John James Medical Centre,
Suite 18,
175 Strickland Crescent
Deakin Act 2600
Tel: 02-6282 1200
Liver Surgery
What is the liver?
The liver is the largest organ in the body. It filters nutrient filled blood from the intestines. It has key roles in removing drugs and toxins from the blood and in maintaining blood sugar levels. It produces hormones involved in the production of blood components, is a major store of iron and makes proteins involved in fluid balance and clotting. The liver also clears the blood of the break down products of red blood cells (bilirubin) and produces bile which is stored in the gallbladder and aids in digestion of fats.
Why do people need liver surgery?
People usually undergo liver surgery to remove tumors in the liver. These tumors may arise in the liver or have spread to the liver from cancers in other organs. Occasionally liver surgery is required to treat infections or manage traumatic injuries.
Who is suitable for liver surgery?
A major risk of liver surgery is liver failure. Whilst the liver has an amazing capacity to recover and grow after liver surgery, there are limits to the amount of liver that can be safely removed. Livers damaged by cirrhosis may also have a limited capacity to recover. To undergo liver surgery to remove tumors there needs to be an adequate liver remnant for the patient to survive the post-operative period whilst liver regeneration occurs. Furthermore, major liver surgery usually involves prolonged anesthesia and a large incision. Patients need to be fit enough to withstand these insults.
Who is not suitable for liver surgery?
1. Patients who will be not left with adequate liver reserve following surgery.
2. Patients who are not fit enough to undergo major surgery.
3. Patients with tumors that do not have a reasonable prospect of being cured by liver surgery.
What kind of investigations are required prior to liver surgery?
Most patients usually required imaging of the liver such as ultrasound, CT scanning and often MRI scanning with liver specific contrast to determine the size, location and probable nature of the liver tumor. Other investigations include blood tests to determine underlying liver function and possible causes of liver damage such as viral hepatitis. Tumor markers are also typically required. A CT scan of the chest to exclude spread of liver tumors to the lungs. For patients with known cancers such as bowel cancer a PET scan may be required. For patients with underlying cirrhosis measurement of liver function (ICG-15R) may be required. If there is suspicion of portal hypertension, then measurement of Hepatic Portal Venous Gradients may be ordered.
Is a pre-operative biopsy necessary?
We try to avoid pre-operative biopsies in patients with liver tumors. We are concerned about the risk of spreading tumor cells during the biopsy and converting a potentially curable disease into an incurable one. We can usually have an accurate diagnosis based on imaging alone.
What is neoadjuvant therapy?
Patients with known cancers such as bowel cancer sometimes receive chemotherapy prior to liver surgery.
What is a multidisciplinary team meeting?
Often patients with suspected cancers in their liver are discussed in meeting with other medical specialists such as surgeons, radiologists, pathologists, hepatologists, medical oncologists, radiation oncologists and interventional radiologists to ensure that patients are offered what is thought to be gold standard care. At Canberra Hospital we have a Liver Tumor Group that meets once a month and a Gastrointestinal Multidisciplinary Meeting that meets weekly.
What kinds of liver surgery are there?
Surgery on the liver is usually performed under general anesthesia using an open technique ie a large incision on the abdomen. Occasionally small tumors located in favorable locations can be removed with small incisions using the operating telescope (laparoscopic liver surgery).
Are there alternatives to liver surgery?
1. Liver transplantation is occasionally used for patients with advanced liver cirrhosis and small tumors arising in the liver.
2. Ablation involves inserting a probe into the liver and using an energy form such as microwaves to burn liver tumors that are small and deeply located within the liver.
3. Chemotherapy can sometimes be given either through a peripheral vein or sometimes directly into the liver, particularly for patients who are not thought to be curable with surgery
4. Radiotherapy can be given by injecting radioactive beads directly into the liver.
What is my experience with liver surgery?
I have been performing liver surgery as a consultant surgeon at the Canberra Hospital since 2005. I have performed over 250 liver resections.
What is involved in the surgery?
Once the decision for surgery has been made the patient is asked to sign a consent form and a request for admission is lodged with Canberra Hospital along with an expected surgery date. Patients usually attend a pre-admission meeting with an anesthetist a few days prior to their surgery. They are admitted to hospital on the morning of their surgery.
In the operating theatre the anesthetist will insert an intravenous drip. Often, they will also insert an arterial line and epidural catheter or spinal anesthetic. Once the patient is asleep a catheter is placed in the bladder. An incision is made in the upper abdomen, usually a reverse L shape. The liver is mobilized (i.e., released from its attachments to the abdominal wall) and lifted up into the wound. The main tumor is identified, and an inspection is made for other tumors. The relationship of the tumor to major vascular structures is usually identified using intra-operative ultrasound. The gallbladder may be removed if it is thought to be in the way.
The tumor is removed usually using a combination of ultrasound dissection (CUSA), harmonic scalpel and vascular staplers. The raw surface of the liver is inspected for bile leaks and bleeding. The abdomen is closed in layers using absorbable sutures. An abdominal drain is usually not necessary.
At the end of the operation the anesthetist usually removes the breathing tube, and the patient is taken to the intensive care unit for overnight observation. In the usual course of events patients are then transferred to a ward and a diet is commenced. All being well, patients are usually ready to be discharged home five to seven days after their surgery.
What are the risks of liver surgery?
There are risks that are part of any major abdominal surgery and those that are specific to liver surgery. General risks include:
1. Death - whilst liver surgery is very safe, overall, the chance of not making it out of hospital after liver surgery is about one percent. This risk depends on the age of the patient, the presence of underlying liver disease and the size of the resection being contemplated.
2. Medical risks such as heart attack, stroke, clot in the lungs and pneumonia. Usually, the risks of these complications is very small.
3. Surgical risks such as bleeding, infection, hernias and injury to the bowel.
Risks specific to liver surgery include;
1. Benign diagnosis - rarely a tumor that is thought to be a cancer can be found be a benign tumor when it is looked at by our pathologists.
2. Non-resection - rarely, at the time of surgery, the disease can be more extensive than predicted based on pre-operative imaging making a major liver resection futile.
3. Liver failure - the major risk of liver surgery, particularly in patients with cirrhosis is liver failure. Liver failure is usually manifested by confusion, a swollen abdomen and jaundice. This often improves by itself as the liver regenerates after the surgery. Occasionally medications are required to help control symptoms whilst the liver is recovering. Liver failure is the major cause of death following liver surgery.
4. Bile leak - bile can leak from the cut surface of the liver. This is usually not a major issue unless the fluid becomes infected in which case a drain may need to be placed into the fluid collection.
5. Bile duct injury - the bile takes bile from the liver and puts it in the small bowel. Occasionally the bile duct can be injured during liver surgery, and this may require surgical repair.
6. Pleural effusion - occasionally fluid can collect above diaphragm after liver surgery. This may require a drain to be placed through the skin, near the lung.
7. Recurrence - occasionally cancerous tumors can re-occur within the liver or beyond it following liver surgery. Recurrences within the liver can often be treated with further surgery.
8. Adjuvant therapy - if the removed tumor in the liver is a cancer patients may be referred to a medical oncologist to discuss the benefit of further treatment in the form of chemotherapy in order to reduce the risk of recurrence.
What are the costs of liver surgery?
As a public patient in Canberra Hospital there should minimal or no out of pocket costs. Occasionally patients are asked to undergo specialized imaging tests such as liver specific MRI which is not rebated by Medicare and may be out of pocket for this investigation.
What are the results of liver surgery?
The results of liver surgery are usually very good. Patients with benign tumors should be cured by liver surgery and require no further treatment or follow-up. Patients with primary liver tumors and colorectal cancer metastases can usually expect 5-year disease specific survival to be above 50%.
Is further treatment required after liver surgery?
Occasionally further treatment, usually in the form of chemotherapy, is recommended following surgery.
What follow up is required after liver surgery?
Patients are seen one to two months after surgery in the general outpatient clinic at Canberra hospital. Follow-up thereafter depends on the tumor that has been removed. Usually the recommendations of the NCCN (National Comprehensive Cancer Network) are followed. This usually involved blood tests and CT scanning.
