LIVER RESECTION SURGERY

LIVER RESECTION

A liver resection is the surgical removal of a section of the liver. This procedure is performed as a treatment option for liver cancer & during liver transplantation. The liver is a vital organ and the only one that has the ability to regenerate itself so liver resection can be done without damage to body.

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Risk Factor

Status of liver tissue (parenchyma) is important factor in deciding the risk of liver resection. When liver tissue is normal, then more liver tissue can be removed safely because the remaining liver tissue is normal and can sustain the need of body.
When liver is affected by disease like cirrhosis or by effect of chemotherapy, then remaining liver tissue volume should be more than usual to sustain the need of body.
In person with jaundice, cirrhosis, obesity, old age, diabetes or chemotherapy treatment, less amount of liver is removed.
Jaundice may be due to non-functioning of liver or duo to blockage of bile-duct due to cancer. In case of blockage of bile duct, stent is placed (ERC) across to block (cancer) or in another bile-duct (PTBD) to facilitate bile flow. Once bilirubin comes below 2 mg%, safe liver resection can expected.
Cirrhosis is a condition in which the liver slowly deteriorates and is unable to function normally due to chronic, or long lasting, injury. Scar tissue replaces healthy liver tissue and partially blocks the flow of blood through the liver.
Obesity leads to storage of excess fat into liver. This excess fat slowly damages with liver over the years.
Old age person & Diabetes has slow the process of liver regeneration (a process of new liver formation)
Chemothapy (therapy to kill cancer cells) also damages the liver.

Safe limit for Liver resection

Assessment of Liver

Liver function tests are done to assess functional reserve of liver (how normal is your liver). High levels of Jaundice (Bilirubin > 2 mg) impose risk of liver failure after liver resection. So jaundice should be treated and bilirubin levels should be normalised to minimise the risk after liver resection.
Volume: Liver resection can be “major” if more than 4 segments of liver are removed. Normally liver has 8 segments and all segments don’t have same volume. So liver surgeon do assessment (CT or MR volumetry) of liver volume to plan the limit of safe liver resection.
Fat: Now a day, due to high cases of obesity in society, person with obesity, also have “fatty liver”. Excess fat in liver, although add the weight to liver, but it slowly damage the liver cells so effectively volume of functional volume of liver is less. This is very important in case of liver transplantation because fatty liver from obese person have more chances of poor performance in recipient (person who receives new liver in liver transplantation).
Now MRI is a simple test to know that fat content in liver. In doubtful cases, liver biopsy is taken for accurate assessment.

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Preparation for Surgery

Our expert team members shall help you to prepare you for surgery. You are strongly advised to stop smoking, stop drinking alcohol, try to improve your diet, lose weight, or actively exercise before surgery.

Pre-operative testing

in most cases, you will need some tests before your surgery. The tests routinely used include:

Blood tests to measure your blood counts, your risk of bleeding or infection, and how well your liver and kidneys are working. Your blood group type is also be checked in case you need blood transfusions during the operation.
Chest x-ray and ECG (electrocardiogram) to check your lungs and your heart’s electrical system.
CT scans/ MRI to look at the size and location of the tumors and see if the cancer looks like it has spread to nearby tissues. Also volume of remaining liver is assessed to execute safe liver surgery.

Anaesthetic Assessment before Surgery:

Our expert team of Anaesthetist will ask you questions pertaining to your health and to assess your fitness for surgery. You are requested to tell them in detail about your current and past medical ailments, allergic reactions you’ve had in the past and current medicines that you are taking like blood thinning medicine. This medicine should be stopped 1 week prior to surgery.

Informed Consent

Informed consent is one of the most important parts of “getting ready for surgery”. It is a process during which you are told about all aspects of the treatment before you give your doctor written permission to do the surgery.

Getting ready for Surgery

Depending on the type of operation you have, there may be things you need to do to be ready for surgery:

Emptying your stomach and bowels (digestive tract) is important. Vomiting while under anaesthesia can be very dangerous because the vomit could get into your lungs and cause an infection. Because of this, you will be asked to not eat or drink anything starting the night before the surgery.
Laxative: You may also be asked to use a laxative or an enema to make sure your bowels are empty.
Shaving of Operative part: You need to have an area of your body shaved to keep hair from getting into the surgical cut (incision). The area will be cleaned before the operation to reduce the risk of infection.

Anaesthesia

Anaesthesia is the use of drugs to make the body unable to feel pain for a period of time. General anaesthesia puts you into a deep sleep for the surgery. It is often started by having you breathe into a face mask or by putting a drug into a vein in your arm. Once you are asleep, an endotracheal or ET tube is put in your throat to make it easy for you to breathe. Your heart rate, breathing rate, and blood pressure (vital signs) will be closely watched during the surgery. A doctor watches you throughout the procedure and until you wake up. They also take out the ET tube when the operation is over. You will be taken to the recovery room to be watched closely while the effects of the drugs wear off. This may take hours. People waking up from general anaesthesia often feel "out of it" for some time. Things may seem hazy or dream-like for a while. Your throat may be sore for a while from the endotracheal (ET) tube.

Approach for Liver Resection

How surgery is performed? (Special surgery techniques): Open Or Laparoscopic

Open Surgery:

Laparoscopic Surgery

A laparoscope is a long, thin, flexible tube that can be put through a small cut (incision) to look inside the body. In recent years, doctors have found that by creating small holes and using special instruments, the laparoscope can be used to perform surgery without making a large cut. This can help reduce blood loss during surgery and pain afterward. It can also shorten hospital stays and allow people to heal faster.
The role of laparoscopic liver surgery is increasing. Minor liver resection and treatment of liver cyst is most likely treated with laparoscopic approach. But surgeon may prefer to change to open approach for safety reasons.

Recovery from Surgery

Your recovery right after surgery depends on many factors, including your state of health before the operation and how extensive the operation was performed.

Pain

You may feel pain at the site of surgery. We aim to keep you pain free after surgery with the help of latest and most effective technique or analgesic (pain relieving medicine).

Tube/ Drains

You may also have Ryle’s Tube (tube going through nose to stomach) that drain out intestinal fluid. This tube helps to relieve nausea and vomiting after surgery and usually removed 1-2 day after surgery.
You may also have “Tube” (called a Foley catheter) draining urine from your bladder into a bag. This will be taken out soon after surgery, once you are comfortable enough to go to bathroom.
You may have a tube or tubes (called Drains) coming out of the surgical opening in your skin (incision site). Drains allow the excess fluid that collects at the surgery site to leave the body. Drain tube will also be removed once they stop collecting fluid, usually a few days after the operation.

Leg stocking / Compression boot

As you are remains in bed on day of surgery, circulation of blood in leg become sluggish that may increase possibility of thrombo-embolism. To minimise it, you will be wearing leg stocking/ pneumatic compression boot to improve your leg circulation thus minimising the risk of thrombolism.

Eating and Drinking

Once you are eating and walking, and then you are ready to go home, in most case in next day following surgery. Before leaving for home our health care team shall give you detailed guidance regarding diet, activities, medications & further plan of treatment

You may not feel much like eating or drinking, but this is an important part of the recovery process. Our health care team may start you out with ice chips or clear liquids. The stomach and intestines (digestive tract) is one of the last parts of the body to recover from the drugs used during surgery. You will need to have signs of stomach and bowel activity before you will be allowed to eat. You will likely be on a clear liquid diet until this happens. Once it does, you may get to try solid foods.

Activity

Our health care team will try to have you move around as soon as possible after surgery. They may even have you out of bed and walking the same day. While this may be hard at first, it helps speed your recovery by getting your digestive tract moving. It also helps your circulation and helps prevent blood clots from forming in your legs.

Our team shall also encourage you to do deep breathing exercises. This helps fully inflate your lungs and reduces the risk of pneumonia. You are advised to take deep breaths and cough every hour to help prevent lung infections. You will use an incentive spirometer (a small device used in breathing exercises to prevent complications after major surgery) 10-15 times every hour.

Going home

Once you are eating and walking, all tube/drains placed during surgery are removed, and then you may be ready to go home. Before leaving for home our health care team shall give you detailed guidance regarding diet, activities, medications & further plan of treatment.

Risks and side effects of surgery

There are risks that go with any type of medical procedure and surgery is no longer an exception. Success of surgery depends upon 3 factors: type of disease/surgery, experience of surgeon and overall health of patients. What's important is whether the expected benefits outweigh the possible risks.

Doctors have been performing surgeries for a very long time. Advances in surgical techniques and our understanding of how to prevent infections have made modern surgery safer and less likely to damage healthy tissues than it has ever been. Still, there’s always a degree of risk involved, no matter how small. Different procedures have different kinds of risks and side effects. Be sure to discuss the details of your case with our health care team, who can give you a better idea about what your actual risks are. During surgery, possible complications during surgery may be caused by the surgery itself, the drugs used (anesthesia), or an underlying disease. Generally speaking, the more complex the surgery is the greater the risk. Complications in major surgical procedures include:

Complications related to Anaesthesia: Reactions to drugs used (anesthesia) or other medicines. Although rare, these can be serious because they can cause dangerously low blood pressures.
Complications related to underlying medical illness llike heart disease, diabetes, kidney disease, obesity, malnutrition.
- Lung: Pneumonia, Atelectasis (collapse of lung), effusion (fluid in chest) can occur, especially in patients with reduced lung function, such as smokers. Doing deep breathing exercises as soon as possible after surgery helps lessen this risk.
- Thrombosis (blood clot) in leg & embolism (blood clot) in lung. Blood clots can form in the deep veins of the legs after surgery, especially if a person stays in bed for a long time. Such a clot can become a serious problem if it breaks loose and travels to another part of the body, such as a lung. This is a big reason why you will be encouraged to get out of bed to sit, stand, and walk as soon as possible.
- Cardiovascular: Myocardial infarction (heart attach), Arrhythmia (irregular heart beat), Stroke (cerebro-vascular accidents)
- Kidney & urinary tract infection, acute kidney failure if patient has uncontrolled/non-responding infection

Complication related to Liver Surgery
- Post-resection Liver failure: It happens upto 15% cases, despite careful selection of case. Appearance of jaundice, progressive deepening of jaundice and change in behaviour of patient are alarming symptoms. It usually invites more complications after surgery and can progress to death.
- Bile leak
- Bleed
Complications related to Major Surgery
- Infection: Infection at the site of the wound, lung and urinary infection. Infection risk is more if intestine is perforated before surgery, operated for colon and rectum, stent in placed in bile duct to relieve jaundice or intestinal joint is leaking.
- Bleeding: The risk of bleeding during or after surgery is more if patient taking blood thinning medicine till day of surgery or having liver dysfunction. Bleeding during surgery that may cause you to need blood transfusions. There is a risk of certain problems with transfusions, some of them serious. Still, some operations involve a certain amount of controlled blood loss. Bleeding can happen either inside the body (internally) or outside the body (externally). It can occur if a blood vessel sealed during surgery opens up or if a wound opens up. Serious bleeding may cause the person to need another operation to find the source of the bleeding and stop it.
- Leakage from anastomosis (joint of anastomosis) & fluid collection in tummy
- Blockage of intestine (Intestinal obstruction)

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