Overview
Definition:
Right hepatectomy is an extended hepatectomy involving the removal of the right lobe of the liver, including Couinaud segments V, VI, VII, and VIII, and often segments IVa and IVb, and sometimes segment I (caudate lobe)
It is a major surgical procedure performed for malignant and benign liver tumors, as well as other liver pathologies
The extent of resection depends on the location and size of the lesion, along with vascular and biliary anatomy.
Epidemiology:
Liver resections, including right hepatectomies, are performed for various indications, with primary liver cancers (hepatocellular carcinoma, cholangiocarcinoma) and colorectal liver metastases being the most common
The incidence of primary liver cancer is increasing globally
The decision for resection is based on tumor characteristics, patient comorbidities, and liver function
Advanced liver disease or unresectable tumors significantly impact prognosis.
Clinical Significance:
Right hepatectomy is a critical procedure in the surgical management of liver tumors
Achieving complete oncologic resection (R0) is paramount for improving survival in patients with liver malignancies
Understanding the indications, contraindications, surgical techniques, and management of complications is essential for surgical residents preparing for DNB and NEET SS examinations, as well as for providing optimal patient care.
Indications
Malignant Tumors:
Hepatocellular carcinoma (HCC) in patients with adequate liver reserve
Colorectal liver metastases amenable to complete resection
Intrahepatic cholangiocarcinoma
Other rare primary or secondary liver malignancies.
Benign Tumors:
Large symptomatic benign tumors such as hepatic adenomas or hemangiomas that pose a risk of rupture or hemorrhage
Focal nodular hyperplasia (FNH) if symptomatic or large
Other rare benign conditions requiring resection.
Other Conditions:
Selected cases of liver trauma requiring major resection
Certain parasitic infections (e.g., hydatid cysts) if extensive or complicated
Benign biliary strictures with extensive liver involvement requiring segmentectomy.
Preoperative Assessment
Liver Function Assessment:
Comprehensive evaluation of liver function using Child-Pugh score, MELD score, and indocyanine green (ICG) retention test
Estimation of future liver remnant (FLR) volume is crucial, often using CT volumetry
An FLR volume of at least 30-40% is typically required, increased in cases of cirrhosis or chemotherapy.
Imaging Studies:
Contrast-enhanced computed tomography (CECT) is the primary modality for tumor staging, assessing vascular involvement, and planning resection
Magnetic resonance imaging (MRI) may be used for better characterization of lesions and for biliary tree assessment
Angiography or multiphasic CT angiography helps delineate hepatic arterial and portal venous anatomy.
Patient Evaluation:
Thorough assessment of comorbidities (cardiac, pulmonary, renal) to optimize anesthetic and surgical risk
Nutritional status assessment
Discussion of surgical risks, benefits, and alternatives with the patient and family.
Surgical Management
Anesthesia And Monitoring:
General anesthesia with careful hemodynamic monitoring
Central venous pressure monitoring, arterial line, and urine output monitoring are standard
Transesophageal echocardiography (TEE) may be used for hemodynamic assessment
Intraoperative ultrasound is invaluable for tumor localization and assessing vascular structures.
Surgical Approach:
Laparotomy (subcostal or mercedes incision) or laparoscopic/robotic approaches are used
The choice depends on surgeon experience, tumor complexity, and patient factors
Laparoscopic right hepatectomy has shown comparable outcomes with reduced morbidity in selected cases.
Liver Parenchyma Dissection:
Dissection plane is typically along the hepatic veins (e.g., right hepatic vein) and portal pedicles
Techniques like Pringle maneuver (hepatic inflow occlusion) and Peli-Peli maneuver (intermittent clamping) are used to control bleeding
Glissonian sheath dissection at the porta hepatis can simplify pedicle control
Advanced energy devices (ultrasonic dissectors, bipolar devices) are commonly used.
Vascular And Biliary Control:
Meticulous control of hepatic artery, portal vein, and hepatic veins supplying the right lobe is essential
The right hepatic vein is often ligated early
Biliary stumps are closed with sutures or ligated
Reconstruction may be necessary for the inferior vena cava or major hepatic veins if involved.
Hemostasis And Drainage:
Careful hemostasis is achieved using sutures, clips, and hemostatic agents
The raw surface of the liver may be covered with omentum or peritoneum to reduce bleeding and bile leakage
Placement of drains (e.g., Jackson-Pratt) is standard to monitor for bile leaks or bleeding.
Postoperative Care
Intensive Care Unit Monitoring:
Close monitoring of vital signs, fluid balance, and liver function tests in the ICU for at least 24-48 hours
Pain management is critical
Early mobilization is encouraged.
Fluid And Electrolyte Management:
Aggressive fluid resuscitation may be required initially
Electrolyte imbalances, particularly hyponatremia, can occur
Careful monitoring and correction are necessary.
Nutritional Support:
Early enteral nutrition is preferred once bowel function returns
Parenteral nutrition may be required if enteral intake is insufficient
Adequate protein intake is important for liver regeneration.
Monitoring For Complications:
Vigilant monitoring for bile leaks (biloma, biliary peritonitis), post-hepatectomy liver failure (PHLF), hemorrhage, infection, and thromboembolic events
Serial abdominal ultrasound or CT scans may be performed.
Complications
Post Hepatectomy Liver Failure Phlf:
The most feared complication, characterized by impaired liver function (jaundice, coagulopathy, ascites) after resection
Risk factors include small FLR, underlying cirrhosis, and extensive resection
Management is supportive, with close monitoring and optimization of organ support.
Biliary Leaks And Fistulas:
Occurs in 5-10% of cases, manifesting as bile in drains, jaundice, or peritonitis
Management ranges from conservative (drainage, observation) to interventional (ERCP with stenting) or re-operation.
Hemorrhage:
Can occur from the raw liver surface, hepatic veins, portal vein, or hepatic artery
Early bleeding may require re-operation
delayed bleeding can be managed endoscopically or radiologically.
Infection:
Includes intra-abdominal abscesses, wound infections, pneumonia, and urinary tract infections
Prophylactic antibiotics and prompt treatment of infections are crucial.
Other Complications:
Pulmonary complications (pleural effusion, atelectasis), deep vein thrombosis (DVT), pulmonary embolism (PE), pancreatitis, and gastrointestinal dysmotility.
Prognosis
Factors Influencing Outcome:
Stage of the tumor, completeness of resection (R0 vs
R1/R2), patient comorbidities, liver function reserve, and surgeon experience are key determinants of prognosis
For malignant tumors, the underlying histology and grade are critical.
Outcomes For Malignancies:
For resectable HCC and colorectal metastases, a curative-intent resection can offer the best chance of long-term survival
Recurrence rates can be high, necessitating vigilant follow-up
Survival rates vary significantly based on tumor type and stage
For example, 5-year survival for resected HCC can range from 40-70%, while for colorectal metastases, it can be 30-50%.
Outcomes For Benign Conditions:
Benign conditions generally have excellent outcomes after successful resection, with complete cure and resolution of symptoms.
Key Points
Exam Focus:
Understanding FLR estimation and its clinical implications
Recognizing indications for extended hepatectomy
Differentiating surgical complications like PHLF from biliary leaks
Knowing Pringle maneuver and its modifications.
Clinical Pearls:
Always confirm vascular and biliary anatomy with pre-operative imaging
Use intraoperative ultrasound extensively
Maintain meticulous hemostasis
Early recognition and management of PHLF are crucial
Laparoscopic approach can be safe and effective for selected patients.
Common Mistakes:
Underestimating the risk of PHLF by not adequately assessing liver reserve or FLR
Inadequate control of major vascular or biliary structures
Failure to achieve R0 resection for malignant tumors
Delayed diagnosis and management of post-operative complications.