Overview
Definition:
Left hepatectomy is a major surgical procedure involving the removal of the left lobe of the liver
The left lobe comprises segments I (caudate lobe, though sometimes considered separate), II, III, and IV according to Couinaud classification
This procedure is indicated for a variety of benign and malignant conditions affecting this portion of the liver.
Epidemiology:
The incidence of left hepatectomy is lower than that of right hepatectomy, reflecting the distribution of liver pathology
It is more commonly performed for tumors arising from the left lobe, such as hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma, or liver metastases, as well as for certain benign lesions like adenomas or large hemangiomas that cannot be managed otherwise.
Clinical Significance:
Left hepatectomy is a critical intervention for treating localized liver disease within the left lobe
Successful execution requires a deep understanding of liver anatomy, vascular supply, and biliary drainage, as well as careful perioperative management to minimize morbidity and mortality
It is a procedure that significantly impacts patient survival and quality of life when indicated for oncological indications.
Indications
Malignant Tumors:
Hepatocellular carcinoma (HCC) confined to the left lobe
Intrahepatic cholangiocarcinoma involving the left lobe
Liver metastases from colorectal, neuroendocrine, or other primaries located predominantly in the left lobe and amenable to complete resection.
Benign Lesions:
Large or symptomatic hepatic adenomas in the left lobe
Giant or symptomatic hemangiomas in the left lobe
Congenital cysts or other rare benign lesions requiring resection.
Other Conditions:
Selected cases of liver trauma involving the left lobe
Management of hepatic artery pseudoaneurysm or arteriovenous malformations within the left lobe
Focal suppurative disease in the left lobe not responding to conservative management.
Preoperative Preparation
Patient Evaluation:
Comprehensive assessment of liver function (Child-Pugh score, MELD score)
Evaluation of tumor resectability and extent
Assessment of future remnant liver function and volume
Thorough cardiopulmonary evaluation.
Imaging Studies:
Contrast-enhanced CT scan (arterial, portal venous, delayed phases) for tumor staging, vascular anatomy, and future remnant liver volume calculation
MRI for better soft tissue characterization and vascular assessment
Chest X-ray and CT chest for metastatic workup
Doppler ultrasonography for vascular assessment.
Nutritional Support:
Optimization of nutritional status
Administration of high-protein, low-sodium diet
Vitamin and mineral supplementation as required.
Medical Optimization:
Management of ascites, encephalopathy, and coagulopathy
Prophylaxis against infections, particularly in patients with cirrhosis
Blood product availability and cross-matching.
Procedure Steps
Surgical Approach:
Open laparotomy (subcostal or Mercedes-Benz incision) or laparoscopic approach
Choice depends on surgeon expertise, patient factors, and tumor characteristics.
Liver Mobilization:
Dissection of the falciform ligament, left triangular ligament, and hepatogastric ligament to mobilize the left lobe
Identification and preservation of the inferior vena cava and suprahepatic veins.
Vascular Control:
Careful identification and ligation or division of the left portal vein and left hepatic artery
Mobilization and control of the left hepatic vein before its entry into the suprahepatic inferior vena cava.
Biliary Dissection:
Identification and division of the left hepatic duct
If the confluence is involved, a more extensive resection or reconstruction may be necessary
Meticulous hemostasis is paramount throughout the procedure.
Transection:
Division of the liver parenchyma using an ultrasonic dissector, cavitron ultrasonic surgical aspirator (CUSA), harmonic scalpel, or electrocautery, following the planned resection margin
Careful identification and control of smaller vessels and bile ducts within the parenchyma.
Postoperative Care
Monitoring:
Close monitoring of vital signs, fluid balance, and urine output in an intensive care unit (ICU) setting
Serial assessment of abdominal girth and presence of ascites.
Pain Management:
Effective analgesia using patient-controlled analgesia (PCA) or epidural anesthesia
Early mobilization to prevent deep vein thrombosis (DVT) and pulmonary complications.
Fluid And Electrolyte Balance:
Intravenous fluid management guided by hemodynamic parameters and urine output
Monitoring and correction of electrolyte imbalances, particularly potassium and sodium.
Nutritional Support:
Initiation of enteral feeding as soon as bowel function returns
parenteral nutrition may be required in select cases
Monitoring for signs of malnutrition.
Complication Surveillance:
Vigilant monitoring for early complications such as hemorrhage, bile leak, sepsis, hepatic insufficiency, and pulmonary issues
Regular laboratory investigations including liver function tests, coagulation profile, and electrolytes.
Complications
Early Complications:
Hemorrhage from the resection surface or major vessels
Bile leak from the cut surface or hepatic ducts (biloma)
Hepatic insufficiency (acute liver failure), characterized by jaundice, coagulopathy, and encephalopathy
Sepsis
Wound infection
Pneumonia
Acute kidney injury
Postoperative ileus.
Late Complications:
Biliary strictures leading to secondary biliary cirrhosis
Recurrence of malignancy
Incisional hernia
Chronic liver disease progression if underlying cirrhosis is present
Portal hypertension complications.
Prevention Strategies:
Meticulous surgical technique with precise vascular and biliary control
Adequate future remnant liver volume calculation and preservation
Prophylactic antibiotics
Early mobilization and pulmonary hygiene
Judicious use of blood products
Careful fluid management
Close postoperative monitoring.
Prognosis
Factors Affecting Prognosis:
Histological type of tumor
Stage of malignancy
Completeness of resection (R0 resection)
Underlying liver function (presence of cirrhosis)
Patient's general health status
Development of postoperative complications
Experience of the surgical team.
Outcomes:
For malignant conditions, successful R0 resection can offer the best chance of long-term survival and cure
For benign conditions, the goal is symptomatic relief and prevention of complications
The overall survival depends heavily on the underlying pathology.
Follow Up:
Regular follow-up appointments with imaging (CT/MRI) and laboratory tests to monitor for tumor recurrence or disease progression
For benign conditions, follow-up is aimed at monitoring for any late complications or recurrence of symptoms.
Key Points
Exam Focus:
Understand the anatomical segments of the left liver lobe (II, III, IV, and potentially I)
Recall the major vessels and ducts supplying and draining these segments
Differentiate indications for left vs
right hepatectomy
Recognize key complications like bile leak and hepatic insufficiency.
Clinical Pearls:
Accurate preoperative assessment of future remnant liver volume is crucial to prevent postoperative hepatic failure
Intraoperative ultrasound can aid in precise tumor localization and vascular structure identification
Careful hemostasis and identification of aberrant vessels are vital.
Common Mistakes:
Underestimation of remnant liver volume leading to insufficient future liver remnant
Inadequate control of the left hepatic vein or artery resulting in uncontrollable bleeding
Failure to identify accessory bile ducts leading to bile leaks
Not adequately addressing perioperative coagulopathy.