Overview of Hepatic Resection

3/30/2016 Overview of hepatic resection
Official reprint from UpToDate®

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Overview of hepatic resection
Authors Section Editor Deputy Editor

Steven A Curley, MD, FACS Stanley W Ashley, MD Wenliang Chen, MD, PhD
Evan S Glazer, MD, PhD, MPH
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2016. | This topic last updated: Nov 05, 2014.
INTRODUCTION — Hepatic (liver) resection is needed to manage many types of pathology, malignant and
benign. Planning hepatic resection needs to take into account the nature of the lesion and its location within the
liver, the patient's anatomy, and the quality and volume of the liver tissue that will remain after resection.
Perioperative outcomes for hepatic resection have improved due to better surgical techniques that take
advantage of the segmental anatomy of the liver, improved techniques for control of bleeding, and improved
intensive care. Hepatic resection that is performed in highvolume centers by specially trained hepatobiliary
surgeons is associated with better outcomes [13].
Surgical resection of the liver and complications of liver resection will be reviewed here. Specific management
of pathologies that indicate a need for liver resection and diseasespecific outcomes related to liver resection
are discussed in separate topic reviews. (See "Surgical management of potentially resectable hepatocellular
carcinoma" and "Surgical management of gallbladder cancer" and "Surgical techniques for managing hepatic
injury" and "Treatment of localized cholangiocarcinoma: Adjuvant and neoadjuvant therapy and prognosis".)
LIVER ANATOMY AND PHYSIOLOGY — The liver is divided into two lobar segments (right and left), and
further subdivided into eight (Couinaud) segments based upon vascular supply and bile duct distribution (figure
1). The segmental anatomy of the liver is the basis for the various types of anatomic hepatic resections (figure
2). The surgical anatomy of the liver and types of hepatic resection are discussed in detail elsewhere. (See
"Hepatic resection techniques", section on 'Surgical anatomy'.)
Liver function and regeneration after resection — The hepatocytes perform a variety of metabolic functions
including:
● Removing metabolic waste products, hormones, drugs, and toxins

● Producing bile to aid in digestion
● Processing nutrients absorbed from the digestive tract
● Storing glycogen, certain vitamins, and minerals
● Maintaining normal blood sugar
● Synthesizing plasma proteins, albumin, and clotting factors
● Producing immune factors and removing bacteria
● Removing senescent red blood cells from the circulation
● Excreting bilirubin
The expected volume of functional liver (ie, functional liver remnant) that is needed to maintain these important
metabolic functions following liver resection depends upon the quality of the remaining liver tissue and its
ability to regenerate. Liver regeneration is fundamental to the ability to perform more extensive hepatic
resections. The mechanisms responsible for this capability are an area of active research [46]. In an animal
model, angiogenesis inhibitors severely suppressed hepatic regeneration [5]. Although the exact amount of
hepatic tissue regenerated will vary from patient to patient, healthy livers can regenerate significant amounts of
liver within weeks to months after resection. In a series of 91 patients, liver volumes were measured before
and after liver resection [7]. At six months postoperatively, the volume of liver regenerated was linearly related
to the resected volume, but the liver volume had not yet reached total preoperative liver volume. Some patients
have insufficient regeneration and may experience functional liver failure if the liver remnant is too small. One
small study suggested that liver regeneration in obese patients with body mass index >30 may be slower than
in nonobese patients [8]. (See 'Contraindications' below.)
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Preoperative portal vein embolization prior to large volume hepatic resection can stimulate liver hyperplasia [4].
(See 'Preoperative portal vein embolization' below.)
INDICATIONS FOR HEPATIC RESECTION — Malignant tumor within the liver (primary or secondary) is the
most common indication for hepatic resection. However, benign liver conditions, which can be congenital or
acquired, may also require hepatic resection. Although hepatic trauma is most commonly managed
conservatively, on occasion, hepatic resection may be required to definitively manage hemorrhage.
Malignancy — Patients with underlying conditions of the liver known to predispose to malignancy are generally
screened at a regular interval for the development of cancer with imaging studies (eg, ultrasound, computed
tomography, magnetic resonance) and serum markers (eg, alpha fetoprotein) [9,10]. In susceptible patients, a
lesion that is clearly not a benign cyst should be considered malignant until proven otherwise, and dysplastic
nodules are considered premalignant lesions and generally treated as malignant [11].
Hepatocellular carcinoma is the most common primary hepatic malignancy and can occur in the context of
inherited (eg, hemochromatosis) or acquired (eg, chronic hepatitis C, alcoholic cirrhosis) preexisting conditions
[12,13]. In one large series, cholangiocarcinoma was the second most common malignant tumor for which
hepatic resection was performed [14]. (See "Epidemiology and etiologic associations of hepatocellular
carcinoma" and "Treatment of localized cholangiocarcinoma: Adjuvant and neoadjuvant therapy and
prognosis".)
The liver is a common site for metastasis from solid tumors. In selected patients with focal or isolated disease,
resection of liver metastases is associated with low rates of major perioperative morbidity (about 3 percent)
and mortality (about 4 percent) with good longterm results [1519]. Neuroendocrine lesions, primarily from the
foregut, are another source of metastases that respond well to liver resection [20,21]. Resection of
nondigestive endocrine, and noncolorectal, nonneuroendocrine tumor metastases (eg, breast, sarcoma,
genitourinary, melanoma) has also been reported [2224]. (See "Management of potentially resectable colorectal
cancer liver metastases" and "Metastatic gastroenteropancreatic neuroendocrine tumors: Local options to
control tumor growth and symptoms of hormone hypersecretion".)
Surgical treatment of gallbladder cancer involves resection of the gallbladder and involved tissues to obtain a
tumorfree margin. However, less than half of patients are candidates for resection at the time of diagnosis
because of advanced disease. Provided there is no evidence of disease elsewhere, options for hepatic
resection in patients with gallbladder cancer include extended cholecystectomy (en bloc resection of the
gallbladder and a rim of liver), reresection of portions of segments IVb and V, and less commonly, right
hemihepatectomy. (See "Surgical management of gallbladder cancer".)
Benign disease
● Simple cysts, hemangiomas, adenomas, and focal nodular hyperplasia comprise the majority of benign
hepatic lesions [2528]. Symptomatic lesions causing pain or discomfort can be resected with minimal
margins, often laparoscopically [29]. Most asymptomatic lesions can be managed conservatively and will
not require resection; however, some asymptomatic lesions, such as large or giant hemangiomas, and
adenomas larger than 4 to 5 cm, warrant resection when anatomically feasible [27]. (See "Hepatic
hemangioma" and "Hepatic adenoma" and "Diagnosis and management of cystic lesions of the liver".)
● Bacterial hepatic abscesses are generally managed with broadspectrum antibiotics and percutaneous
drainage [30,31]. Surgical resection may be needed to bring the infection under control. In one study,
aggressive local surgical resection for pyogenic abscess was found to be beneficial [32]. (See "Pyogenic
liver abscess".)
● Amebic liver abscesses are usually treated effectively with metronidazole without the need for surgical
intervention, biopsy, or drainage [33]. However, liver resection may be an option for the few very large
abscesses where rupture is a concern, for patients who do not respond to medical treatment, or if the
diagnosis is unclear [33]. (See "Extraintestinal Entamoeba histolytica amebiasis", section on 'Amebic
liver abscess'.)
● Hepatic resection is also effective treatment of intrahepatic stone disease when accompanied by biliary
stricture or segmental atrophy [34,35]. The management of these patients is individualized based upon
the location of stricture(s) and atrophic regions.
Trauma — Although the management of liver trauma is primarily conservative, liver resection may be needed
to control hemorrhage from higher grade (grade IV, V) liver injuries. Angioembolization for vascular liver injuries
is a safe and effective alternative to surgery for lower grade injuries in many institutions. The grading and
management of liver injuries and approach to the management of liver trauma in adults is discussed elsewhere.
(See "Management of hepatic trauma in adults", section on 'Surgical management' and "Management of
hepatic trauma in adults", section on 'Hepatic embolization' and "Surgical techniques for managing hepatic
injury".)
CONTRAINDICATIONS — Patients with severe underlying functional liver disease (eg, cirrhosis, non
alcoholic steatohepatitis [NASH], chemotherapyrelated) are not candidates for major liver resection. For
patients with less severe disease, the degree to which the underlying liver disease constitutes an absolute
versus relative contraindication to hepatic resection depends upon the anticipated volume of liver remaining
after resection (ie, future liver remnant [FLR]), the presence of medical comorbidities, and resources available
in the event of perioperative liver failure, such as the availability and proximity of liver transplantation. Model for
endstage liver disease (MELD) scores do not directly impact decisionmaking related to liver resection but
may be useful in counseling a patient when choosing between liver resection and transplant [36,37]. In these
cases, perioperative mortality after resection, death from primary disease, and risks associated with transplant
need to be taken into account. (See "Model for Endstage Liver Disease (MELD)".) [3841]
In retrospective reviews evaluating outcomes of patients undergoing liver resection, primarily resection of
hepatocellular carcinoma or colorectal metastases, the risk of death increases with decreasing volumes of the
future liver remnant [38,39,4246]. For patients with normal liver function, FLR <20 percent increases the risk of
liver failure and death following major hepatic resection [38,39]. In a review of 300 patients undergoing
extended hepatectomy, multivariate analysis found a significantly increased risk of mortality if the FLR was
≤20 percent (odds ratio 3.18, 95% CI 1.347.54) [39]. The incidence of postoperative liver insufficiency and
death were significantly greater in those with a FLR <20 percent compared with FLR 20.1 to 30 percent or FLR
>30 percent (liver insufficiency 34 versus 10 and 15 percent, respectively; death 11 versus 3 and 2 percent,
respectively). Patients with mildtomoderate underlying functional liver disease have further increases in the
risk of liver failure and death if the future liver remnant is inadequate, but there are no firm guidelines to define
what constitutes “inadequate” for specific populations [4749].
We use the following approach:
● We consider cirrhotic patients with ChildPugh (table 1) class C and ChildPugh class B with a FLR <40
percent as absolutely unresectable [42]. Other ChildPugh B (liver remnant >40 percent) and some Child
Pugh A patients may be relatively unresectable.
● We do not offer hepatic resection to patients with nonalcoholic steatohepatitis (NASH) who have a FLR
<30 percent [42]. There are few data on the safety of hepatic resection in patients with NASH but the
FLR should be higher than in patients with normal liver tissue. It may be reasonable to stratify these
patients as mediumrisk or highrisk based upon the presence of additional comorbidities such as insulin
resistance, cardiovascular disease, or morbid obesity [46]. For NASH patients with a FLR >30 percent
and no other major comorbidities, it may be reasonable to offer liver resection.
● For patients who are candidates for hepatic resection but who are deemed to have an inadequate FLR,
we suggest preoperative portal vein embolization. Preoperative portal vein embolization increases the
volume of the FLR and may permit subsequent hepatic resection. (See 'Preoperative portal vein
embolization' below.)
Additional contraindications to hepatic resection include comorbidities precluding/limiting safe anesthesia, or

location of disease near major vascular or biliary structures that would preclude a marginnegative resection.
Documented extrahepatic disease is a contraindication to hepatic resection for many malignancies, but not for
all. Inferior vena cava invasion is generally considered a contraindication to surgical intervention; however,
hepatic vein invasion away from the inferior vena cava, although suggestive of aggressive tumor biology, is not
an absolute contraindication. Diseasespecific contraindications to hepatic resection are discussed in separate
topic reviews.
PREOPERATIVE IMAGING — We obtain a preoperative imaging study on all patients prior to elective hepatic
resection to evaluate the potential margins of resection, which will determine the volume of the future liver
remnant (ie, anticipated volume of liver remaining after resection) (table 2) [50]. Considerations for specific
diseases are discussed elsewhere. (See "Surgical management of potentially resectable hepatocellular
carcinoma" and "Management of potentially resectable colorectal cancer liver metastases".)
It is important to obtain the highest quality imaging available. At some institutions, this will be computed
tomography (CT), and at others, magnetic resonance imaging (MRI); either is a reasonable choice provided the
study is performed with appropriately thin slice images and a properly timed intravenous contrast bolus. The
most experienced radiologist available with the chosen modality should provide the interpretation, and the
surgeon should also be comfortable interpreting the images. Although thinslice CT is more commonly used,
MRI may surpass CT in clinical utility as it becomes more time efficient, cost effective, and more readily
available [51].
We generally determine future liver remnant using CT volumetry in consultation with a radiologist. MRI
volumetry provides similar information. The volume of the remnant liver (FLV) will be according to the equation,
FLV = (future liver volume / total estimated liver volume) × 100 [52]. Although there are numerous equations
used to estimate liver volume [52,53], we prefer to have frank and detailed discussions with the radiologist to
measure the values of these volumes based upon the individual’s images to better tailor management.
Multiphase computed tomography (CT) includes noncontrast, arterial, venous, and portal phases, and should
also include volumetric analysis of the future liver remnant. The arterial phase should identify important arterial
anatomy, any aberrant vessels (such as replaced arteries), and define the relationship of intrahepatic tumor to
critical vascular or biliary structures. Omitting the portal venous phase increases the risk of missing small,
isodense hepatocellular carcinoma lesions [54].
Although other imaging modalities such as ultrasound, positive emission tomography (PET), and single photon
emission computed tomography (SPECT) may be useful adjuncts in management; poor resolution limits their
usefulness for defining anatomy in planning hepatic resection.
PREOPERATIVE PORTAL VEIN EMBOLIZATION — Preoperative portal vein embolization (PVE) is a

valuable adjunct to major liver resection, particularly for rightsided tumors [5559]. PVE initiates hypertrophy of
the anticipated future liver remnant (FLR) and may allow for a more extensive resection, or allow staged,
bilateral resections [4,41].
The probability of successful liver enlargement is inversely related to the volume of increase in the FLR that is
needed. In addition, as the amount of underlying liver disease increases, the likelihood that the liver will
actually enlarge in response to PVE decreases [60]. Systemic disease such as diabetes may additionally limit
liver hypertrophy and the success of the procedure. However, given the overall safety of PVE, and based upon
observational studies demonstrating improved survival and reduced rates of postoperative liver failure following
extended hepatic resections in those who have undergone PVE [38,40,61], in the absence of severe liver
dysfunction, we suggest an attempt at PVE in most patients with a marginal predicted future liver remnant (ie,
<20 percent in patients with a normal liver, <30 percent for patients with nonalcoholic steatohepatitis, <40
percent in patients with cirrhosis) [62]. PVE appears to be most beneficial for patients with steatohepatitis with
no metabolic dysfunction.
In evaluating the need for PVE, the ratio of future liver remnant and total estimated liver volume should be
determined from imaging studies. Volumetric assessment of the liver volume (CT or MR) imaging should be
performed before PVE and repeated four weeks after PVE to assess the extent of liver hypertrophy prior to
undertaking surgery [52,63]. In patients found to have an insufficient future liver remnant, the study scan can
be repeated in three to four weeks to assess further for hypertrophy. (See 'Preoperative imaging' above.)
Two techniques can be used for PVE: transileocolic portal embolization (TIPE) and percutaneous transhepatic
portal embolization (PTPE).
● The percutaneous approach (PTPE) is more commonly used [56], and can be performed in the radiology
suite with local anesthesia/conscious sedation.
● The TIPE procedure is performed via a minilaparotomy and requires general anesthesia.
Benefits — There are at least five potential benefits to PVE [55]:
● Postresection morbidity is diminished, as evidenced by minimal reductions in postresection liver function

[64], fewer pulmonary complications, and decreased length of intensive care unit and inpatient
hospitalization.
● Patients who were initially unresectable because of insufficient remaining normal hepatic parenchyma can
undergo resection for potential cure. In one study involving resection of extensive colorectal metastases,
the rate of curative resection was increased from 46.4 to 79.2 percent following portal vein embolization
[65].
● Subclinical disease or rapid progression may be detected prior to definitive surgery on postembolization
imaging studies, thus preventing an unnecessary operation.
● The volume of remaining liver standardized to patient size (body surface area) predicts mortality after
resection in cirrhotics, and the increase in functional liver volume achieved by PVE may decrease
mortality of resection in these patients [55,64,66].
● The absence of compensatory hypertrophy in response to successful PVE indicates the patient is not
suitable for major hepatic resection.
Risks — Some reports have shown accelerated tumor growth in the liver after PVE. However, tumor growth is
not seen when all of the tumorbearing areas of the liver are embolized [41]. Risks specific to portal vein
embolization include portal vein thrombosis, liver infarction and necrosis, and portal hypertension [52]. Other
risks related to percutaneous transhepatic access are similar to those of any percutaneous intervention such
as bleeding, infection, pseudoaneurysm, and arteriovenous fistula [52].
Alternative to PVE: ALPPS — The Associating Liver Partition and Portal Vein Ligation for Staged
Hepatectomy (ALPPS) procedure is an alternative to PVE [6772]. With ALPPS, two hepatic operations are
performed consecutively typically within two weeks of each other [73]. As an evolving technique, data
supporting ALPPS are limited, and percutaneous portal vein embolization remains the preferred technique for
patients with an inadequate future liver remnant [67]. Although conceptually interesting, the patient is exposed
to additional operative risk. We suggest that this approach should only be used in highly selected patients at
hepatobiliary centers of excellence with experience with ALPPS.
The goal of this procedure is to provide an oncologically sound operation when there is a high likelihood of an
inadequate future liver remnant, as is often the case with bilateral disease. The first operation consists of focal
ablation/limited resection of the future liver remnant combined with contralateral PV ligation (eg, leftsided
clearance of minimal tumor plus rightsided PV ligation). Usually, the liver parenchyma is divided (but not
resected) during the first procedure. One to two weeks after the first procedure, the second procedure resects
the remaining tumor burden with hepatectomy on the ipsilateral side of the PV ligation. The intervening time
period allows for liver hypertrophy of the future liver remnant such that, theoretically, there will be adequate
future liver remnant after the second operation. A small case series of patients undergoing ALPPS showed an
average hypertrophy rate of 85 percent of liver volume and major morbidity and mortality rates of 35 and 6
percent, respectively [72]. A retrospective review compared outcomes of patients undergoing portal vein
embolization (n = 72) or ALPPS (n = 48) [71]. The primary endpoint was complete tumor resection.
Significantly more patients achieved complete resection in the ALPPS group (83 versus 66 percent). The
extrapolated liver growth rate was 11 times higher with ALPPS (34.8 mL/day versus 3 mL/day). There were no
differences for tumor recurrence at one year (54 versus 52 percent).
PREOPERATIVE EVALUATION AND PREPARATION — The evaluation of the patient undergoing hepatic
resection involves medical risk assessment and a determination of the location of the lesion using imaging
studies, expected margins of resection, and the volume of the residual liver remnant. Together, these will
determine if resection is feasible, and if so, the extent of the resection. Some patients may benefit from portal
vein embolization. These considerations are discussed in the sections above. (See 'Preoperative imaging'
above and 'Preoperative portal vein embolization' above.)
Prior to hepatic resection, a frank conversation should be undertaken with the patient and their family regarding
the potential benefits of hepatic resection and complications, particularly the possibility of liver failure for those
at risk. The risk of bile duct injury and bile leak and the potential need for repair, which might require an
additional procedure, such as a hepaticojejunostomy or other biliaryenteric anastomosis, should also be
discussed. (See 'Complications' below and 'Mortality' below.)
The patient with malignancy should understand that the procedure usually begins with diagnostic laparoscopy
and intraoperative ultrasound, and if unresectable hepatic or extrahepatic lesions are found, the procedure will
be terminated without hepatic resection.
Medical assessment — Assessment of operative risk prior to liver resection includes establishing the severity
of liver disease, and the presence of other medical comorbidities. The majority of hepatic resections are
performed under elective circumstances for which there is adequate time for risk assessment and optimization
of the patient's medical status. Preoperative medical assessment is discussed elsewhere. (See "Assessing
surgical risk in patients with liver disease" and "Evaluation of cardiac risk prior to noncardiac surgery" and
"Evaluation of preoperative pulmonary risk" and "Preoperative medical evaluation of the healthy patient".)
Prior to hepatic resection, a complete blood count, serum chemistries, and liver function tests, albumin and
coagulation studies should be obtained. Patients found to have liver dysfunction may not tolerate the extent of
resection that would otherwise be indicated on imaging studies. (See 'Contraindications' above.)
Risk stratification for hepatic resection depends upon properly identifying those with liver tissue abnormalities.
Core liver biopsy should be performed if there is any concern about nonalcoholic steatohepatitis (NASH),
chemotherapyinduced steatohepatitis, or liver fibrosis. (See "Percutaneous, fineneedle aspiration, and
laparoscopic liver biopsy".)
Prophylactic antibiotics — A decision to administer antibiotics in patients undergoing hepatic resection

should take into account the indication for the procedure (eg, tumor, infection) and any additional procedures
(eg, cholecystectomy, colectomy) that will be performed. When hepatic resection is being performed without
surgery on other organs, and without known or suspected infectious conditions, hepatic resection can be
considered clean surgery.
In general, prior to clean, uncontaminated hepatic resection, we give antibiotics directed against skin flora
(table 3) within one hour prior to the incision [74]. In the placebo arm of one small, randomized trial, patients did
not receive any antibiotics in the perioperative period [75]. Wound infection rates were similar to those reported
using prophylactic antibiotics suggesting that routine prophylaxis prior to clean hepatic resection may not
always be necessary. Perioperative antibiotics generally suffice, but patients undergoing combined surgeries
and those with complications may require ongoing antimicrobial therapy [76]. (See "Control measures to
prevent surgical site infection following gastrointestinal procedures in adults".)
For hepatic resection associated with cholecystectomy, we give antibiotics according to the presence of any
biliary tract complications with antibiotics directed against skin flora if the gallbladder is normal (table 3), and
against biliary flora if there are complications such as obstruction, infection, or prior biliary tract
instrumentation. (See "Open cholecystectomy", section on 'Prophylactic antibiotics'.)
When resection of hepatic metastases is combined with surgery of other gastrointestinal structures (eg, colon
resection) (table 3), antibiotic prophylaxis should be directed toward any likely sources of contamination.
For hepatic resection being performed to control infection, antibiotics appropriate to the diagnosis should be
continued. (See "Pyogenic liver abscess", section on 'Antibiotics'.)
Thromboprophylaxis — Patients undergoing major liver resection are at risk for thromboembolism (table 4),
due to the nature of the surgery (major open surgery >45 minutes) and intraoperative maneuvers that may lead
to caval compression. The presence of malignancy increases the risk [77]. We place intermittent pneumatic
compression devices prior to induction and continue their use until the patient is ambulatory. Pharmacologic
thromboprophylaxis is recommended for moderate and highrisk patients. (See "Prevention of venous
thromboembolic disease in surgical patients", section on 'Moderate risk general and abdominalpelvic surgery
patients' and "Prevention of venous thromboembolic disease in surgical patients", section on 'High risk general
and abdominalpelvic surgery patients'.)
Anesthesia and analgesia — Hepatic resection is generally performed under general anesthesia with or
without epidural anesthesia/analgesia. The choice of anesthesia and the effects of anesthesia in patients with
liver dysfunction are discussed elsewhere. (See "Overview of anesthesia and anesthetic choices" and "Effects
of anesthesia and surgery on the liver".)
For open hepatic resection, epidural analgesia is a useful adjunct due to the extent of the incisions and also to
aid pain management in the postoperative period, which improves pulmonary mechanics and decreases the
risk for pulmonary complications. We have found that the benefits of epidural analgesia for postoperative pain
outweigh the risks associated with liver resection, but the choice to proceed requires close collaboration with
the medical providers managing the epidural catheter, usually an acute pain consulting service or the
anesthesia providers. (See "Overview of anesthesia and anesthetic choices" and 'Complications' below and
"Management of acute perioperative pain", section on 'Epidural analgesia with local anesthetics and opioids'.)
For major hepatic resections, invasive blood pressure and central pressure monitoring may aid anesthetic
management. Warming devices (fluid warmers, external circulation devices) are routinely used given the extent
and duration of exposure of the abdominal cavity, and the frequent need for fluid therapy and transfusion. (See
"Intraoperative fluid management".)
HEPATIC RESECTION — Hepatic resection is performed in a stepwise fashion starting with laparoscopy and
ultrasound imaging to evaluate the potential for complete resection and to define the relevant anatomy. (See
"Hepatic resection techniques", section on 'Staging laparoscopy and use of ultrasound'.)
Type and extent of resection — The type of hepatic resection chosen depends upon the location of the
lesion(s), the ability to provide an adequate future liver remnant, and for malignant disease, a tumornegative
margin. The types of hepatic resection include wedge resection, segmental resection (sectionectomy,
sectorectomy), hepatectomy (right or left), and extended hepatectomy (right or left) (figure 2). Each of these
(except wedge resection) constitutes anatomic resection based upon the segmental anatomy of the liver
according to Couinaud (figure 1), but alternatively, nonanatomic resection can be performed. For most
resections, cholecystectomy is performed followed by dissection of the porta hepatis to isolate and control the
vascular and ductal structures. Thereafter, the liver tissue is divided to the extent that is mandated by the type
of liver resection being undertaken, and hemostasis achieved prior to abdominal closure. The general
techniques used for hepatic resection and the manner in which specific resections are performed are discussed
elsewhere. (See "Hepatic resection techniques", section on 'General techniques' and "Hepatic resection
techniques", section on 'Specific resections'.)
Anatomic resection, rather than nonanatomic resection, may be preferred because of improved perioperative
outcomes and longterm survival [7881]. However, nonanatomic resection may be needed if anatomic
resection will result in inadequate residual liver volume to support recovery, such as in the patient with
cirrhosis. More bleeding may occur with nonanatomic resection, which is a disadvantage of this technique;
however, inflow occlusion can be used to reduce blood loss. (See "Hepatic resection techniques", section on
'Vascular control'.)
Bilobar metastatic malignant disease is typically found in two variants: small lesions in fewer than four
segments and larger lesions diffusely spread throughout the liver. Small lesions can be resected with similar
outcomes using two partial anatomic or nonanatomic hepatic resections, provided sufficient healthy liver
remains [82]. Another option is resection of one lesion and radiofrequency ablation of the second [83,84]. Portal
vein embolization can also be used to induce hypertrophy of the parenchyma, allowing bilateral or staged
resections [83,85]. (See 'Preoperative portal vein embolization' above.)
Tumor invasion into the diaphragm may require concurrent resection of a portion of the diaphragm. However, it
is not clear if this extended procedure provides a longterm benefit [8688]. If the resection can be
accomplished enbloc, we believe it is reasonable to resect such a tumor. Mesh repair of the defect has been
reported, but the oncologic consequences are unknown [87].
Resection margins — The margin of resection that is needed depends upon the indication for liver resection.
Benign lesions, such as hemangiomas, adenomas, complex cysts, and fibronodular hyperplasia can be
excised by enucleation or resection with limited margins.
Data to guide the margin of hepatic tumor resection are relatively sparse. We suggest a margin of at least 1 cm
when resecting malignant tumor. A margin of 2 cm may be even more desirable for aggressive tumor biology,
but this is frequently not possible. As an example, for tumor in proximity to major vascular structures, a
resection margin of only a few millimeters may be all that can be achieved.
For resecting colorectal metastases, some have suggested that a negative margin as little as 1 mm (compared
with a traditional 1 cm margin) is adequate, but this is controversial [8992]. Studies evaluating outcomes using
greater or lesser margins have been confounded by a greater proportion of patients for whom a lesser margin
was used because of multiple metastases or synchronous bowel disease [91]. It is possible that other types of
metastatic lesions could be treated similar to colorectal metastases, but until more evidence is available for
other specific types of liver metastases, we prefer at least a 5 mm tumorfree margin, if at all possible. (See
"Management of potentially resectable colorectal cancer liver metastases".)
We use a 1 cm margin for hepatocellular carcinoma or cholangiocarcinoma because of lower recurrence rates
with this margin and slightly prolonged rates of survival [9397]. (See "Surgical management of potentially
resectable hepatocellular carcinoma".)
The ‘optimal’ margin of resection for managing gallbladder cancer is also not well defined. For primary
resection, a 5 mm tumorfree margin may be reasonable; however, if reresection is being undertaken, a 1 to 2
cm tumor free margin should be the goal. (See "Surgical management of gallbladder cancer", section on
'Surgery'.)
POSTOPERATIVE CARE — Following hepatic resection, patients can typically be extubated in the operating
room. The patient should be admitted to a monitored setting, the nature of which depends upon the extent of
the operation and hospital facilities (eg, intensive care unit, stepdown type unit with telemetry).
Intensive care is often needed for one or two days to monitor hemodynamics, glucose levels, coagulation
parameters and electrolytes. In the immediate postoperative period, hyperglycemia and coagulation
abnormalities are relatively common. We aggressively monitor and control blood sugar and correct abnormal
coagulation parameters, as described below. Hypophosphatemia, potentially related to increased phosphate
uptake by regenerating liver cells, occurs in nearly all patients following major hepatic resection and should be
corrected, as needed [98]. (See "Evaluation and treatment of hypophosphatemia".)
For minor hepatic resection and uncomplicated major resections, the diet can usually be resumed on the first
postoperative day and advanced as tolerated, and ambulation is encouraged starting on postoperative day one.
Discharge is generally possible between postoperative days four and six.
Glycemic control — Postoperative hyperglycemia is common following major hepatic resection, and insulin
resistance after liver resection can make adequate blood glucose control challenging. We obtain routine blood
glucose measurements every one to two hours for the first two to three days postoperatively and control blood
glucose with an insulin drip to maintain blood glucose within a normal range (typically 90 to 130 mg/dL), until
longeracting insulin is effective at controlling blood glucose levels. In general, we do not advocate overly tight
control due to the increasing evidence that hypoglycemia may be as harmful as hyperglycemia [99101]. (See
"Management of diabetes mellitus in hospitalized patients" and "Glycemic control and intensive insulin therapy
in critical illness".)
Coagulopathy and hemorrhage — The incidence of posthepatectomy coagulopathy is difficult to determine.

Factors that contribute to coagulopathy following hepatic resection include hemodynamic instability,
intraoperative blood loss, preexisting hepatic dysfunction, acute liver injury in the remnant liver tissue, and
hypothermia [102105].
We correct any coagulation abnormalities as they are identified (intraoperative, postoperative) with early and
aggressive component transfusion. However, recombinant Factor VII should not be used when there is ongoing
intraoperative bloodloss. One trial that randomly assigned patients undergoing hepatic resection to blood
transfusion or recombinant Factor VII did not find any significant differences in outcomes between the
treatments [106]. (See "Use of blood products in the critically ill" and "Clinical use of plasma components" and
"Clinical and laboratory aspects of platelet transfusion therapy", section on 'TTP or HIT' and "Therapeutic uses
of recombinant coagulation factor VIIa in nonhemophiliacs" and "Massive blood transfusion".)
FOLLOWUP — When the patient is ready for discharge, it is important to develop a strategy to manage
potential complications for patients who have travelled to a regional center of excellence to undergo hepatic
resection. In one retrospective review of 1281 patients, 14.4 percent of patients required readmission and 6.8
percent required reoperation [107].
The patient should return to see their surgeon one to two weeks after the surgery to evaluate wound healing
and their overall recovery. The patient should also followup with their primary physician and/or medical
oncologist within a month of discharge regarding longterm treatment plans and options for adjuvant therapy.
We make an appointment to see the patient again at three to six months postoperatively and again at 12
months to reassess the surgical incision, the patient’s weight, and their liver function. For patients with
malignancy, we continue to followup every six months to assess for recurrent disease, or new metastatic
disease to the liver.
In cases of early recurrence, or the unfortunate occurrence of a positive margin, whether or not to proceed with
a second (ie, reresection) becomes a complex decision that is rarely encountered. The same considerations
that are discussed above for primary resection should also be applied. Reresection can be considered for
patients with primary liver tumors or metastatic liver tumors, but only for patients with no metastatic disease
outside the liver. There must be adequate hypertrophy of the liver after the first resection and the resection
should be anatomically feasible based upon the location of the recurrent disease. Fundamentally, prior to re
resection, the patient’s liver function (and other comorbidities) as well as functional status should have returned
to baseline. We prefer to wait at least three months; however, if the tumor biology is more aggressive in nature,
we will wait six months or longer to allow for a trial of chemotherapy or biologic therapy, as indicated.
COMPLICATIONS — Complications of any kind after hepatic resection occur in up to 40 percent of patients
without cirrhosis, and at a higher rate in patients with some degree of cirrhosis [18,44,102,108,109]. In a review
of 13,558 hepatobiliary operations from the American College of Surgeons National Surgical Quality
Improvement Program (NSQIP) database, overall perioperative morbidity was 18 percent for the resection of
benign hepatic lesions, and 21 percent for resection of hepatic malignancy [110]. Morbidity was highest for
patients undergoing extended hepatic resection at 33 percent compared with 25 percent for hemihepatectomy,
and 21 percent for partial hepatectomy (ie, segmentectomy or sectorectomy).
Major complications occur in about 10 to 20 percent of patients [102,103,109,111], and include bile leak,
pulmonary complications, acute kidney injury, and liver failure. Advanced age and the presence of metabolic
syndrome are associated with an increased risk for complications following hepatic resection [112,113].
Bile leak — Bile leak occurs in less than 10 percent of patients following hepatectomy. The International Study
Group of Liver Surgery (ISGLS) has defined bile leakage as bilirubin concentration in drainage fluid at least
three times the serum bilirubin concentration on or after postoperative day three, or as the need for radiologic or
operative intervention resulting from biliary collections or bile peritonitis [114]. Bile leakage following hepatic
surgery is further classified as Grade A, B, or C. Grade A bile leakage causes no change in patients' clinical
management. A Grade B bile leakage requires active therapeutic intervention but is manageable without re
laparotomy, whereas for Grade C bile leakage, relaparotomy is required.
In retrospective reviews, independent risk factors associated with clinically relevant bile leakage (B, C) include
drain fluidtoserum total bilirubin concentration, prolonged operative time, resection for hepatocellular
carcinoma, repeat hepatectomy, and left trisegmentectomy [115,116]. The majority of bile leaks can be
managed with endoscopic decompression and percutaneous drainage [116]. The main causes of intractable bile
leak are latent biliary stricture due to prior treatments and intraoperative hepatic duct injury during repeat
hepatectomy [115]. (See "Endoscopic retrograde cholangiopancreatography: Indications, patient preparation,
and complications".)
Pulmonary complications — Due to the altered respiratory physiology from the extent of the incision and
retraction needed for surgical exposure, pulmonary complications following open upper abdominal surgery are
common. In a retrospective study of 555 patients undergoing hepatic resection, pleural effusion and pneumonia
occurred in 40 and 22 percent, respectively [117]. On multivariate analysis, independent risk factors for pleural
effusion included prolonged surgery, right hepatectomy, neoadjuvant chemotherapy, and bilateral subcostal (ie,
Chevron) incision. Risk factors for pneumonia included intraoperative blood transfusion, diabetes, and atrial
fibrillation. The diagnosis and treatment of postoperative pulmonary complications are discussed elsewhere.
(See "Overview of the management of postoperative pulmonary complications".)
Ascites — Ascites is common in patients with liver disease and is often found postoperatively [118]. Severe or
increased amounts of ascites should alert the physician to the possibility of portal vein thrombosis [119], or that
liver failure may be ensuing. Routine aspiration or drainage is not recommended.
Thrombotic complications — Portal vein thrombosis and hepatic artery thrombosis are regarded as
uncommon but serious potential complications of hepatic resection, and may be related to technical issues
during the operation. A study of 222 patients without preoperative portal vein thrombosis underwent
hepatectomy [120]. The incidence of postoperative portal vein thrombosis was 9.1 percent. Multivariate
analysis identified right hepatectomy as a significant independent risk factor for main portal vein thrombosis
(odds ratio 109, 95% CI 112906). Patients with peripheral portal vein thrombosis had a significantly longer
duration of the Pringle maneuver than patients without portal vein thrombosis (76 versus 43 minutes). Patients
were selectively anticoagulated depending on extent of thrombus, effect on portal flow, and risk for bleeding.
Among those who were anticoagulated, portal vein thrombosis resolved in all patients after a mean treatment
period of 1.6 months (total mean duration of therapy 4.6 months).
Symptoms of portal vein thrombosis are often vague and may be obscured by postoperative pain, but sharp
increases in liver function tests should raise suspicion for portal vein thrombosis [119,120]. If there is any
concern for a thrombotic complication, we suggest imaging evaluation (Doppler ultrasound or computed
tomography of the abdomen) to assess portal venous and/or hepatic artery flow. Portal vein or hepatic artery
thrombosis may require reoperation. (See "Acute portal vein thrombosis in adults: Clinical manifestations,
diagnosis, and management".)
Liver failure — The most severe complication of hepatic resection is posthepatectomy liver failure (PHLF)
[102]. One clinically useful definition of PHLF is impairment in the liver’s ability to maintain its synthetic,
excretory and detoxifying functions as characterized by an increased international normalized ratio (INR) and
hyperbilirubinemia on or after postoperative day number five [121]. Mortality related to PHLF can be as high as
70 percent [14,122124]. The main risk factors for PHLF are underlying functional liver disease and an
insufficient volume of the residual liver remnant [125,126]. In small, experimental studies, elevated portal
venous or hepatic venous pressures were found to predict PHLF [127,128]. However, preoperative pressures
are not readily available, and thus, proper patient selection and preparation remains the most effective means
of prevention. The importance of an adequate future liver remnant cannot be overly stressed. Management of
PHLF is primarily supportive [121,124]. (See "Acute liver failure in adults: Management and prognosis".)
MORTALITY — Perioperative mortality following hepatic resection is 1 to 3 percent at highvolume centers

[102]. In a review of 13,558 patients who underwent hepatobiliary surgery from the American College of
Surgeons National Surgical Quality Improvement Program (NSQIP) database, perioperative (30day) mortality
was 2.1 percent for patients undergoing hepatic resection, and was similar for benign and malignant lesions
[110].
A retrospective database review in Taiwan identified 13,159 patients who underwent liver resection. Overall
mortality was 3.9 percent [129]. Preexisting renal disease and cirrhosisrelated complications were the
strongest predictors of mortality. A risk score was developed based upon known risk factors for mortality.
Mortality for those with scores ≤3 were <2 percent, whereas for a score >3, mortality was between 7 and 15
percent. The components of the score included:
● No points:
• Benign disease
• Less than lobectomy
● 1 point:
• Age (>65 years)
http://www.uptodate.com/contents/overviewofhepaticresection?topicKey=SURG%2F15094&elapsedTimeMs=0&source=search_result&searchTerm=… 10/27
• Lobectomy or more
● 2 points:
• Ischemic heart disease
• Heart failure
• Cerebrovascular disease
• Malignancy as indication for surgery
● 3 points:
• Preexisting cirrhosisrelated complications
● 4 points:
• Preexisting renal disease
In another series of over 100 resections for hepatocellular carcinoma, the presence of cirrhosis (95 percent
ChildPugh A patients) similarly increased operative mortality from 1 to 14 percent [44]. Mortality of ChildPugh
Class C (table 1) patients ranges from 30 percent to 100 percent, depending upon the extent of liver resection
[36,37]. Nonalcoholic steatohepatitis (NASH), which is highly associated with obesity, diabetes, and
inflammation, is also associated with increased perioperative morbidity and mortality following liver resection
[45].
Longterm survival following hepatic resection depends upon the pathology treated, and, for malignancies, the
ability to achieve a negative margin. As examples, hepatic resection of colorectal metastases is associated
with overall 1, 5, and 10year survival rates of 93, 47, and 28 percent, respectively [130]. Overall, fiveyear
survival following resection of hepatocellular carcinoma ranges from 60 percent for small, nonfibrotic lesions
(T1F0) to 10 percent for large, fibrotic lesions (T3F1) [131]. The prognosis of these malignancies and the
outcomes of the various benign pathologies treated with hepatic resection are discussed in separate topic
reviews.
SUMMARY AND RECOMMENDATIONS
● Hepatic (liver) resection is used to manage many types of liver pathology. Malignant tumor within the liver
(primary or secondary) is the most common indication for hepatic resection. Benign liver conditions that
require hepatic resection are usually symptomatic and can be congenital or acquired. Hepatic trauma is
most commonly managed conservatively, but on occasion, will require hepatic resection to definitively
manage hemorrhage. (See 'Indications for hepatic resection' above.)
● The preoperative evaluation of patients undergoing hepatic resection involves medical assessment and
imaging studies to determine the location of the lesion, potential margins of resection, and the expected
volume of functional liver following resection (ie, future liver remnant). Together, these will determine if
resection is feasible, and if so, the type and extent of the resection. (See 'Preoperative evaluation and
preparation' above.)
● For patients with future liver remnant <20 percent of the total volume of the liver, we suggest not
performing hepatic resection (Grade 2C). Perioperative morbidity and mortality is significantly increased
with lesser volumes. The risk of liver failure and death is further increased for patients with underlying
liver dysfunction (eg, cirrhosis, steatohepatitis), such that an even larger volume of future liver remnant is
required. (See 'Contraindications' above and 'Liver function and regeneration after resection' above.)
● For patients with a future liver remnant that contraindicates hepatic resection, we suggest preoperative
portal vein embolization (PVE) (Grade 2C). PVE stimulates liver hyperplasia in the remnant liver. In
patients with certain malignancies, PVE has improved survival and reduced rates of postoperative liver
failure following more extensive hepatic resections. (See 'Preoperative portal vein embolization' above.)
● We recommend prophylactic antibiotics prior to incision in patients undergoing hepatic resection (Grade
1B). The specific agent given should take into account the indication for the procedure (eg, tumor,
infection) and any additional surgical procedures (eg, cholecystectomy, colectomy) that will be performed
(table 3). (See 'Prophylactic antibiotics' above.)
● For malignant liver lesions, we suggest a margin of at least 1 cm rather than a lesser amount, whenever
possible (Grade 2C). A margin greater than 2 cm may be desirable for aggressive tumor biology, but this
is frequently not possible, and for some tumors, a lesser margin may be appropriate. Benign lesions
(hemangiomas, adenomas, complex cysts, fibronodular hyperplasia) can be excised by enucleation or
resection with limited margins. (See 'Resection margins' above.)
● At highvolume centers, surgical mortality following hepatic resection is 1 to 3 percent and is highest
among patients with underlying liver disease. In patients with no evidence of diffuse liver disease and
minimal comorbidities, liver failure is uncommon following limited resections (ie, adequate liver remnant).
Longterm survival depends upon the specific pathology for which the hepatic resection was performed.
Complications of any kind occur in up to 40 percent of patients without cirrhosis, with a higher incidence
in patients with some degree of cirrhosis. Major complications include bile leak, coagulopathy and
postoperative bleeding, hyperglycemia, and liver failure. (See 'Complications' above and 'Mortality'
above.)
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102. Mullen JT, Ribero D, Reddy SK, et al. Hepatic insufficiency and mortality in 1,059 noncirrhotic patients
undergoing major hepatectomy. J Am Coll Surg 2007; 204:854.
103. Shimada M, Matsumata T, Akazawa K, et al. Estimation of risk of major complications after hepatic
resection. Am J Surg 1994; 167:399.
104. Meijer C, Wiezer MJ, Hack CE, et al. Coagulopathy following major liver resection: the effect of rBPI21
and the role of decreased synthesis of regulating proteins by the liver. Shock 2001; 15:261.
105. Tanabe G, Sakamoto M, Akazawa K, et al. Intraoperative risk factors associated with hepatic resection.
Br J Surg 1995; 82:1262.
106. Shao YF, Yang JM, Chau GY, et al. Safety and hemostatic effect of recombinant activated factor VII in
cirrhotic patients undergoing partial hepatectomy: a multicenter, randomized, doubleblind, placebo
controlled trial. Am J Surg 2006; 191:245.
107. Barbas AS, Turley RS, Mallipeddi MK, et al. Examining reoperation and readmission after hepatic
surgery. J Am Coll Surg 2013; 216:915.
108. Schroeder RA, Marroquin CE, Bute BP, et al. Predictive indices of morbidity and mortality after liver
resection. Ann Surg 2006; 243:373.
109. Sano T, Shimada K, Sakamoto Y, et al. One hundred two consecutive hepatobiliary resections for
perihilar cholangiocarcinoma with zero mortality. Ann Surg 2006; 244:240.
110. Kneuertz PJ, Pitt HA, Bilimoria KY, et al. Risk of morbidity and mortality following hepatopancreato
biliary surgery. J Gastrointest Surg 2012; 16:1727.
111. Schemmer P, Friess H, Hinz U, et al. Stapler hepatectomy is a safe dissection technique: analysis of
300 patients. World J Surg 2006; 30:419.
112. Bhayani NH, Hyder O, Frederick W, et al. Effect of metabolic syndrome on perioperative outcomes after
liver surgery: A National Surgical Quality Improvement Program (NSQIP) analysis. Surgery 2012;
152:218.
113. Cauchy F, Zalinski S, Dokmak S, et al. Surgical treatment of hepatocellular carcinoma associated with
the metabolic syndrome. Br J Surg 2013; 100:113.
114. Koch M, Garden OJ, Padbury R, et al. Bile leakage after hepatobiliary and pancreatic surgery: a
definition and grading of severity by the International Study Group of Liver Surgery. Surgery 2011;
149:680.
115. Sadamori H, Yagi T, Shinoura S, et al. Risk factors for major morbidity after liver resection for
hepatocellular carcinoma. Br J Surg 2013; 100:122.
116. Erdogan D, Busch OR, van Delden OM, et al. Incidence and management of bile leakage after partial
liver resection. Dig Surg 2008; 25:60.
117. Nobili C, Marzano E, Oussoultzoglou E, et al. Multivariate analysis of risk factors for pulmonary
complications after hepatic resection. Ann Surg 2012; 255:540.
118. Chan KM, Lee CF, Wu TJ, et al. Adverse outcomes in patients with postoperative ascites after liver
resection for hepatocellular carcinoma. World J Surg 2012; 36:392.
119. Thomas RM, Ahmad SA. Management of acute postoperative portal venous thrombosis. J Gastrointest
Surg 2010; 14:570.
120. Yoshiya S, Shirabe K, Nakagawara H, et al. Portal vein thrombosis after hepatectomy. World J Surg
2014; 38:1491.
121. Rahbari NN, Garden OJ, Padbury R, et al. Posthepatectomy liver failure: a definition and grading by the
International Study Group of Liver Surgery (ISGLS). Surgery 2011; 149:713.
122. Hyder O, Pulitano C, Firoozmand A, et al. A risk model to predict 90day mortality among patients
undergoing hepatic resection. J Am Coll Surg 2013; 216:1049.
123. PaugamBurtz C, Janny S, Delefosse D, et al. Prospective validation of the "fiftyfifty" criteria as an
early and accurate predictor of death after liver resection in intensive care unit patients. Ann Surg 2009;
249:124.
124. PaugamBurtz C, Wendon J, Belghiti J, Mantz J. Case scenario: postoperative liver failure after liver
resection in a cirrhotic patient. Anesthesiology 2012; 116:705.
125. Wibmer A, Prusa AM, Nolz R, et al. Liver failure after major liver resection: risk assessment by using
preoperative Gadoxetic acidenhanced 3T MR imaging. Radiology 2013; 269:777.
126. Hirashita T, Ohta M, Iwashita Y, et al. Risk factors of liver failure after rightsided hepatectomy. Am J
Surg 2013; 206:374.
127. Boleslawski E, Petrovai G, Truant S, et al. Hepatic venous pressure gradient in the assessment of portal
hypertension before liver resection in patients with cirrhosis. Br J Surg 2012; 99:855.
128. Chen X, Zhai J, Cai X, et al. Severity of portal hypertension and prediction of postoperative liver failure
after liver resection in patients with ChildPugh grade A cirrhosis. Br J Surg 2012; 99:1701.
129. Chang CM, Yin WY, Su YC, et al. Preoperative risk score predicting 90day mortality after liver resection
in a populationbased study. Medicine (Baltimore) 2014; 93:e59.
130. Wei AC, Greig PD, Grant D, et al. Survival after hepatic resection for colorectal metastases: a 10year
experience. Ann Surg Oncol 2006; 13:668.
131. Ribero D, Abdalla EK, Thomas MB, Vauthey JN. Liver resection in the treatment of hepatocellular
carcinoma. Expert Rev Anticancer Ther 2006; 6:567.
Topic 15094 Version 10.0
GRAPHICS
Segmental anatomy of liver
Drawing depicting the functional segments of the liver (Couinaud's segments).

Segments II to IV make up the left lobe and segments V to VIII constitute the right
lobe.
Graphic 81897 Version 3.0
Types of hepatic resection
The types of hepatic resection are based on the anatomic nomenclature. "Wedge
resection" refers to any nonanatomic liver resection exclusive of biopsy.
"Sectorectomy" refers to any one of the following: right anterior sectorectomy, right
posterior sectorectomy, left medial sectorectomy, and left lateral sectorectomy.
ChildPugh classification of severity of cirrhosis
Points assigned
Parameter
1 2 3
Ascites Absent Slight Moderate
Bilirubin <2 mg/dL (<34.2 2 to 3 mg/dL (34.2 to >3 mg/dL (>51.3

micromol/L) 51.3 micromol/L) micromol/L)
Albumin >3.5 g/dL (35 g/L) 2.8 to 3.5 g/dL (28 to <2.8 g/dL (<28 g/L)
35 g/L)
Prothrombin time
Seconds over <4 4 to 6 >6
control
INR <1.7 1.7 to 2.3 >2.3
Encephalopathy None Grade 1 to 2 Grade 3 to 4
Modified ChildPugh classification of the severity of liver disease according to the degree
of ascites, the serum concentrations of bilirubin and albumin, the prothrombin time, and
the degree of encephalopathy. A total ChildTurcottePugh score of 5 to 6 is considered
ChildPugh class A (wellcompensated disease); 7 to 9 is class B (significant functional
compromise); and 10 to 15 is class C (decompensated disease). These classes correlate
with one and twoyear patient survival: class A: 100 and 85 percent; class B: 80 and 60
percent; and class C: 45 and 35 percent.
INR: international normalized ratio.
Volume of future liver remnant after hepatic resection
Percentage of
Resection type Couinaud's segments remnant liver mass
(%)
Right hepatectomy 1, 5, 6, 7, 8 35
Left hepatectomy 2, 3, 4 65
Right trisectionectomy 1, 4, 5, 6, 7, 8 25
Left trisectionectomy 2, 3, 4, 5, 8 30
Left lateral sectionectomy 2, 3 75
Posterior sectionectomy 6, 7 70
%: percent.
Reproduced with permission from: Yoo PS, Enestvedt K, Kulkarni S. Anatomic considerations in the
surgical resection of hepatocellular carcinoma. J Clin Gatroenterol 2013; 47:S11. DOI:
10.1097/MCG.0b013e318280ce5f. Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized
reproduction of this material is prohibited.
Antimicrobial prophylaxis for gastrointestinal surgery in adults
Usual
Nature of Common Recommended Redose
adult
operation pathogens antimicrobials interval ¶
dose*
Gastroduodenal surgery
Procedures Enteric gram Cefazolin Δ <120 kg: 2 g Four hours

involving entry negative bacilli, IV
into lumen of grampositive
≥120 kg: 3 g
gastrointestinal cocci
IV
tract
Procedures not Enteric gram High risk ◊ only: <120 kg: 2 g Four hours
involving entry negative bacilli, cefazolin Δ IV
into lumen of grampositive
≥120 kg: 3 g
gastrointestinal cocci IV
tract (selective
vagotomy,
antireflux)
Biliary tract surgery (including pancreatic procedures)
Open Enteric gram Cefazolin Δ ￥ <120 kg: 2 g Four hours

procedure or negative bacilli, IV
laparoscopic enterococci,
≥120 kg: 3 g
procedure clostridia
IV
(high risk) §
OR cefotetan 2 g IV Six hours
OR cefoxitin 2 g IV Two hours
OR ampicillin 3 g IV Two hours

sulbactam
Laparoscopic N/A None None None

procedure (low
risk)
Appendectomy ‡
Enteric gram Cefoxitin Δ 2 g IV Two hours

negative bacilli,
OR cefotetan Δ 2 g IV Six hours
anaerobes,
enterococci OR cefazolin Δ <120 kg: 2 g Four hours
IV
≥120 kg: 3 g
IV
PLUS metronidazole 500 mg IV N/A
Small intestine surgery
Nonobstructed Enteric gram Cefazolin Δ <120 kg: 2 g Four hours

negative bacilli, IV
grampositive ≥120 kg: 3 g
cocci
IV
Obstructed Enteric gram Cefoxitin Δ 2 g IV Two hours
Δ
negative bacilli, OR cefotetan Δ 2 g IV Six hours

anaerobes,
OR cefazolin Δ <120 kg: 2 g Four hours
enterococci
IV
≥120 kg: 3 g
IV
PLUS metronidazole 500 mg IV N/A
Hernia repair
Aerobic gram Cefazolin Δ <120 kg: 2 g Four hours

positive IV
organisms ≥120 kg: 3 g
IV
Colorectal surgery †
Enteric gram Parenteral:

negative bacilli,
Cefoxitin Δ 2 g IV Two hours
anaerobes,
enterococci OR cefotetan Δ 2 g IV Six hours
OR cefazolin Δ <120 kg: 2 g Four hours

IV
≥120 kg: 3 g
IV
PLUS 500 mg IV N/A
metronidazole
OR ampicillin 3 g IV (based Two hours

sulbactam Δ,** on
combination)
Oral (used in conjunction with mechanical bowel

preparation):
Neomycin PLUS ¶¶ ¶¶
erythromycin
base or
metronidazole
IV: intravenous.
* Parenteral prophylactic antimicrobials can be given as a single IV dose begun within 60 minutes
before the procedure. If vancomycin or a fluoroquinolone is used, the infusion should be started
within 60 to 120 minutes before the initial incision to have adequate tissue levels at the time of
incision and to minimize the possibility of an infusion reaction close to the time of induction of
anesthesia.
¶ For prolonged procedures (>3 hours) or those with major blood loss or in patients with extensive
burns, additional intraoperative doses should be given at intervals one to two times the halflife of the
drug.
Δ For patients allergic to penicillins and cephalosporins, clindamycin (900 mg) or vancomycin (15
mg/kg IV; not to exceed 2 g) with either gentamicin (5 mg/kg IV), ciprofloxacin (400 mg IV),
levofloxacin (500 mg IV), or aztreonam (2 g IV) is a reasonable alternative. Metronidazole (500 mg
IV) plus an aminoglycoside or fluoroquinolone are also acceptable alternative regimens, although
metronidazole plus aztreonam should not be used since this regimen does not have aerobic gram
positive activity.
◊ Morbid obesity, gastrointestinal (GI) obstruction, decreased gastric acidity or GI motility, gastric
bleeding, malignancy or perforation, or immunosuppression.
§ Factors that indicate high risk may include: Age >70 years, pregnancy, acute cholecystitis,
nonfunctioning gall bladder, obstructive jaundice, common bile duct stones, immunosuppression.
￥ Cefotetan, cefoxitin, and ampicillinsulbactam are reasonable alternatives.
‡ For a ruptured viscus, therapy is often continued for approximately five days.
† Use of ertapenem or other carbapenems not recommended due to concerns of resistance.
** Due to increasing resistance of Escherichia coli to fluoroquinolones and ampicillinsulbactam, local
sensitivity profiles should be reviewed prior to use.
¶¶ In addition to mechanical bowel preparation, the following oral antibiotic regimen is administered.
1 g of neomycin plus 1 g of erythromycin base at 1 PM, 2 PM, and 11 PM, or 2 g of neomycin plus 2 g
of metronidazole at 7 PM and 11 PM the day before an 8 AM operation. Issues related to mechanical
bowel preparation are discussed further separately. Refer to UpToDate topic on overview of colon
resection.
Data from:
1. Antimicrobial prophylaxis for surgery. Treat Guidel Med Lett 2012; 10:73.
2. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial
prophylaxis in surgery. Surg Infec (Larchmt) 2013; 14:73.
Modified Caprini risk assessment model for VTE in general surgical

patients
Risk score
1 point 2 points 3 points 5 points
Age 41 to 60 years Age 61 to 74 years Age ≥75 years Stroke (<1 month)
Minor surgery Arthroscopic surgery History of VTE Elective arthroplasty
BMI >25 kg/m 2 Major open surgery Family history of VTE Hip, pelvis, or leg
(>45 minutes) fracture
Swollen legs Laparoscopic surgery Factor V Leiden Acute spinal cord

(>45 minutes) injury (<1 month)
Varicose veins Malignancy Prothrombin 20210A
Pregnancy or Confined to bed (>72 Lupus anticoagulant

postpartum hours)
History of Immobilizing plaster Anticardiolipin

unexplained or cast antibodies
recurrent
spontaneous abortion
Oral contraceptives or Central venous access Elevated serum

hormone replacement homocysteine
Sepsis (<1 month) Heparininduced

thrombocytopenia
Serious lung disease, Other congenital or

including pneumonia acquired
(<1 month) thrombophilia
Abnormal pulmonary
function
Acute myocardial
infarction
Congestive heart
failure (<1 month)
History of
inflammatory bowel
disease
Medical patient at bed

rest
Interpretation
Estimated VTE risk

in the absence of
Surgical risk pharmacologic or
Score
category* mechanical
prophylaxis
(percent)
Very low (see text for 0 <0.5

definition)
Low 1 to 2 1.5
Moderate 3 to 4 3.0
High ≥5 6.0
VTE: venous thromboembolism; BMI: body mass index.

* This table is applicable only to general, abdominalpelvic, bariatric, vascular, and plastic and
reconstructive surgery. See text for other types of surgery (eg, cancer surgery).
From: Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients:
antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians
evidencebased clinical practical guidelines. Chest 2012; 141:e227S. Copyright © 2012. Reproduced
with permission from the American College of Chest Physicians.
Disclosures
Disclosures: Steven A Curley, MD, FACS Nothing to disclose. Evan S Glazer, MD, PhD, MPH Nothing to disclose. Stanley W
Ashley, MD Nothing to disclose. Wenliang Chen, MD, PhD Nothing to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting
through a multilevel review process, and through requirements for references to be provided to support the content. Appropriately
referenced content is required of all authors and must conform to UpToDate standards of evidence.
Conflict of interest policy

Overview of Hepatic Resection

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Overview of Hepatic Resection

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3/30/2016 Overview of hepatic resection

Official reprint from UpToDate®

Overview of hepatic resection

Authors Section Editor Deputy Editor

● Removing metabolic waste products, hormones, drugs, and toxins

We use the following approach:

Additional contraindications to hepatic resection include comorbidities precluding/limiting safe anesthesia, or

PREOPERATIVE PORTAL VEIN EMBOLIZATION — Preoperative portal vein embolization (PVE) is a

suite with local anesthesia/conscious sedation.

Benefits — There are at least five potential benefits to PVE [55]:

● Postresection morbidity is diminished, as evidenced by minimal reductions in post­resection liver function

above and 'Preoperative portal vein embolization' above.)

Prophylactic antibiotics — A decision to administer antibiotics in patients undergoing hepatic resection

Coagulopathy and hemorrhage — The incidence of post­hepatectomy coagulopathy is difficult to determine.

MORTALITY — Perioperative mortality following hepatic resection is 1 to 3 percent at high­volume centers

SUMMARY AND RECOMMENDATIONS

Use of UpToDate is subject to the Subscription and License Agreement.

and blood transfusion on long­term survival. Analysis of 209 consecutive patients.

Topic 15094 Version 10.0

Segmental anatomy of liver

Drawing depicting the functional segments of the liver (Couinaud's segments).

Graphic 81897 Version 3.0

Types of hepatic resection

Graphic 66282 Version 1.0

Child­Pugh classification of severity of cirrhosis

Ascites Absent Slight Moderate

Bilirubin <2 mg/dL (<34.2 2 to 3 mg/dL (34.2 to >3 mg/dL (>51.3

INR <1.7 1.7 to 2.3 >2.3

Encephalopathy None Grade 1 to 2 Grade 3 to 4

INR: international normalized ratio.

Graphic 78401 Version 11.0

Volume of future liver remnant after hepatic resection

Left lateral sectionectomy 2, 3 75

Graphic 93783 Version 1.0

Antimicrobial prophylaxis for gastrointestinal surgery in adults

Procedures Enteric gram­ Cefazolin Δ <120 kg: 2 g Four hours

Biliary tract surgery (including pancreatic procedures)

Open Enteric gram­ Cefazolin Δ ￥ <120 kg: 2 g Four hours

OR cefoxitin 2 g IV Two hours

OR ampicillin­ 3 g IV Two hours

Laparoscopic N/A None None None

Enteric gram­ Cefoxitin Δ 2 g IV Two hours

PLUS metronidazole 500 mg IV N/A

Small intestine surgery

Nonobstructed Enteric gram­ Cefazolin Δ <120 kg: 2 g Four hours

negative bacilli, OR cefotetan Δ 2 g IV Six hours

PLUS metronidazole 500 mg IV N/A

Aerobic gram­ Cefazolin Δ <120 kg: 2 g Four hours

Enteric gram­ Parenteral:

OR cefazolin Δ <120 kg: 2 g Four hours

OR ampicillin­ 3 g IV (based Two hours

Oral (used in conjunction with mechanical bowel

Graphic 65369 Version 29.0

Modified Caprini risk assessment model for VTE in general surgical

1 point 2 points 3 points 5 points

Minor surgery Arthroscopic surgery History of VTE Elective arthroplasty

Swollen legs Laparoscopic surgery Factor V Leiden Acute spinal cord

Varicose veins Malignancy Prothrombin 20210A

Pregnancy or Confined to bed (>72 Lupus anticoagulant

History of Immobilizing plaster Anticardiolipin

Oral contraceptives or Central venous access Elevated serum

Sepsis (<1 month) Heparin­induced

Serious lung disease, Other congenital or

● Postresection morbidity is diminished, as evidenced by minimal reductions in postresection liver function

Coagulopathy and hemorrhage — The incidence of posthepatectomy coagulopathy is difficult to determine.

MORTALITY — Perioperative mortality following hepatic resection is 1 to 3 percent at highvolume centers

and blood transfusion on longterm survival. Analysis of 209 consecutive patients.

ChildPugh classification of severity of cirrhosis

Procedures Enteric gram Cefazolin Δ <120 kg: 2 g Four hours

Open Enteric gram Cefazolin Δ ￥ <120 kg: 2 g Four hours

OR ampicillin 3 g IV Two hours

Enteric gram Cefoxitin Δ 2 g IV Two hours

Nonobstructed Enteric gram Cefazolin Δ <120 kg: 2 g Four hours

Aerobic gram Cefazolin Δ <120 kg: 2 g Four hours

Enteric gram Parenteral:

OR ampicillin 3 g IV (based Two hours

Sepsis (<1 month) Heparininduced