This document provides an overview of basic principles of liver resection, including: - A brief history of liver resection and techniques like hepatic inflow occlusion. - Concepts of liver regeneration, surgical anatomy, and terminology as described by Couinaud. - Surgical techniques for liver transection including finger fracture, water jet, CUSA, Ligasure, and vascular staplers. - Methods of vascular control during resection like Pringle maneuver, liver hanging maneuver, and total hepatic vascular exclusion. - Postoperative management considerations like fluid/electrolyte balance, nutrition, pain control, and monitoring for liver failure.

1. Basic Principles of Liver
Resection
Anup Shrestha

2. History
 first recognized by the
Greeks.
 Langenbuch was
credited with the first
liver resection for a
tumor in 1888.
 Hepatic inflow occlusion
was first used by James
Hogarth Pringle an
Australian born British
surgeon in 1908.

3. Surgical Anatomy And
Nomenclature
 French anatomist,
Couinaud, based his
description on the
distribution of the portal
pedicles and the location
of the hepatic veins.
 The recommendations of
the committee were
adopted at the World
Congress of the IHPBA in
Brisbane in 2000 and
were termed “The
Brisbane 2000
terminology of liver

9. Concept of Liver
Regeneration
 A normal human liver tolerates resections of
up to 70% of its functioning mass.
 Liver regeneration after surgical resection is
carried out by proliferation of existing mature
cellular populations.
 Immediately after liver resection, the rate of
DNA synthesis in hepatocytes begins to
increase while they exit the resting state of
the cell cycle (G0) and enter G1, traverse to
DNA synthesis (S phase), and ultimately
undergo mitosis (M phase).
 Significant amount of regeneration occurs in
human within 2 weeks following resection
and is nearly complete at 3 months following
resection

10. Pre-Op Preparation
 vigorous chest physiotherapy, deep breathing
exercises, incentive spirometry
 parenteral or enteral hyperalimentation with high
protein content
 bowel preparation
 Jaundiced patients are hydrated well with intravenous
crystalloids over a period of 2–3 days
 Prothrombin time is corrected using vitamin K
injections
 A broadspectrum parenteral antibiotic regimen is
started on the day of operation, before the patient is
shifted to the operating room

11. Surgical Techniques
 Low Central Venous Pressure-reducing the
central venous pressure (CVP) to around 5
cm water helps to reduce the bleeding
 -change of posture: placed in a 15⁰
Trendelenburg position

12. Methods of Liver Transection
Liver transection involves division of hepatocytic
parenchymal tissue (collective hepatic lobules),
the branching portal triad inflow structures (portal
vein, hepatic artery, bile duct, lymphatics and
vagal nerve fibres)
 Finger Fracture or Clamp Crushing :Softer
parenchymal tissue is crushed between surgical
clamps to expose more significant vessels,
which can be ligated by any variety of method
according to their size. This method is quick,
cost-effective and remains a reference point
from which all other techniques are compared.

13. Water Jet Transection
 Uses a pressurized jet of water to
fragment the liver tissue and
expose the vascular and ductal
structures. This is combined with
a suction device which clears the
surgical field of blood and
hepatocytes. The capsule is
incised with a diathermy and the
water jet is applied on the liver
parenchyma, rapidly moving it
along the dissection line.

14. CUSA
 The Cavitron Ultrasonic
Surgical Aspirator
(CUSA, TycoHealthcare)
is currently the preferred
method of parenchymal
dissection
 The device combines
ultrasonic energy with
continuous suction to
disrupt and aspirate
susceptible tissue,
exposing structures
greater than 2 mm for
individual control

15. Ligasure
 This is an ingenious system for sealing
blood vessels. The Ligasure system
(Covidien) uses a combination of
pressure and energy to seal the blood
vessels.
 The heat generated from the bipolar
energy causes the fusion of collagen and
elastin in the walls of the vessel with the
creation of a permanent sealed zone. An
acoustic signal informs the surgeon
when the vessel is sealed and it can be

16. Tissue Link Dissecting Sealer
 The thermal effect generated by ionic agitation
caused by radiofrequency generator system can
also be used to coagulate tissue. The tissue link
dissecting sealer is a new technology developed for
liver transection using saline linked radiofrequency
energy.
 This device offers parenchymal dissection as well
as coagulation of small surface vessels

17. Use of Vascular Staplers in Liver
Transection
 Vascular staplers make this task safer
and faster.They can also be used to
divide the liver parenchyma. Care should
be taken while applying the vascular
stapler at the inflow especially in large
tumors close to the confluence.
 If not applied with care there is a risk of
narrowing or occluding the hepatic duct
confluence. With staplers there is an
increased risk of bile leak because the
staples are not very effective in sealing
small bile ducts.

18. TECHNIQUES OF VASCULAR
CONTROL
 Broadly, these techniques can be
grouped into three types:
1. Ligation of inflow and outflow vessels
for hemihepatectomies.
2. The liver hanging maneuver
3. Methods of temporary vascular
control.

19. Ligation of inflow and outflow
vessels for hemihepatectomies
 First described by Lortat-Jacob
 Involves the ligation of right portal pedicle
and the RHV before-hand to reduce the
blood loss during parenchymal transection
 The extrahepatic isolation of RHV needs
to be carried out judiciously avoiding any
injury to RHV and IVC which can lead to a
fatal massive hemorrhage or an air
embolism

20. Liver Hanging Maneuver (LHM)
 The liver is lifted by a tape passed between
the anterior surface of the vena cava and
the liver, thereby providing effective
vascular control, in order to make the
anterior approach safer and easier.

21. Total Inflow Occlusion: The
Pringle’s Maneuver (PM)
 Complete inflow occlusion of the portal
triad is known as the Pringle manoeuvre
(PM) and is the oldest and best
established method of vascular control.
 involves clamping of the entire portal
pedicle at the hepatoduodenal ligament
and is effective in minimizing the blood
loss
 A broad atraumatic vascular clamp or a
tourniquet around the hepatoduodenal
ligament is used to effect the occlusion
 Intermittent Pringle manoeuvre (IPM) is
considered standard practice. Inflow is
interrupted for a period of 10e15
minutes followed by unclamping for 5
minutes.

22. Hepatic Tolerance and
Preconditioning
 an initial period of ischemia for 10
minutes followed by reperfusion for 10
minutes protects the liver against
subsequent prolonged ischemia. It is
called preconditioning of the liver.
 This technique was found to be
hepatoprotective. The intermittent
release of the clamp also allows
gradual haemostasis during a
prolonged period of time over smaller
transaction areas.

23. Total Hepatic Vascular
Exclusion
 The IVC and major hepatic veins are
clamped to isolate the liver completely from
the systemic circulation. This technique
decreases the risk of retrograde bleeding
from the hepatic veins and the risk of air
embolism
 THVE has significant physiological
consequences and is poorly tolerated.
Clamping of the IVC causes a reduction in
venous return of up to 60% and a reduction
in cardiac output.

24. Postoperative Management
 Fluid and Electrolyte Management -
maintenance of adequate fluid balance and
renal function is important.
-Postoperative ascites is controlled with salt
restriction (<2 g/day), potassium sparing and
loop diuretics, fluid and electrolyte
replacement and albumin infusions

25. Nutrition
 The preoperative hyperalimentation and
resumption of early feeding in the
postoperative period helps in faster recovery
and is likely to reduce the morbidity due to
sepsis and ascites.
 Patients are in a catabolic state after liver
resection and require glucose and other
nutrients
 Malnourished patients and those with
cirrhosis should preferably be given by the
enteral route.
 Supplementation with BCAA in patients with
advanced cirrhosis resulted in better
nutritional status and lower rate of

26. Pain Management
 Good pain relief after liver resection
allows early mobilization and better
respiratory function
 Epidural analgesia reduces chest
infection, duration of ileus and
provides better pain control
 However, there is risk of epidural
hematoma, spinal cord injury and
epidural abscess with these catheters

27. Liver Failure
 Postoperative liver failure is the most
important and common cause of in-
hospital mortality
 The signs of postoperative liver failure
include progressive hyperbilirubinemia
with normal transaminases, glucose
intolerance or refractory
hypoglycemia, progressive ascites
and mental obtundation.

28. The End