients may require a re-operation.
Liver abscess
Liver abscess is defined as an infection within the liver itself. This occurs as a result of transection through the liver but in the absence of pre-operative infection, this is a rare complication. This complication is more common post-liver ablation as the destructed liver tissue is left in-situ (it is not removed) and can be a nidus (source) of infection.
Contraindications to Liver Surgery All patients undergo a thorough assessment before deciding whether to proceed with liver surgery. This will include clinical examination, blood tests and advanced imaging (CT or MRI Liver). Dr. Michael Chu will work alongside you at each step of the assessment and make sure you have a thorough understanding. If the potential benefit from surgery is less than the risks of surgery, surgery would not be recommended.
Post-Operative Management Depending on the extent of liver resection, you may be required to be admitted to the High Dependency Unit (HDU) for the night of your surgery. Most patients stay in HDU for one night and you will be cared for on the ward after your HDU stay. There will be a number of routine checks performed by the nursing staff, including overnight.
During your hospital stay, Dr. Michael Chu will review you twice a day and the anaesthetist will review you at least once a day. The ward staff are very experienced in caring for post-liver surgery patients and will be responsible for your care.
Post-operative Diet Patients are allowed to eat and drink as tolerated following surgery. On the night following surgery in HDU, patients are allowed to drink oral fluids as tolerated and then progress to a full diet as tolerated in the next 24-48 hours. Please ensure that you listen to your body with regards to appetite/hunger and if you feel full/bloated, do not try and push more oral intake. If required, a dietitian will visit you on the ward to advise you about post-operative dietary requirements and prescribe supplemental nutrition drinks as needed.
In the initial stages, you may find that eating small meals regularly throughout the day may be more tolerable than three large meals a day. As you improve, you will be able to adjust your dietary intake to suit your body. If you are really struggling with your oral intake, there are dietary supplements available and this can be liaised with a dietitian.
Alcohol should be avoided for at least three months following liver surgery to allow full liver regeneration.
Post-Operative Mobility You will be encouraged to mobilise as much as possible during your hospital stay to reduce the risk of post-operative lung complications and DVT. In the first post-operative day (this may be in HDU), you will be encouraged and assisted to mobilise into a chair, and sometimes for a short distance.
Post-Operative Analgesia The majority of patients will have a mild discomfort post-operatively and liver surgery is not routinely considered a painful operation. Pain management will be managed between Dr. Michael Chu and the anaesthetist. It usually consists of regular paracetamol with addition of stronger analgesia (in the form of opioids) on an “as required” (PRN) basis.
Prophylaxis for Blood Clots (VTE) To prevent VTE, patients will require a daily injection to be self-administered subcutaneously in the abdomen. This will be for 28 days post-operatively and patients will be instructed how to administer this prior to their discharge.
Wound Care The surgical incision will be sutured with dissolvable sutures and do not require removal. Steristrips (thin-adhesive bandages) are placed over the incision to support the skin edge and reduce the tension on the wound, and are usually left on the wound for 10 days. On top of the Steristrips, a waterproof dressing is placed and should stay for at least 3-5 days. You are able to shower with this dressing and it should be pat dry afterwards. Some patients prefer to leave the waterproof dressing for a bit longer and that is okay. If the Steristrips fall off earlier than 10 days, it is acceptable.
Once the dressing is removed and the wound appears clean and dry, the wound does not need further dressings. Occasionally, the wound may leak some “dark-ish” fluid or looks a little red, and this is not unusual. The staff will keep a close eye on the wound. If staples or non-dissolvable sutures are used to close the wound, these will need to be removed after 10-14 days. The district nurse will be able to do this for you. If you would like to use Vitamin E or Bio-Oil on the wound to reduce scar prominence, please do so after the first week.
Duration of Hospital Stay The majority of patients spend 4-6 days in hospital prior to discharge. The general criteria for discharge are: Mobilising independently, have an adequate oral intake (fluids and food), able to perform the majority of self-cares and only requiring oral analgesia.
Post-Operative Activity
Activity & Work
Patients are allowed to perform their regular activity as long as it is not too uncomfortable for them. However, it is recommended to be off heavy lifting or activity for 4-6 weeks. Most patients do return back to work after this period but some may take longer to do so. Irrespective of surgical approach (open or laparoscopic), it normally takes ~3 months to return to normal activities. Additionally, most patients experience reduced energy level post-operatively for a few weeks and can be up to 6-8 weeks. Please be patient and give yourself time to recover.
Driving
It is recommended that patients should not drive for a minimum of 3 weeks post-liver surgery. When you get home and feel ready to drive, sit in the car seat and ensure you are able to perform a full emergency stop/brake before you start driving. It is also advisable that you should be able to have the strength to control the car and respond quickly before you start driving.
Importantly, please check with your insurance policy and company to ensure that you do not invalidate your insurance policy by driving post-operatively. Tubes & Drains In rare occasions, patients may have a drain or feeding tube in the post-operative period.
Feeding Tube
The feeding tube passes through the nose into the stomach and allows supplementary nutrition to be administered in the post-operative period in conjunction with a dietitian.
Drain
In the case where a drain is inserted, it allows drainage of any fluid (blood or bile) that may leak off the cut surface and will generally be left for 2-3 days.
Urinary Catheter
A catheter is placed in the urinary bladder in the operating theatre to monitor urine output (kidney function) during the post-operative period. This is usually removed on post-operative day 2.
Post-Discharge Management When should I seek medical input? If you or your family have any concerns, please contact Dr. Michael Chu directly or his rooms, or the hospital. If it is a medical emergency, please dial 111 for an ambulance to take you the nearest acute hospital.
If you have any of these symptoms, please let Dr. Michael Chu know:
Fever over 38.5 C
Vomiting or diarrhoea
Wound infection or discharge of blood/pus from the wound
Lack of bowel movement after 3-4 days
Persistent abdominal pain not controlled by prescribed analgesia
Persistent abdominal distension (bloating)
Becoming jaundiced (yellow-tinge to the eyes or skin)
How does my General Practitioner (GP) know about my surgery? Dr. Michael Chu will send a letter to your GP summarising your hospital stay, and a copy of your operation note, to keep your GP up-to-date with your status. It is advisable that you make an appointment with your GP a few days after your discharge so they can physically assess your clinical status.
Dr. Michael Chu is happy to be contacted by your GP if they have any questions or concerns.
Common side-effects of surgery & solutions
Pain or discomfort
After an operation, a degree of discomfort is expected and usually improves over the first two weeks. In some patients, the discomfort may last for a few weeks. The aim of the prescribed analgesia is to ensure that the discomfort is manageable so that you can continue to improve physically. However, if the pain is worsening or you have any concerns regarding it’s duration (greater than two weeks), please contact your GP or Dr. Michael Chu.
Bruising
There are usually bruising around the incision and may extend up to the ribs. The bruising may appear within 24-48 hours after surgery. If you feel that the bruising is worsening, becoming painful or there is discharge of pus from the wound, please contact Dr. Michael Chu.
Right shoulder pain
Due to the location of the liver and its proximity to the diaphragm, the irritation of the diaphragm may lead to right shoulder pain. This can last for a few days and should slowly improve. Heat packs can often alleviate the shoulder pain. However, if it lasts greater than 2 days, or worsens, please contact Dr. Michael Chu as it may also indicate the development of a collection around the liver.
Constipation
This is a common occurrence following any abdominal surgery. It is usually related to the opioids during general anaesthetic or those given post-operatively for analgesia. There are a few laxatives that can be obtained over the counter at the pharmacy or by prescription. Similarly, natural dietary supplements such as kiwi-fruit are also quite effective. Importantly, please drink plenty of fluid.
Frequently Asked Questions about Liver Surgery Does the liver regenerate? Yes, the liver is able to regenerate and is the only organ in the body that can regenerate. When part of the liver is resected, the remnant liver hypertrophies (grow) to the volume of the original whole liver. However, bile ducts and the blood vessels in the liver do not re-grow; only the hepatocytes (liver cells) in the remnant liver grows. This process takes 8-12 weeks and allows major liver resection to proceed.
How much liver can a surgeon remove safely? This depends on the quality of the liver in the patient. For a healthy liver, up to 70% can be removed leaving 30% behind. In a patient with chronic liver disease or following chemotherapy, a larger volume of remnant liver is required and the amount of liver that can be removed safely is reduced.
Do I need further chemotherapy after liver surgery? This is dependent on the reason for the liver resection and your clinical status following surgery. In patients with colorectal (bowel) cancer, chemotherapy is generally given before and after resection of the metastatic liver disease. However, for many of other cancers, liver resection alone is adequate. Each case is unique and will be discussed with an oncologist (medical cancer specialist) who are the specialist providing the chemotherapy.
What is my risk of dying from liver surgery? With any operation, there is a risk of death from the surgery and its complications.
Specifically for liver resection, the risk is dependent on:
Extent of liver resection
Condition or quality of the liver
Medical co-morbidity
Within the peri-operative period, the estimated risk of death as a result of a complication is around 2% of all patients that undergo liver resections. It is important to note that it is extremely rare to die in the operating theatre. As liver resection is usually performed for a cancer, the risk and benefit of surgery is balanced against the risk of not undergoing surgery. You are encouraged to discuss your risks and your operation with the surgeon and anaesthetist before the operation.
What do I do need to do to prepare for surgery? Once a proposed date for surgery has been set, you will need to follow these instructions:
Blood tests are taken 1-2 days prior to the day of surgery. This ensures that blood is available if you require a blood transfusion.
Specific instructions will be given on where and when to present for surgery
Specific instructions will be given on when to stop drinking and eating. It is important that you follow these instructions as it will pose an anaesthetic risk and we may have to cancel or delay your surgery.
You do not need to shave before coming into hospital
You will be advised on what normal medications to take on the day of surgery, but only take them with a small amount of water.
If you are on any blood thinners that affect clotting, please inform Dr. Michael Chu during your consultation, as they may need to be stopped well in advance before the day of surgery. If you are unsure about any medications, please ask Dr. Michael Chu and the anaesthetist.
What is the follow-up process for me? A follow-up will be arranged for you after you have been discharged from the hospital. Dr. Michael Chu’s PA will get in contact with you and the follow-up is usually 1-2 weeks after leaving hospital.
At the follow-up consultation, Dr. Michael Chu will go through with you:
How you are recovering
Operative findings
Pathology report from the surgery
Depending on your recovery and the pathology result, Dr. Michael Chu may recommend additional investigations, treatment or follow-up reviews. Dr. Michael Chu will ensure you are fully aware of the plan and answer any questions that may arise during the consultation.
If you have any questions or concerns during your post-operative period, please contact Dr. Michael Chu on +64 27 216 7288.