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Where is the
liver and how large is it?
What does the
Liver do?
What
diseases affect the liver?
What are
liver metastases?
Can liver metastases be surgically removed?
What happens to the piece of liver left behind?
Is it sufficient for a person to live on?
Are there cancers that arise in the liver?
Can primary liver cancer be removed surgically?
Are there any benign conditions that require
liver resection?
How is a
resection done?
Can liver resection be done laparoscopically?
What are the risks and possible complications of
liver resection?
How long is
the recovery from a "standard", open resection?
Q: Where is the
liver and how large is it?
A: The liver is situated in the upper right side
of the abdomen, just under the lower ribs and
diaphragm. In the adult, it weighs between 3 to
4 pounds and is about the size (though not the
shape) of a college football. Although it looks
like one solid organ, it can be considered as
made up of several segments, as shown below,
based on the blood vessels that come in and go
out. These segments form the basis upon which
different surgical procedures are designed,
depending on the location and size of the tumor
to be removed.
 
Q: What does
the liver do?
A: The
liver is responsible for many important
functions, including the breaking down of toxic
substances, protein building, and production of
enzymes that help in digestion. You can not
survive without a functioning liver; there is
currently no way to compensate for the absence
of liver function.
The liver is
intimately involved with essentially all the
digestive processes, whether it be
carbohydrates, proteins, or fats. It is able to
convert one energy form into another, depending
on the supply and demand (though it cannot make
the basic protein molecules “from scratch”).
Virtually all of the blood flow from the
intestines flow directly to the liver, so that
it can do its digestive work.
Other important
functions include storage of energy in the form
of glycogen, synthesis of blood proteins, like
albumin, and factors that help blood to clot, or
coagulate normally, production of hormones, and
breakdown of aging red blood cells. There are
countless biochemical reactions taking place or
regulated in the liver, both synthesizing and
decomposing various body compounds and drugs,
many of which are absolutely vital to health.
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Q:
What
diseases affect the liver?
A: Although the
liver is sensitive to many things, the most
common things that have a major impact are:
alchohol, specific viruses (Hepatitis A, B, C,
and others), certain drugs, particularly, large
doses of acetominophen (Tylenol), gallstones,
particularly when they travel into the bile duct
which drains bile from the liver into the
intestines, and cancers, either those that
originate in the liver, or those that spread
from other organs.
Q: What are
liver metastases?
A: Cancer in the original organ is called
primary tumor. Cancer that has spread to
other organ(s) is called metastatic and
the cancer in those other organs is known as
metastasis (pl. metastases). The liver
is one of the organs to which cancer spreads
most often. In part, this is due to the fact
that the blood supply of the liver is so rich
(about ¼ of our blood volume is in the liver at
any given time). Another reason, as it applies
to cancer that arises in abdominal organs (such
as the colon, pancreas or stomach), is that all
the venous blood that drains from these organs
passes through the liver on the way back to the
heart.
Q:
Can liver metastases be surgically removed?
A: Under certain circumstances, liver metastases
can be removed, either by “coring” them out, or
removing larger parts of the liver (a procedure
known as resection) that contain the
metastases. Whether metastases can be resected
depends on the nature of the cancer (colon, for
example), the number of metastases and the
location in the liver. Each patient must be
evaluated individually to determine if resection
is feasible.
Q:
What happens to the piece of liver that is left
behind? Is it sufficient for a person to
live on?
A: Normal liver regenerates, and rather quickly
(weeks), so even though a large portion of the
liver might be removed, you will grow some “new
liver”. If the uninvolved liver has been
affected by cirrhosis (scarring of the liver),
too much fat, or, sometimes, chemotherapy, the
remaining liver can be very slow to regenerate,
or may not regenerate at all, sometimes
resulting in liver failure. This possibility
must be considered carefully if a liver tumor is
going to be removed, since a diseased liver is
less able to renew itself.
Q:
Are there cancers that arise in the liver?
A: Yes. The cancer that arises from the liver
cells is called hepatocellular carcinoma
(HCC) or hepatoma, and, in this country,
it is almost always associated with chronic
viral hepatitis, alcohol abuse or obesity-linked
fatty liver. Cancer which arises from the bile
ducts in the liver is called
cholangiocarcinoma (CC). Though these
unusual tumors are surprisingly common in the
Orient, there are only about 2,500 cases per
year in the entire USA. The high incidence of
certain parasites in Oriental countries
predisposes to a higher risk of this type of
cancer, which typically is a very aggressive
form of cancer, and is often incurable when
diagnosed.
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Q:
Can primary liver cancer be removed surgically?
A: HCC (hepatoma) can be removed if relatively
small and if the rest of the liver is in good
enough shape to tolerate the procedure and
regenerate. Often, the only possible cure is
with a liver transplant, but only if certain
criteria are met. CC (cholangiocarcinoma) is
less amenable to resection. When cancer of the
gallbladder is found prior to removal of
the gallbladder (cholecystectomy), the
gallbladder must be removed together with the
adjacent area of the liver, or even a larger
portion (known as a lobe, the procedure
being a lobectomy). When resection is
not possible, chemotherapy and/or radiation may
be of help, occasionally with fairly impressive
results. Other modalities include destruction
of the tumor(s) with microwaves, know as
radiofrequency ablation (RFA), 95% alcohol, or
freezing (cryoablation).
Q:
Are there any benign conditions that require
liver resection?
A: Yes. The most common are liver adenoma,
which is often associated with oral
contraceptives (although modern preparations are
less likely to cause this), and focal nodular
hyperplasia (FNH). Liver cysts do not
usually require resection, but only drainage.
Before the use of oral contraceptives, there
were almost no reports of such liver adenomas.
At least 90% of cases occur in birth control
users, and are more common in those on birth
control pills for >10 years. Patients may have
either no symptoms, or they may experience pain
under the rib cage, usually on the right side,
and may even feel a mass. In some women, the
symptoms occur suddenly, due to development of
bleeding into the tumor. In these cases, the
symptoms invariably bring the patient to an
emergency room, and the tumor will be seen on
either a CT scan, or an ultrasound. If the
bleeding does not stop, surgery is almost always
necessary as an emergency life-saving measure.
For those women in whom a liver adenoma is
diagnosed without evidence of bleeding, a
planned surgical removal is the usual
recommendation, particularly for the larger
ones, as shown in the picture below.
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Q: How is a
resection done?
A: Most often, liver resection is an “open”
procedure, meaning that the abdomen is open
widely, to ensure that there is adequate
exposure of the liver and surrounding structures
and that the operation is safe. Usually, the
incision (cut) is under both rib margins,
like an inverted “V” (also known as a chevron
incision), with or without an upper extension in
the midline, toward the lower end of the breast
bone. There are several options for how the
surgeon might actually remove the tumor.
Dr. Stieber
often uses a technique known as “total vascular
exclusion” (TVE) (meaning that the blood supply
to and from the liver is temporarily
interrupted, in order to minimize blood loss),
with a unique modification he has derived from
his experience with liver transplantation, which
helps to keep the patient’s blood pressure
stable during the surgery.
 
Q:
Can liver resection be done laparoscopically?
A: It can, under very limited and strict
circumstances. When laparoscopic techniques are
used, the operation is most often known as
“hand-assisted laparoscopic resection”, since an
opening big enough to introduce a hand in the
abdomen must be made, the same opening being
used to remove the portion of the liver that has
been resected.
Q:
What are the risks and possible complications
of liver resection?
A: The primary operative risk is bleeding. As
mentioned before, the liver is a very
vascular organ (meaning it has a rich blood
supply), so there is always the risk of major
bleeding. This is, however, not a frequent
event, especially with the TVE technique. The
major possible complications are hematoma
(blood clot), bile leak and infection.
Of course, if the liver has disease, such as
cirrhosis, the risks for bleeding or other
complications are higher, particularly since
proper blood coagulation requires the production
of many factors which are produced by the liver.
Q: How long
is the recovery from a “standard”, open
resection?
A: If there are no complications, most patients
stay in the hospital about one week, and are
back to baseline within 2 to 3 months. Recovery
and return to normal activity can be shorter in
some patients, even as little as 5 days in the
hospital and 3-4 weeks to essentially complete
recovery. It all depends on the indication for
resection, the magnitude of resection, the
patient’s age and general condition and his/her
motivation.
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To set up a
consultation, or if you have other questions
regarding your specific situation, you may
contact our office at 404-508-4320, or email Dr.
Stieber directly at
drstieber@dekalbsurgical.com. |
