The liver is the largest organ in the body, located in the upper right portion of abdomen. It is one of the most vital organs which regulates various functions and supports the normal functioning of other organs in the body, as well.
Some of the key functions of the liver includes: Conversion of sugar into energy; Helps in digestion of fats; Helps in excretion of waste products; Protects against infections; Produces blood clotting factors; Regulates sex hormones and cholesterol level; Supplies vitamins and minerals; Metabolism and elimination of various drugs. Liver (hepatic) surgery is a subspecialty that involves surgical procedures on the liver, for the management of different diseases. Liver resection is the most common surgical procedure performed on the liver and comprises the removal of a portion of the liver. A malignant tumour (cancer) is the most common indication for a liver resection. Based on the origin, tumours in the liver are categorized into: Primary tumours: they develop within the liver; and Secondary (Metastatic) tumours: they develop in some other organ and migrate (spread) to the liver usually through the blood stream. Colorectal (cancer of the colon or rectum) cancer is the most common cause of secondary liver cancer. Single or multiple metastases involving the different lobes of the liver can be resected with a high success rate, depending on the distribution, number and stage of the primary tumour. Liver resection may also be employed for benign tumours of the liver such as hepatic cyst, hepatic adenoma, and rarely hemangioma. Liver resection can either be performed by an open technique or laparoscopically (see below). The liver surgery can also be performed at the same time as other procedures in some instances, such as resection of the primary tumour.
Purpose of Liver Surgery
The purpose of Liver Resection is to remove the cancer and preserve as much normal liver as possible. This is the main treatment for primary liver cancer. It is only useful for secondary liver cancer if all of the cancer can be resected.
Liver (hepatic) resection
Most patients who require a liver resection have metastases from a colorectal (bowel) cancer. Less commonly other secondary cancers from neuroendocrine tumors (like carcinoid), renal cancer, breast or melanoma are resected. The most common primary liver cancer that is resected is hepatocellular carcinoma (HCC or Hepatoma). This is a cancer that originates in liver cells (primary), and is usually associated with underlying chronic liver disease. Primary cancers of the bile ducts, cholangiocarcinoma, are less commonly resected. There are a number of benign lesions that occur in the liver. Most don’t cause any symptoms or problems and can be monitored or left alone. Sometimes it is not possible to be sure of a diagnosis and resection is undertaken to establish the diagnosis. Biopsy of the liver is not routinely recommended as it has the potential to cause bleeding and spread of the cancer. The most common method of removing part of the liver is by an open operation (laparotomy). In some instances it is possible to undertake the operation laparoscopically (keyhole surgery). The open technique is the preferred method for major resections particularly and in those tumours that are difficult to access. Some liver resections can be performed laparoscopically. A camera, known as a Laparoscope, connected to a high intensity light is introduced through a small incision and a further three puncture wounds are made to allow the surgical instruments to be introduced. Once the liver has been resected a small incision is made low down in the abdomen to allow the tumour to be extracted. Irrespective of the method used the principals are the same: The liver is mobilized. The vessels to the portion being resected are isolated and controlled. A cut is then made through the liver substance (parenchyma) and care is taken to seal off the blood vessels and bile ducts that pass across the plane of transection.
General Risks of Surgery
General risks of surgery including wound infection, deep vein thrombosis (DVT), pulmonary embolism, or development of a hernia at the incision site. There is an increased risk of post- operative complications if you are overweight or if you smoke.
Specific Risks and complications from liver resection surgery
There are risks with all surgery. Complications occur in about 20-30% of cases and most are mild and easily resolved. Rare but severe complications that are specific to undergoing liver resection include; : Liver failure; Liver abscess; Infection around the surgical site; Bleeding; Blood clots; Bile leakage; Pneumonia;
Liver failure may occur if the liver remnant is insufficient to support normal function. This is one of the most severe complications of undergoing liver surgery. Liver failure leads to progressive jaundice (yellow); ascites (fluid collection in the abdomen) and coagulopathy (abnormality in blood clotting). It may result in death if the liver is unable to regenerate in a timely manner. As part of the work up for surgery A/Professor Adam Bartlett will calculate the size of the liver remnant and depending upon the quality of the liver, be able to estimate the risk of liver failure. It is a rare complication if pre-operative work up is completed carefully.
This is an infection within the liver. As a result of cutting through the liver, there is a risk of infection. In the absence of infection pre-operatively, this occurs rarely. Liver abscess is more common following liver ablation, due to destruction of liver tissue that is left in situ.
Infection around the surgical site
Bleeding either at the time of surgery or soon after, may require blood transfusion or re-operation. In most instances it resolves without further intervention.
Bile leak from the cut surface occurs in 5-10% of patients. This is usually self-limiting and is treated by external drainage. It may require an endoscopic procedure to decompress the bile ducts, and rarely re-operation.
Respiratory complications (infection (pneumonia), collapse (atelectasis), fluid collections) are not uncommon as a result of prolonged ventilator support and poor inspiratory effort post-operatively. This may require antibiotic treatment or drainage. It is important that you get moving after the operation, to help re-expand your lungs and prevent complications.
Post operative care
A/Professor Adam Bartlett will see you twice daily while you are in hospital. The anaesthetist will visit at least daily. The staff on the ward will attend to you and are very experienced in managing patients following liver surgery. Depending upon the extent of the resection, and you other medical conditions you may be transferred to the High Dependency Unit (HDU) the night of your surgery. There after you will be cared for on the ward, in a single room. Patients are able to eat and drink as they wish following the operation. Day one following surgery, you will be assisted to mobilise at least into a chair, and usually for a short distance. Most patients spend 4-6 days in hospital before being discharged home. The skin incision is closed with dissolvable sutures, that do not need to be removed. Steristrips are placed over the incision to help support the skin edge, and these should stay on for 10 days. If they come away sooner, it is okay. A waterproof dressing is placed over the Steristrips and this is left on for at least three days. Some people prefer to leave this on for longer, as you are able to shower as you wish. Pain management usually involves regular paracetamol, with the addition of stronger (opioids) on an as needs basis. Most patients have a mild degree of discomfort, but it is not regarded as a painful operation.
You will be carefully assessed prior to deciding upon proceeding with liver surgery.
If the risks or surgery are outweighed by the potential benefit then surgery would not be advised. A/Professor Adam Bartlett will take time to work through this with you to ensure that you have a clear understanding.
Liver Surgery FAQs
How is the liver divided up?
The liver can be divided into a right and left lobe. Within each lobe the liver can be divided into segments, based on the division of the blood vessels within the liver. The segments are numbered from one to eight in Roman numerals. The left lobe is composed of segments II – IV, while the right lobe is composed of segments V-VIII. From the outside it is not possible to determine the division between the segments. Pre-operatively radiological imaging of the liver (CT, MRI, USS) is used to define the segmental anatomy, while intra-operatively USS can be used directly on the surface of the liver. The segmental anatomy of the liver provides the basis for determining the plane of transection during liver resections.
Is it true that the liver regrows following resection?
The liver is the only organ in the body that is able to regenerate (regrow). This means that when part of the liver is removed, the volume of the remaining liver increases (hypertrophies) until it returns to the volume of the original whole liver. Bile ducts and blood vessels do not re-grow, rather the remnant liver increases in size. This normally takes up to 8 – 12 weeks following a major liver resection. Up to 70% of a healthy liver can be removed. However, in the presence of chronic liver disease or chemotherapy, a larger remnant is required, reducing the amount of liver that can be removed.
What is the goal of performing liver resection?
Liver resection refers to the removal of a portion of the liver. This operation is usually done to remove various types of liver tumors, either primary (arisen within the liver) or secondary (spread to the liver from elsewhere). The principal aim of performing a liver resection is to completely remove the tumor without leaving any tumor behind. The success of liver resection depends upon the location of the tumor, the number of tumors, the amount of liver left after removal of the tumor, and the biology of the tumour.
What patients require a liver resection?
Most patients who require a liver resection have metastases (secondaries) from a colorectal (bowel) cancer. Less commonly other secondary cancers from neuroendocrine tumors (like carcinoid), renal cancer, breast or melanoma are resected. The most common primary liver cancer that is resected is hepatocellular carcinoma (HCC or Hepatoma). This is a cancer that originates in liver cells (primary), and is usually associated with underlying chronic liver disease. Primary cancers of the bile ducts, cholangiocarcinoma, are less commonly resected. There are a number of benign lesions that occur in the liver. Most don’t cause any symptoms or problems and can be monitored or left alone. Sometimes it is not possible to be sure of a diagnosis and resection is undertaken to establish the diagnosis. Biopsy of the liver is not routinely recommended as it has the potential to cause bleeding and spread of the cancer.
How is a liver resection performed?
The most common method of removing part of the liver is by an open operation (laparotomy). In some instances it is possible to undertake the operation laparoscopically (keyhole surgery). The open technique is the preferred method for major resections particularly and in those tumors that are difficult to access. Laparoscopic liver resection involves using a camera, known as a Laparoscope, connected to a high intensity light is introduced through a small incision and a further puncture wounds are made to allow the surgical instruments to be introduced. Once the liver has been resected a small incision is made low down in the abdomen to allow the tumour to be extracted. Irrespective of the method used the principals are the same: The liver is mobilized. The vessels to the portion being resected are isolated and controlled. A cut is then made through the liver substance (parenchyma) and care is taken to seal off the blood vessels and bile ducts that pass across the plane of transection.
Is there a chance of dying from this operation?
There is a risk of dying associated with any operation. The risk of dying following a liver resection depends upon the extent of the resection, the quality of the liver and your other medical conditions. About 2 patients in every 100 undergoing liver resection will die within the peri-operative period as a result of a complication. It is extremely rare to die during liver surgery in the operating room. You will be able to discuss your personal risks that apply to your surgery with the surgeon and anaesthetist prior to your operation. Because a liver resection is generally performed after a diagnosis of cancer, the risk of not having the surgery is balanced against the risks of the surgery itself.
How long will I be in hospital?
Most patients will be in hospital between 4-6 days. At the time of discharge you will be mobilizing independently, eating and drinking a reasonable diet and able to undertake most self cares. It normally takes approximately 3 months to completely get back to your normal activities. Most people return back to work after 4-6 weeks. This is very individual and it may take longer.
What happens before the operation?
This very much depends on upon the reason that you require a liver resection. You would have undergone imaging of your liver, USS and CT or MRI, to stage the extent of the disease, and had a number of blood tests and other investigations to determine your suitability for the operation. Prior to being scheduled for theatre the findings of these investigations will be discussed with you, and the various treatment options outlined. Once you have agreed to proceed with surgery, you will be asked to complete an anaesthetic questioner. This will be passed onto the anesthetist that will be looking after you during the operation. Depending upon your medical status you may require an appointment to see the anaesthetist in person or be sent for other investigations. You will need to have bloods taken immediately prior to your proposed date of surgery to ensure that blood is available in the event that you require a blood transfusion. You will be given specific instructions as to where and when to present for surgery and when to stop eating and drinking. Please follow these carefully as otherwise this may pose an anaesthetic risk and we may have to cancel your surgery. You should bath or shower before coming to hospital as you normally would. You do not need to shave any of the abdominal hair. You should take all your normal medication even on the day of surgery with a small amount of water. If you are on any medication that affects blood clotting you need to let A/Professor Adam Bartlett know well in advance of your surgery, as they may need to be stopped. If you are unsure, please ask.
What happens when I arrive at the hospital?
You will be seen by the nursing staff and taken to a bed in the pre-operative area. You will be asked to change into a theatre gown. A/Professor Adam Bartlett and anaesthetist will visit you and answer any questions that you have. You will then be taken into the operating room by a nurse who will be with you until you are asleep.
What happens after the operation?
You will be woken in the operating room after the operation has been completed, and taken into the recovery area. It is unlikely you will recall being in the operating room, and most patients can only recall waking in the recovering room. You will have an intravenous line in you arm and usually a larger central line in the jugular vein in your neck that are attached to fluid, and enables the staff to give you medication. A small cannula will be in the radial artery in your wrist that is used to monitor your blood pressure continuously. You will have an oxygen mask over your mouth that will administer supplemental oxygen. Rarely you will have a feeding tube in your nose that passes into your stomach to allow feed to be administered post-operatively. Often a drain will be left in your abdomen to drain any fluid that may collect off the cut surface, and this will remain in for 2-3 days. You will have a catheter in your urinary bladder to monitor your kidney function, and this is removed usually on day 2. You will be able to eat and drink as soon as you are hungry after the procedure. It is very important in the first 24 hours after your operation that we are able to monitor your condition closely. For this reason you may be cared for in a High Dependency Unit (HDU). There are a number of checks that will be routinely performed, over this time including throughout the night.
How much pain will I experience post-operatively?
Most people experience mild to moderate pain, which is readily, controlled using a combination of treatments. The anaesthetist will have a discussion with you prior to the operation regarding how your pain will be controlled. It is our usual practice to combine local nerve blocks (intra-thecal, epidural or wound catheters) with local anaesthetic that is placed at the time of your surgery. Systemic analgesia (intravenous or oral painkillers) are then used to supplement this if needed. You will be given patient controlled analgesia (PCA) post-operatively which allows you to control the administration of the painkillers. Once you are tolerating a reasonable diet, the PCA will be removed and you will be given oral painkillers as required. You will experience some pain/discomfort from your wounds, especially on movement, and you will need to communicate the severity of the discomfort to the medical staff looking after you so that the medication can be optimized to your needs. At the time of discharge you will be given a supply of painkillers and post-operative instructions on what to take when. Usually by day 4 most patients are only requiring minimal analgesia to control their pain.
What will need to be done to care for my wound?
The open operation is usually performed through an incision that is like a reversed “L” in the right upper quadrant of your abdomen. The skin is re-approximated using dissolvable sutures that do not need to be removed post-operatively. Steri-strips (thin white tape) are placed along the incision, and a waterproof dressing is placed over. The dressing will be left undisturbed for at least 3 days postoperatively to try and avoid contamination. You will be able to shower each day as the dressing is waterproof. Once the dressing has been taken down and it appears clean and dry the wound will be left without a dressing and you can shower as normal, taking care not to use any strong soaps or creams around the area. It may be that your wound leaks some darkish fluid or looks a little inflamed. This is not unusual and the staff will observe it closely. Occasionally stitches or staples will be used to close the skin. These will need to be removed after 10 days, and can be done by the district nurse. It is ok to use Bio-oil or Vitamin E on the incisions after the first week to help reduce scar prominence.
How long will it take to recover from the anaesthetic?
Whilst most of the effects of anaesthesia wear off in a few hours, it is common to have poor concentration and memory for a few days thereafter. After any major operation it takes some time to get back to feeling yourself again. Once all the tubes and drains have been removed it is not uncommon to feel easily tired and emotionally upset. This is normal and as time passes you will begin to feel more like yourself again. Try to be patient with yourself and allow yourself some time to get over your operation.
When can I return to normal activities?
You will be expected to transfer, with assistance, to a chair the day following your operation. Most patients are walking short distances around the ward by the second day. The physiotherapist will visit you on the ward and assist in getting you mobile and give you some simple exercises that will help. The quicker you mobilse the easier it is to get moving. It becomes easier as the various tubes and lines are removed. Upon discharge from the hospital you can return to normal physical and sexual activities when you feel comfortable. You should avoid heavy lifting and vigorous exercises for at least six weeks following the operation. It is normal to feel tired after surgery, so take some rest, two or three times a day, and try to get a good nights sleep.
Will I need chemotherapy afterwards?
That will depend upon the reason for undertaking liver resection and the outcome of the surgery. Chemotherapy is usually given prior to and after liver resection for patients with colorectal (bowel) cancer. Many of the other cancers are treated by surgery alone. Your case will be discussed with an oncologist (medical cancer specialist).
When can I start driving?
You should not drive for at least three weeks post-resection. Before driving you should ensure that you could perform a full emergency stop, have the strength and capability to control the car, and be able to respond quickly to any situation that may occur. Please be aware that driving whilst unfit may invalidate your insurance, and you should check with the conditions of your insurance policy as they do vary.
When can I return to work?
You can return to work as soon as you feel up to it. This will depend on how you are feeling and the type of work that you do. If you have a relatively sedentary job then you may feel ready to return within 3-4 weeks. If you are involved in manual labor or heavy lifting you need to avoid straining for at least 6 weeks.
What can I eat?
You can resume eating and drinking immediately following the operation. It is not unusual to lose your appetite. It will recover, as you get better. Fluids are often better tolerated than solids, and it is often recommended that you try soft foods before resuming a normal diet. The dietician will visit you on the ward to give you advice about your diet and will prescribe supplement drinks if you need them. Once at home, there are no dietary restrictions, and you should try and eat a balanced healthy diet. You should avoid alcohol for at least six weeks post-operatively to allow the liver to regenerate.
When should I seek help?
If you have concerns then either ring A/Professor Adam Bartlett directly or his rooms, or the hospital for advice. If it is medical emergency then dial 111 for an ambulance to take you to an acute hospital. You should let us know if you have a discharge of blood or pus coming from your wounds, develop a fever over 38.5 ° C, vomiting or diarrhoea, inability to have a bowel movement after four days, have persistent pain not relieved with your prescribed painkillers or persistent abdominal distension (bloating of your tummy), develop increasing pain or swelling around your wounds or become jaundiced (yellowing of the eyes or skin).
Here are some guidelines to follow for your first few weeks at home:
Undergoing any surgery is stressful – liver resection is a major operation which for many of you is the first time, so we expect that you will have questions. A/Professor Adam Bartlett’s contact details are there for you if you need to ask questions or have concerns.
- When you leave the hospital we will give you tablets to take for pain relief. Please take as directed.
- It is recommended that you take 1g (two 500mg tablets) of paracetamol (panadol) four times a day for the first 4-6 days.
- It is preferable that you don’t take non-steroidal anti-inflammatory drugs (NSAIDs) such as asprin, voltaren or ibuprofen as it increases the risk of post-operative bleeding, gastric irritation and kidney injury. Please ask A/Professor Adam Bartlett prior to taking any NSAID’s.
- Once at home, if you require further pain relief, either contact your General Practitioner or A/Professor Adam Bartlett as it may be that you require clinical review.
- Prior to discharge, A/Professor Adam Bartlett will also discuss with you, the position regarding re-commencement of your usual medications.
- Some patients will require an injection to be self-administered into their abdomen each day to help prevent blood clots in the deep veins. You will be instructed how to administer this prior to discharge.
- Depending on your wound and whether or not you have drains in place, the ward staff may arrange the district nurses to visit you at home following discharge.
- The staff at Mercy Hospital will be in touch by phone when you are at home to ensure that you are okay. They are happy to hear from you if you have any concerns and they will relay these to A/Professor Adam Bartlett if they think it is necessary.
Contact with your General Practitioner
- It is recommended that you make contact with your General Practitioner a few days after discharge so that they can assess how you are.
- A letter will be sent to your General Practitioner at the time of your discharge from hospital, along with a copy of the operation notes, to ensure they are fully aware of your situation.
- A/Professor Adam Bartlett is happy to take calls from your GP if they have any questions.
- Don’t put yourself to bed, instead keep moving regularly. If you need to rest, sit in a chair rather than staying in bed.
- Gentle walking for the first 2-3 days then increase your level of activity as tolerated.
- Try to avoid doing too much during the day. Accept that you need time to recover. Most people will have an afternoon sleep for the first few weeks.
- It is illegal to drive or operate machinery for 24 hours following a general anaesthetic. Most people feel sufficiently comfortable to drive a car 10-14 days after surgery. Be guided by how you feel and discuss any concerns in this regard with either your General Practitioner or A/Professor Bartlett. It is important that you check with your insurance provider as some policies have a standard stand down period for all abdominal surgery.
- Avoid straining or lifting more than 6kg for 6 weeks, then get back to your normal level of activity, appreciating however, that you would have lost physical condition during your recovery.
- You may return to work when you feel ready. Most people take 4-6 weeks to feel comfortable doing so. It is preferable to go back initially for short days and accept that you may need a rest in the afternoon.
- You may resume your normal diet when you feel up to it.
- There are no dietary restrictions. Initially you may find that your bowels are a little erratic but they will settle back to normal. It is important that you increase your normal intake to ensure that you recover. This can usually best be achieved by taking smaller amounts of food more regularly, rather than aiming for three larger meals a day. There are supplements that are available if you are struggling with your dietary intake.
- It is preferable to avoid alcohol for the first three months following liver resection to enable the liver to fully regenerate.
How to deal with common side-effects of your surgery, If you have:
Constipation: This is common due to the narcotics taken during the general anaesthetic and post-operatively for pain management. There are a number of different types of laxatives that you can get over the counter at the pharmacy or by prescription. Alternatively, dietary supplements such as prune juice, alpine tea or kiwi fruit are usually just as effective. Ensure that you drink plenty of fluid.
Bruising: It is not unusual for bruising to appear a day or so after the surgery. This is usually around the incision and extending up to the rib cage. If you feel it is getting worse or becoming painful, please notify A/Professor Adam Bartlett.
Pain: Discomfort is to be expected after this operation and it usually fades by the end of the second week, although sometimes it can last for many weeks. Each day, the pain should be similar or better than the day before, but it will fade slowly. If the pain is worsening daily or persists beyond two weeks, then you need to make contact with either your General Practitioner or A/Professor Adam Bartlett.
Headache: Some patients experience headaches after operations. It usually relates to dehydration. Ensure you drink plenty of fluids. If the headache persists beyond 24 hours, then make contact with your General Practitioner or A/Professor Adam Bartlett.
Shoulder pain: this may be common for several days due to irritation of the diaphragm over the liver. It is often relieved by heat packs. If it persists for more than 2 days, then you should contact A/Professor Adam Bartlett as it may indicate the development of a collection.
The incision(s): It is normal to have a little redness that becomes purple and/or “black and blue” around the incisions. This represents bruising from the surgery. It should appear, then fade within days. If you feel it is getting worse, or becoming painful, please notify A/Professor Adam Bartlett.
Dressings: Your incisions are dressed with two layers. The first layer is a water-proof dressing, called Comfeel. Try and leave it on for three days after surgery. After that you can peel it off whenever you wish. Beneath the water-proof layer are Steri-strips that are placed to reduce tension across the incision. Leave the Steri-strips on for 10 days or until they fall off, whichever occurs first. The nurses may change the dressings prior to you leaving the hospital. You can shower with the dressings on and once they have been taken off just leave the wound open to the air. You can apply vitamin E, Bio-oil or the like to the incisions to keep them moist and to facilitate healing.
Unusual side effects
When to call the doctor immediately, Call your GP or A/Professor Bartlett if you experience
Abdominal pain that is getting progressively worse. In a normal recovery, you should feel a little better each day although your discomfort may take a couple of weeks to completely disappear.
Redness (erythema) or foul-smelling drainage from the incision as this may indicate infection.
A temperature greater than 38.5ºC or profuse sweating at night.
Vomiting or diarrhoea lasting more than 24 hours.
Jaundice (yellow skin/eyes).
Follow Up Visit
When you leave the hospital, A/Professor Adam Bartlett’s PA will be in touch to arrange your post-operative review. This is usually the following week. At that visit, A/Professor Adam Bartlett will again review the operative findings, assess how you are recovering and have the pathology report of the resected liver. Depending on how you are recovering and the results of the pathology, you may require further investigations, treatment or review. A/Professor Adam Bartlett will spend time discussing this with you so that you are fully aware of the plan.
If you have any concerns or questions during your recovery or following your operation, please call the rooms on +64 6 6234789. If it is after hours or urgent, contact A/Professor Adam Bartlett on his mobile +64 21 2414647.