Liver Resection and Surgical Strategies for Management of Primary Liver Cancer

Abstract

Primary liver cancer-including hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC)-incidence is increasing and is an important source of cancer-related mortality worldwide. Management of these cancers, even when localized, is challenging due to the association with underlying liver disease and the complex anatomy of the liver. Although for ICC, surgical resection provides the only potential cure, for HCC, the risks and benefits of the multiple curative intent options must be considered to individualize treatment based upon tumor factors, baseline liver function, and the functional status of the patient. The principles of surgical resection for both HCC and ICC include margin-negative resections with preservation of adequate function of the residual liver. As the safety of surgical resection has improved in recent years, the role of liver resection for HCC has expanded to include selected patients with preserved liver function and small tumors (ablation as an alternative), tumors within Milan criteria (transplant as an alternative), and patients with large (>5 cm) and giant (>10 cm) HCC or with poor prognostic features (for whom surgery is infrequently offered) due to a survival benefit with resection for selected patients. An important surgical consideration specifically for ICC includes the high risk of nodal metastasis, for which portal lymphadenectomy is recommended at the time of hepatectomy for staging. For both diseases, onco-surgical strategies including portal vein embolization and parenchymal-sparing resections have increased the number of patients eligible for curative liver resection by improving patient outcomes. Multidisciplinary evaluation is critical in the management of patients with primary liver cancer to provide and coordinate the best treatments possible for these patients.

Keywords: hepatectomy; hepatocellular carcinoma; intrahepatic cholangiocarcinoma; liver neoplasms.

Figure 1.

Anatomic central hepatectomy (mesohepatectomy) for HCC. A, Venous phase of abdominal CT showing the centrally located tumor with involvement of the middle and right hepatic veins. The patient had a right inferior hepatic vein, which allowed the plans for a central hepatectomy. B, Intraoperative image of the tumor centrally located in the context of cirrhotic liver. C, Intraoperative image after central hepatectomy showing the central defect and spared right posterior and left lateral sections. D, Delayed phase of abdominal MRI 1 year after resection revealing central defect and enlarged right posterior and left lateral sections. CT indicates computed tomography; HCC, hepatocellular carcinoma; MRI, magnetic resonance imaging.

Figure 2.

Anatomic bisegmentectomy for centrally located HCC—accomplishing complete resection, using segment-oriented technique and able to preserve liver parenchyma. A, Venous phase of abdominal CT scan revealing a deep lesion close to the takeoff of the right anterior pedicle. B, Intraoperative imaging after transection of the right anterior pedicle, showing demarcated bisegment (segments 5 and 8). C, Postresection intraoperative imaging revealing the surgical defect following bisegmentectomy. D, Ex vivo image of surgical specimen revealing the 2 segments and the lesion deep in the area with adequate margins. CT indicates computed tomography; HCC, hepatocellular carcinoma.

Figure 3.

Combination of “hanging maneuver” technique and anterior approach for resection of a large right-sided HCC (14 cm). A, Abdominal CT scan (axial image) revealing a giant right lobe HCC. B, Intraoperative image revealing a Penrose drain inserted along the retrohepatic space and anterior to the inferior vena cava (IVC) to allow to “hang” the liver while anterior transection is performed. C, Intraoperative image revealing post-transection aspect of the liver. Note that the right liver has not yet been mobilized. D, Intraoperative image revealing the last portion of the procedure, after transection of the right hepatic vein, and as the right lobe is being mobilized and once transection has been completed. Note the IVC completely exposed after the anterior approach, which is greatly facilitated by the hanging maneuver. CT indicates computed tomography; HCC, hepatocellular carcinoma.