Liver resection
The liver resection (also hepatectomy ) is a surgical procedure in which a portion of the liver is removed.
If half of the liver is removed, the procedure is called a hemihepatectomy . The removal along the boundaries of the segment is called an anatomical resection , otherwise it involves an atypical resection . The removal of the entire liver ( hepatectomy ) is only used in the context of transplant surgery , since the liver is an indispensable organ .
indication
Partial removal of the liver may be necessary because of both benign and malignant diseases.
A number of reasons for benign diseases lead to the need for liver resection: These are mainly ( intrahepatic ) abscesses located in the liver , progressive cysts or local circulatory disorders in the liver.
Malignant diseases of the liver can occasionally be treated with a liver resection, insofar as they can be precisely defined locally. Liver resections to remove individual (solitary) or locally ( segmental ) limited liver metastases are more common . Whether the liver function is still adequate after such a liver resection can be determined in advance by means of the volume function planning.
execution
The procedure is performed with the patient lying on his back. To improve accessibility, the transition from the thoracic to the lumbar spine is usually hyperextended. The incision includes either an upper abdominal cross-section, which can be lengthened in the midline towards the sternum, or an abdominal incision in the midline (mostly in multi-organ surgery), or a thoracoabdominal approach , in which an upper abdominal incision is elongated in a J-shape in the midline the left half of the chest.
Resection
Anatomical resection: In this case, an entire lobe of the liver or individual, adjacent segments are removed according to their respective blood supply. For this purpose, the segment arteries, veins and portal vein branches are tied off as close as possible to their origin from the higher-level vessels or closed with metal clips. The same applies to the bile ducts. The soft parenchyma is then divided along the segment boundaries, which cannot always be reliably identified . Since all blood vessels and bile ducts are also connected to one another across the segment boundaries, careful attention must be paid to all blood and bile vessels, which is why ultrasound ( ultrasonic knife ) and high-frequency surgical devices of the newer generation are usually used. With these, a “gentle” coagulation of the sensitive tissue can be achieved without scabbing or charring, larger vessels can be easily identified and specifically closed.
Atypical resections or wedge resections are performed in processes that are close to the edge; The aim here is to avoid damaging the larger intrahepatic vessels as much as possible. However, this type of resection does not adhere to anatomically prescribed segments and can certainly exceed segment boundaries.
Laparoscopic liver resections, performed as atypical wedge resections rather than anatomical segment resections, have been performed at specialized centers since the early 1990s. The late expansion of minimally invasive surgery to include liver surgery is due to the complex anatomy and the sometimes serious intraoperative complications (e.g. bleeding, gas embolism). Despite these hurdles, the laparoscopic interventions could be carried out successfully in increasing quantity and extent. This has been confirmed in several studies which did not find any disadvantages of laparoscopy compared to the conventional procedure. In addition, some studies were able to demonstrate advantages in the postoperative healing process.
In all procedures, the control of bleeding and leakage of bile from the resection surface are the most important quality criteria. In addition to the modern coagulation technique mentioned above, special collagen fleece fabrics soaked with coagulation-promoting substances ( hemostyptics ) are used to avoid them .
Risks and possible complications
Bleeding during and after the operation (intra- and post-operative) can occur diffusely from the resection surface as well as locally from inadequately supplied / supplied larger blood vessels (whereby the veins represent the bigger problem here than the strong arteries due to their delicate, torn wall structure ) and assume life-threatening proportions. With more extensive liver resections, the need for blood transfusions is the rule rather than the exception.
Remain accumulations of residual blood ( hematoma ) in the surgical field, to threaten them to infect , with the consequences of an abscess or a purulent peritonitis . So-called bilious peritonitis can be at least as threatening due to the emergence of bile from the resection surface or an unclosed bile duct. These complications almost always require relaparotomy (reopening of the abdomen) or even a stage lavage , regular abdominal opening with irrigation and removal of pus and fibrin .
Less problematic is the formation of a so-called bile fistula, which occurs when bile emerges from the resection surface, but is drained to the outside via previously placed drains . Such fistulas can often persist for a long time without causing any real problems. Often they close by themselves.
Injuries to the draining biliary tract can lead to biliary build-up in the liver and thus to jaundice, or icterus . Usually this situation requires intervention. This can consist of a new operation, but also an ultrasound-controlled puncture ( PTC ) of the blocked bile ducts with subsequent installation of a bile drainage to the outside.
Bacterial infections of the bile ducts can lead to chronic cholangitis with subsequent liver cirrhosis .
If these more severe complications do not occur, the effect of a liver resection on the function of the organ is rather small. The high regenerative capacity of this organ allows resections of up to four fifths of the healthy liver tissue. The remaining organ residue can almost reach its original size again in a very short time.
There are different approaches to minimize risks and possible complications in the future. One approach is to combine the advantages of laparoscopy (shorter hospital stay, less pain, fewer pain relievers, better cosmetic results) with the advantages of interactive imaging. The operation is to be moved to an open MRI (oMRI). The images created there can show the surgeon in real time the position and course of endangered structures such as arteries, veins and bile ducts that he normally cannot see. The aim is to maximize the safety with which such structures can be surgically treated and to improve the surgeon's orientation.
Rehabilitation and prognosis
No special rehabilitation measures are required after an uneventful liver resection. Otherwise, they should be set according to the type and intensity of the complication (e.g. ARDS after long-term ventilation ). The prognosis depends on the underlying disease. If this is benign ( liver abscess or the like), the disease is of course usually brought to a standstill.
Colon cancer : If technically possible, liver metastases from colon cancer should be removed.
Primary hepatocellular carcinoma is treated with liver resection as long as it is operable. Prognosis and further treatment options in the main article.
Individual evidence
- ↑ M. Donadon M et al: Thoracoabdominal approach in liver surgery: how, when, and why. Updates Surg. 2014; 66 (2): 121-5
- ↑ Laparoscopic liver resection. E Vibert, T Perniceni, H Levard, C Denet, NK Shahri, and B Gayet; Br J Surg . 2006 January; 93 (1): 67-72. doi : 10.1002 / bjs.5150 .
- ^ Prospective assessment of the safety and benefit of laparoscopic liver resections. Olivier Farges, Pascal Jagot, Philippe Kirstetter, Jean Marty, and Jacques Belghiti; J Hepatobiliary Pancreat Surg. 2002; 9 (2): 242-248. doi : 10.1007 / s005340200026 .
- ↑ Guidelines ( EbM ) of the AWMF : S3 Guideline Colorectal Carcinoma ( Memento of the original from November 22, 2015 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. , Version 1.1. August 2014
