In addition to treating critical injuries, major hepatic resection is performed to remove malignant neoplasms (hepatoma, cholangiocarcinoma, metastases, carcinoid tumor), benign neoplasms (liver cell adenoma, focal nodular hyperplasia, cavernous hemangioma), cysts (congenital, multicystic disease, echinococcal), and certain abscesses. If the remaining hepatic tissue is normal, as much as 80–90% of the liver can be removed in children and adults.
The availability of MRI and CT scans is leading to earlier detection of hepatocellular carcinoma or hepatic metastases from colorectal cancer. Other biochemical measurements such as elevated alpha-fetoprotein (AFP) and carcinoembryonic antigen (CEA) may prompt earlier imaging.
Preoperative screening with MRI for major hepatic resections
is very sensitive in detecting small nodules, showing the
relationship between tumor nodules and major intrahepatic
and retrohepatic blood vessels, and determining resectability.
MRI can also be used to assess volume reserve in patients with
cirrhosis who need major hepatic resection.
Major hepatic resection is performed under general anesthesia
through an upper abdominal incision for left lobe resection,
and a right subcostal resection for right lobe resection. In
skilled centers, minimally invasive techniques have been used
successfully for major resections. The general stages of major
lobectomy include either vascular inflow occlusion (Pringle
maneuver or clamping of the porta hepatis) or individual
ligation of the lobar hepatic artery, portal vein, and right or
left branch of the hepatic duct. Division of the hepatic parenchyma
is accomplished using finger fracture techniques, blunt
knife handle dissection, cutting staplers, and ultrasonic
vibrating-suction device or ultrasonic shears. Blood loss
depends on the extent of the resection and involvement of
the retrohepatic vena cava. The median blood loss was 600
mL in one recent large series, and only 49% of patients were
transfused at any time. In general, intraoperative fluid restriction
reduces back-pressure bleeding during major hepatic
resection. The operative time is 3–4 hours in experienced
hands, and the stress of a major hepatic resection is moderate