LIVER SURGICAL DISEASES
• The liver is the largest organ in the body : 1200-1600 g • Regarded as a paired organ which is fused along a line which can be drawn between the gallbladder fossa and IVC. • Each lobe receives a full branch of the portal vein, hepatic artery and bile duct. • By further division of the vascular supply- each lobe is composed of 4 segments which are numbered 1 to 4 for the left and 5 to 8 for the right liver. • Recognition of the segmental nature of the liver can be ascribed to the French surgeon, Couinaud.
The classical description of the liver anatomy is based on the external appearance. On the diaphragmatic surface, the ligamentum falciforme divides the liver into the right and left anatomic lobes, which are very different from the functional right and left lobes In this classical description, the quadrate lobe belongs to the right lobe of the liver, but functionally it is part of left lobe.
Segmental anatomy according to Couinaud
Clockwise numbering of the segments
On a frontal view of the liver the posteriorly located segments 6 and 7 are not visible.
• Hepatic veins of surgical importance are three:
– the right hepatic vein which drains segments 6-8 by a short vessel directly into the suprahepatic vena cava, – the middle hepatic vein which drains from both hepatic lobes and empties directly into the vena cava or the left hepatic vein – the left hepatic vein which drains segment 2, 3, 4.
• Segment 1 or caudate lobe drains by several small hepatic veins directly into the infrahepatic vena cava.
• A careful identification of the vessels and ducts supplying each segment can be achieved by dissection above the portal hilum
• Each set may be ligated separately prior to an attempt at resection.
PORTAL VEIN, CBD, CHA
• In the portal hilum the portal vein which has formed behind the head of the pancreas by the junction of splenic and mesenteric veins, passes along the edge of the lesser omentum. • In front of and to the right, common bile duct drains both liver lobes and receives the cystic duct at a variable point of its course and on either side. • To the left of the common bile duct runs the common hepatic artery giving off the main cystic artery and branches to the common bile duct prior to division into right and left branches.
1. Bile formation and excretion • About 500-1000 ml. of bile are secreted each day. • The liver synthesizes bile acids from cholesterol. Almost all of the bile acids are reabsorbed by the terminal ileum and enter the enterohepatic circulation. • Bile pigments are derived from the breakdown of hemoglobin to biliverdin then bilirubin. In the liver unconjugated bilirubin is conjugated and then secreted into the bile canaliculi and transported to the gastrointestinal tract. • Bile contains cholesterol in micellar form, bile acids, phospholipids, electrolytes, mucin and water.
• Jaundice due to unconjugated bilirubinemia results from increased hemoglobin breakdown or diminished conjugation.
• Jaundice due to conjugated bilirubinemia is commonly associated with intrahepatic and extrahepatic bile duct obstruction and with hepatocyte damage.
• Jaundice is caused by a build up of bilirubin in the blood resulting in a yellow tinge to the skin and the whites of the eyes
2. Protein metabolism • The liver is a major sourse of beta and gammaglobulins and the only site of production of albumin and alpha-globulin. • Hepatocytes are capable of protein synthesis from aminoacids. The liver is also the major site of urea synthesis. Most of coagulation factors are synthesized within the liver. 3. Carbohydrate metabolism
4. Lipid metabolism • Cholesterol levels decrease markedly with hepatocellular failure. • Conversely, a rise in cholesterol is usually seen in intra-and extrahepatic obstruction.
5. Enzyme secretion by the liver • TGO (glutamic oxalacetic transaminase ) is found in high levels in hepatocellular damage. • Alkaline phosphatase is excreted through the biliary tree so that biliary obstruction is accompanied by a rise in the serum alkaline phophatase. • However, most liver disorders including hepatic abscess, trauma, metastases and diffuse liver disease (hepatitis) are associated with an elevated value. • A rise in the serum gamma-glutamyl transpeptidase (TGP) is increased in both cholestasis and hepatocellular disease.
1. 2. 3. 4. 5. 6. Plain abdominal X-ray Ultrasonography CT scanning of the liver Scintiscanning of the liver parenchyma Portography and arteriography. Needle biopsy of the liver
Plain abdominal X-ray
• May give helpful information in terms of:
– liver size and the position of the overlying diaphragm. – rarely a small gas/fluid level may be seen within an abscess – hydatic cysts are well shown due to calcification within the cyst wall.
• In patients with cholestasis, dilated IH-BD clearly pinpoint the presence of duct obstruction. • Gallstones may be diagnosed with an accuracy of 95% in the best hands. • Well shown are liver cysts and abscesses • Primary liver tumours and multifocal MTS are readily seen. • Intraoperative US of the liver can demonstrate precisely the anatomy of vascular structures, the boundaries of palpable liver tumours and the presence of impalpable foci enabling a more appropriate resection line.
• A 16-year-old girl presented to the emergency room of pediatrics department with complaints of abdominal pain, nausea and vomiting. • Physical examination revealed tenderness on the right upper quadrant of the abdomen. • Blood analysis showed increased white blood count with left shift, an ESR of 78 mm/h and CRP 279 mg/l. • Liver enzimes- increased levels
On abdominal X-ray, a metallic linear radio opaque image compatible with a foreign body was seen on right hepatic lobe localization
USS examination revealed a 3cm long linear echogeneity in segment 5 surrounded by an irregularly contoured heterogeneous hyper echoic area of 10x7cm in size -? migration of a swallowed foreign body into the liver accompanied by an abscess formation
• The patient remembered that she could have swallowed a sewing needle approximately a month ago while drinking water. She told that she saw a number of sewing needles in the water glass which she noticed after drinking some water. • On further examination with abdominal computed tomography (CT), the metallic foreign body and surrounding inflammation were better demonstrated
CT- foreign body in the right lobe of the liver
• The patient underwent surgical operation for the excision of the foreign body, but it could not be reached. • The patient went home with antibiotherapy for the surrounding inflammation.
• Two and a half months later the patient presented again with abdominal pain • Control CT examination demonstrated the migration of the foreign body near to the gallbladder • The surrounding inflammatory changes were disappeared.
Foreign body near to the gallbladder.
• On reoperation with open abdominal surgery, the sewing needle was found easily due to its migration nearby the gallbladder, and it was removed from the liver. • The patient recovered successfully after the operation.
CT scanning of the liver
• Normally the procedure is combined with contrast meal to define the stomach and duodenum and iv contrast to outline the vessels and focal lesions within the liver.
• The procedure is expensive and time-consuming but it is consistent and leads to relatively easy interpretation. • Furthermore surrounding structures are also well shown, particularly the diaphragm, lung bases and suprahepatic vena cava.
Big liver abscess and other three small liver abscesses
Chest X-ray with free air sickle and local drainage between diaphragm and liver
• The 58-year-old male patient was acutely admitted to emergency unit because of fever and diffuse abdominal tenderness and pain mainly in the right upper abdomen since two weeks. • One year before the patient had undergone a Whipple's procedure in our hospital because of an pT4, N1-Adenocarcinoma of the Vater's papilla.
• Investigations including: gastroscopy, ultrasonography abdominal CT-scan showed only an urinary tract infection. • Blood culture - escherichia coli infection, • The patient was treated in accordance to the microbiological results with ciprofloxacin. • Due to the rapid aggravation of the health condition the patient was finally transferred to another hospital.
• At admission - diffuse tenderness of the abdomen without any bowel sounds and a distinct pain in the upper abdomen. • There were no abdominal guarding or peritonitis signs. • The blood analysis showed a marked increase of the liver enzymes (ALT: 2769 IU/L, AST: 10561 IU/L, total bilirubin: 131,7umol/L), WBC: 34,1Gpt/L, C-reactive protein: 52mg/L) and diffuse coagulation dysfunction (PT: 14%, PTT: 109s, ATIII: 48%) combined with a hypotonic cardiovascular state.
• The abdominal USS was not reliable because of the diffuse gas concentration in the upper abdomen. • The chest X-ray showed a free air sickle between the diaphragm and the liver.
Chest X-ray with free air sickle and local drainage between diaphragm and liver
• A brownish fluid mixed with gas was drained by CT guidance. • A few hours later, the patient presented the clinical symptoms of a multiple organ failure. • Despite maximal intensive care treatment, the patient died 24 hours after admission. • The microbiological presence of clostridium perfringens was revealed in the drainage fluid.
CT-scan with an inserted percutaneous pigtail catheter into an extensive gas producing liver abscess
• Someone who figures that taking a step backward after taking a step forward is not a disaster.. it's a cha-cha.
Scintiscanning of the liver parenchyma
• Technetium scintiscann may detect focal lesions greater than 2 cm. in diameter in about twothirds of cases. • Generalized liver disease is demonstrated as reduced or patchy uptake with increased uptake of the spleen and bone marrow. • Gallium citrate is concentrated in neoplastic foci and abscesses • Hemangiomas concentrate isotope indium.
The use of 99m Tc labelled red blood cells (RBC) for the diagnosis of suspected cavernous haemangioma in the liver. Note the discordant accumulation indicated by the arrow.
Portography and arteriography
• The portal venous system may be demonstrated by splenic puncture using an intercostal route. Injection of contrast medium outlines the splenic and portal veins. • Celiac axis is approached by a Seldinger catheter. This technique has considerable value in planning operability of liver tumours and may be diagnostic of multifocal neoplasia when all other techniques have failed
Needle biopsy of the liver
Indications: - alcoholic liver disease - unexplained hepatomegaly- space-occupying lesions of the liver - drug-related liver disease It is contraindicated in patients with: - coagulopathies, - tense ascites and - suspected hemangiomas.
Pathogenesis • The main etiological factor is bile-duct infection with ascending cholangitis commonly due to E. Coli and anaerobic organisms. • Other sourses of infection include an ascending pylephlebitis- it arises particularly with complicated diverticulitis. • Some hepatic abscesses of staphylococcal and streptococcal origin arise as a complication of generalized septicemia • Others arise by direct extension from suppurative cholecystitis and subphrenic collections. • Obviously trauma to the liver tissue and subsequent infection produces an abscess. All types of abscesses are found more commonly in the right lobe.
• Diagnosis: pain RH, fever, chills, increased WBC, secondary anemia. • Treatment is usually a combination of drainage and prolonged iv antibiotic therapy .
• The patient was a 56-year old female: fever, vomiting and RH pain. • On palpation of the abdomen, there was tenderness and a vague mass in the right hypochondrium. • She was admitted with a diagnosis of acute cholecystitis.
• Lab. Tests: leukocytosis, mild anemia, normal LFT. • CXR normal. • USS showed a cystic mass of size 8 x 6cm in the right hypochondrium inferior to the liver; and a part of it attached to the liver. An opacity was also seen within the mass. Appendix was not visualized. The gall bladder was normal. • CT scan also confirmed the USG findings of the possibility of a liver abscess. Due to doubtful diagnosis - diagnostic laparoscopy.
• There was an inflammatory mass consisting of small bowel, cecum and omentum adherent to the inferior border of the liver. • The liver was normal. • The mass was separated from the liver with blunt dissection. • Gentle nudging with the tip of a suction probe resulted in outpouring of pus from the mass
• This was sucked out and further blunt dissection was carried out with the suction probe. • Along with the pus came fecoliths • It was an appendicular abscess arising from a perforated subhepatic appendix.
• Once the appendix was identified, appendectomy was done. • The abscess cavity was drained with a wide-bore drainage tube. • She had purulent discharge through the drainage tube that gradually stopped on the 4th postoperative day. • The patient was discharged on the 7th POD, totally symptom-free.
Clinical features of hepatic abscesses
• The clinical picture may be dominated by the primary disorder (ascending cholangitis, diverticulitis, suppurative cholecystitis). • Characteristically there is a high fever, rigors, profuse sweating, anorexia and vomiting with pain as a relatively late symptom. • An abscess may reach a very large size before causing pain if it is directed through the bare area of the liver. • Hepatomegaly is common. • On investigation an anemia and leucocytosis may be found. ESR is elevated. • Blood cultures are usually positive with pyogenic abscesses when taken during the height of pyrexia and anaerobic infection should be considered.
• Clinical suspicion of hepatic abscess may be confirmed by a technetium scintiscan or by ultrasonic or CT scanning of the liver which may also demonstrate the presence of pus.
• A plain film of the abdomen and chest may rarely show an air/fluid level within the liver substance and usually an elevated immobile diaphragm with loss of the anterior costophrenic angle is found.
• CT demonstrates a heterogeneous lesion with irregular margins and possibly peripheral contrast enhancement. Internal septations are common. • The radiologic differential diagnosis includes cystic or necrotic metastases and hydatid cysts. • Often the diagnosis of a bacterial abscess is suggested clinically. • Treatment consists of percutaneous or surgical drainage and antibiotics. • The mortality rate is almost 100% if the abscess remains untreated.
Amebic liver abscess is a collection of pus in the liver brought on by an intestinal parasite
Causes • Amebic liver abscess is caused by Entamoeba histolytica, the same organism that causes amebiasis, an intestinal infection also called amebic dysentery. The organism is carried by the blood from the intestines to the liver. • The disease spreads through ingestion of amebic cysts in food or water contaminated with feces • The infection occurs worldwide, but is most common in tropical areas where crowded living conditions and poor sanitation exist. Risk factors for amebic liver abscess include: Alcoholism , Cancer , Homosexual activity, particularly in men, Immunosuppression, Malnutrition, Old age, Recent travel to a tropical region, Steroid use.
Symptoms may include: • Abdominal pain – Particularly in the right, upper part of the abdomen – Intense, continuous, or stabbing pain • Chills • Diarrhea • Fever • General discomfort or ill feeling (malaise) • Jaundice • Joint pain • Loss of appetite • Sweating • Weight loss
Exams and Tests
Tests that may be done include: • Abdominal ultrasound • Abdominal CT scan or MRI • Complete blood count • Liver function tests • Serology for amebiasis • Stool testing for amebiasis
• An antibiotic medicine called metronidazole (Flagyl) is the usual treatment for liver abscess. • A medication such as iodoquinol must also be taken to get rid of all the amebas in the intestine. • This can usually be delayed until after the abscess has been treated. • The abscess may need to be drained to help relieve some of the abdominal pain.
Gross Pathology of amoebic liver abscess
Dysentery showing diffuse ulceration of mucosa
Ultrasound image of a large liver abscess in a child shows a typical hypoechoic collection within a rough/ shaggy walled cavity in the liver. It is likely that this lesion is due to amebic infection of the liver, a common condition in parts of India. As the disease progresses, sonography of the liver may reveal a fluid-debris layering and even later may cause an almost totally anechoic collection.
Complications of the liver abscess
• recurrent septicemia • extension and rupture of the abscess may occur in any direction: - peritoneal rupture results in peritonitis or subphrenic collection - extension through the diaphragm may lead to thoracic empyema or to a rupture into the bronchus with expectoration of large volumes of pus. - rarely, the abscess ruptures into the pericardium with high mortality.
- Antibiotics according to bacterial sensitivity; - Precise microbiological identification may result from aspiration of the abscess with ultrasonic control. - Drainage of the abscess cavity by repeated needle aspiration or fine-bore catheter directed under ultrasonic control. - Antibiotics may be instilled into the cavity. - Progress is monitored by repeated ultrasound scan examinations. - Surgical drainage if: - deterioration in the general condition of the patient - repeated episodes of septicemia - failure of the abscess to decrease in size.
• Most cysts are asymptomatic • When the cysts reach sufficient size to exert pressure on adjacent viscera, produce non-specific symptoms of vomiting, upper abdominal pain. • Clinical examination reveals a non-tender liver tumour. • Plain film of the abdomen may show displacement of the colon or stomach • The lesion may be confirmed by ultrasonography and scintiscanning.
• The main differential diagnosis is parasitic cysts and solid tumours. • With exception of the complications of rupture and intracystic hemorrhage, the operative treatment is confined to large solitary cysts which are usually completely extirpated or removed by limited hepatic resection.
Hydatid cysts of the liver
• This infestation is endemic in certain countries, particularly the southern half of South America, Australia, New Zeeland, France. • Man is the secondary host and becomes infected by ingesting vegetables and water fouled by dogs or more directly by handling the parasite-infested dogs as pets. • After ingestion the shell of the egg is destroyed by gastric acid and hatched within the duodenum. The liberated embryos migrate through the gut wall into the mesenteric circulation and lodge within the liver.
Hydatic cyst of the liver
• 80% of hydatic cysts are ultimatelly found in the liver parenchyma.
• The unilocular hydatic cyst is caused by Echinoccocus granulosus and the alveolar type is caused by Echinococcus multilocularis.
• Since the growth of the parasite is slow, many years elapse before the cyst reaches significant size. • On physical examination an anteriorly located cyst presents as a smooth rounded tense mass. • Secondary infection results in tender hepatomegaly, rigors and pyrexia associated with a deep-seated continuous pain.
Further clinical features are the result of cyst complications
• Intrabiliary rupture may give biliary colic and usually causes jaundice and fever. • Intraperitoneal rupture produces severe pain and shock classically associated with pruritus and urticaria. • Intrathoracic rupture may be preceded by symptoms of diaphragmatic irritation and rupture into bronchus leads to a partly bloodstained sputum which frequently becomes bile stained. Hydatic allergy is manifested by urticaria or very rare anaphylactic shock.
• The appearance of a painless liver swelling in a patient living in an endemic area gives a high index of suspicion. • An unruptured cyst may show on plain radiograph as a calcified reticulated shadow if not calcified by displacement of the diaphragm or a barium-filled stomach. • Scintiscanning shows a large filling defect and ultrasonography reveals an echogenic cyst. • Although the cyst is isolated from the liver by an adventitial layer, there is an absorption of parasitic products which acts as an antigenic stimulus. • This reflects in an eosinophilia in 25% of patients, a complementfixation test which is accurate in 93% of patients.
Multivesicular Hydatid Hepatic Cyst
Univesicular uncomplicated cyst
Multivesicular hydatid with multiple daughter cysts giving a septated appearance to the cyst
Old hypermature liver hydatid. Non-contrast CT shows calcification in the cyst wall and matrix and fluid within the cyst
Complications Rupture. Three types of ruptures are possible: contained, communicating and direct.
1. Contained rupture • This occurs when the endocyst ruptures in the lesion and biliary ducts do not penetrate the pericyst. This is asymptomatic and is diagnosed when sectional imaging (USS, CT) shows floating membranes within the hydatic lesion. Contained rupture does not predispose to secondary bacterial infection. 2. Communicating rupture. • This is possible when biliary ducts perforate the pericyst, allowing fluid and formed elements to escape into the biliary tree. Sectional imaging of liver cysts which have undergone communicating rupture demonstrates detached endocyst floating in the remaining cyst fluid and there may be evidence of downstream biliary obstruction. The bile that floods the pericystic cavity probably always kills the parasite but secondary infection is almost the rule.
• Involves removing the cyst without contamining the patient. • The initial stage involves protection of the operative field against live cysts using multiple coloured towels soaked in hypertonic saline which isolate the main cyst from the exposed peritoneal cavity. • Since hydatid fluid is under high pressure the cyst is decompressed by aspiration and injected with 20% saline and left 5 min. after which the cyst is opened and all daughter cysts removed as well as the germinal layer of the cyst.
• Spillage of cyst content during surgery is a cause of recurrence. • The cavity is drained for a variable period of time depending on the presence of fluid drainage. • Jaundice after intrabiliary rupture requires choledochotomy and clearance of cysts followed by T-tube drainage
• Hemangiomas are the commonest benign tumour but only rarely produce symptoms. • Histologically the lesion is composed of bloodfilled endothelial lined spaces separated by a varible degree of fibrous tissue. • These tumours, having grown to significant size will eventually produce pain or dyspepsia and develop a palpable abdominal mass. • Rupture is rare but leads to a major intraabdominal hemorrhage with shock and collapse.
• CT scann is usually quite diagnostic. • Where the diagnosis remains doubtful, arteriography will demonstrate the lesion. • A biopsy is not indicated. • The preferred treatment for clinically significant hemangiomas is wedge excision where possible. • Lobectomy is reserved for large lesions confined to one lobe. • The residual liver may contain further hemangiomas. • Scintiscanning and angiography will demonstrate the lesion and if there appears to be a major feeding vessel from the hepatic artery, it may be worthwhile ligating this vessel or the main hepatic artery.
• This is the commonest primary tumour of the liver and is usually a solitary lesion. • This ultrasound image shows a hyperechoic, homogenous, well-circumscribed mass of the liver.
Primary malignant tumours of the liver
• Although primary malignant tumours of the liver are uncommon in European and North American populations, the condition is very common in African, Chinese and Indian communities. • The incidence of liver cancer in a community is directly proportional to the incidence of viral hepatitis. Risk factors: • - alcohol intake, micronodular cirrhosis • - chronic liver disease. The incidence of hepatoma in cirrhosis may reach 25% but it is greatly elevated in patients with antigen positive chronic active hepatitis (42%).
• - abdominal distension due to hepatomegaly • - ascites and sometimes is bloodstained. • - hypoglycemia • - hypercalcemia, • - hyperlipidemia • - hyperthyroidism
• Lab. studies: -abnormal liver function tests - anemia due to intratumour hemorrhage - polycytemia due to erythropoietin release. - serum alphafetoprotein is a useful cancer marker - HBS antigen should be looked for in all patients. For patients undergoing surgery a study of the parameters of coagulation is a sensible precaution.
• Lesions greater than 2 cm. in size can be detected as a filling defect on a hepatic scintiscan but this mode of investigation has little value. • Ultrasound scanning demonstrates the size and position. • CXR for pulmonary metastases. • CT scan demonstrates the lesion and its relatioship to major structures. • Needle biopsy under CT guidance. • Arteriography is indicated for those patients in whom liver resection is contempleted.
Tumour localization and evaluation
• The object is to excise the lesion safely with a margin of healthy liver tissue of 2 cm. or more. • Procedures: • - wedge resection • - segmentectomy • - lobectomy • - hepatic transplantation
Radiofrequency ablation (RF ablation)
• Minimally invasive treatment for licer cancer • The RF ablation team includes radiologists, who perform the treatment, and oncologists, who determine whether RF ablation tumor treatment is appropriate for a patient.
• • • Electrical energy delivered through this needle heats and destroys the tumor. Over the following months, dead cells turn into a harmless scar. During the short RF ablation treatment, patients are under general anesthesia. In most cases, a tumor can be adequately treated with one treatment session. Typically, RF ablation creates a zone of tissue destruction uptill 6 centimeters in size. After treatment, patient is observed and the procedure can be repeated if new cancer appears
CT scan of colon cancer spread to the liver, 2 hours post RF treatment
2.5 years post RF treatment
• Tumors are less than 6 cm • No more than three tumors • No evidence of metastatic disease elsewhere
• RF ablation is safe and effective and has a very low rate of complications. • Reported preliminary survival curves are encouraging for small, solitary colorectal carcinoma (less than 2 cm) and hepatomas (less than 6 cm). • Recent reports indicate that RF ablation results in complete cell death in the majority of hepatomas of 6 cm in size. • Patients who have residual tumors can be re-treated if necessary
Non surgical management
• - chemotherapy- doxorubicine • - intra- arterial embolization • - radiotherapy