The liver is a very interesting organ, with two different types of blood supply, and is functionally divided into right and left sides. Each side is further divided into 4 segments, which each have a separate branch of both blood supplies, and produce bile that travels down a separate duct (tube).
Depending on the location of the tumour within the liver, several different types of operations can be needed to remove (resect) the tumour with clear edge of normal liver tissue (called a margin).
Subsegmental resection: if the tumour is located on the surface of the liver, and is pretty small, we can cut into the liver (with various different devices available for this purpose) and remove the tumour with a clear margin without having to remove a whole segment
Segmental resection: if the tumour is confined mostly in the centre of a particular segment, or is a particular type of tumour (such as HCC) we remove the entire segment to ensure an adequate margin.
Hemihepatectomy: this is removal of the entire left or right side of the liver, often required for larger or multiple tumours, or tumours right next to the blood supply/bile drainage of that side of the liver. In these cases the need to remove the whole side is because of the need for adequate tumour clearance.
Extended hepatectomy: this involves removal of all of either the right or left side of the liver, as well as part of the other side of the liver.
There are variations on these operations depending on the individual case.
This involves a large cut in the abdomen, usually starting just below the sternum in the midline, and extending in a curve down to the right hand side of the abdomen.
The first part of the operation involves dividing adhesions (scar tissue) from previous inflammation or surgery, and then freeing up ('mobilising') the liver which is attached to the diaphragm at the back and top of the abdominal cavity so that it can be moved closer to the wound to be operated on. Then a thorough ultrasound of the liver is performed to locate the lesions/tumours that have been shown on pre-operative imaging, as well as to make sure there are no other tumours present that would change the size or nature of the operation. The blood supply going into the liver is encircled with a Nylon tape, in case during the operation we have to interrupt the blood supply to the liver to reduce bleeding. Depending on the type of operation, either the blood supply going into the part of the liver to be removed is dissected out and divided first, or they are encountered and dealt with later in the operation. The liver tissue is divided by one or more of several types of devices that divide the liver tissue in different ways. Usually one of the last steps is to divide the draining veins of the part of the liver being removed, and the specimen is removed. Once bleeding is controlled, and the cut surface of the liver is checked for leakage of bile, a drain is usually placed, and the wound is closed with sutures.
An increasing number of liver operations can be performed with a laparoscopic approach (currently more than 50%), with some benefits in terms of reduced blood loss, less pain, a slightly shorter average length of inhospital stay, and a faster return to usual activities. The principles of operation are similar to the open approach, apart from being performed through laparoscopic ports via incisions generally 5-12mm in size. The main issue with most liver operations is the size of the removed part of liver, and we usually have to make a decent sized incision to take it out. However, because this is incision is still much smaller than the standard open incision, and we can place it lower in the abdomen or around the belly button rather than just under the right ribcage, it tends to result in less post-operative pain.