The role of imaging in surgical planning for liver resection: what the radiologist need to know

Abstract

The management of patients undergoing surgical resection for liver malignancies requires a multidisciplinary team, including a dedicated radiologist. In the preoperative workup, the radiologist has to provide precise, relevant information to the surgeon. This requires the radiologist to know the basics of surgical techniques as well as liver surgical anatomy in order to help to avoid unexpected surgical scenarios and complications. Moreover, virtual resections and volumetries on radiological images will be discussed, and basic concepts of postoperative liver failure, regeneration, and methods for hypertrophy induction will be provided.

Figure 1.

Normal segmental anatomy of the liver. a, b, c, cranio-caudal axial CT slices, portal venous phase. Dashed line: Cantlie’s line dividing the two hemilivers. RHV: right hepatic vein; MHV: middle hepatic vein; LHV: left hepatic vein; LPV: left portal vein. Arabic numbers: Couinaud’s segments.

Figure 2.

Volume Rendering (VR) reconstructions of relevant vascular variants for surgery. A: antero-inferior view of a variant of the hepatic artery (red). Replaced left hepatic artery from the left gastric artery, middle hepatic artery from common hepatic artery, and replaced right hepatic artery from the superior mesenteric artery. Variants of the left hepatic artery are relevant in left hepatectomies (brown hemiliver), while variants of the right hepatic artery are relevant for right hepatectomies (green hemiliver). Ao: aorta. CT: celiac trunk. SMA: superior mesenteric artery. CHA: common hepatic artery. SA: splenic artery. LGA: left gastric artery. GDA: gastro-duodenal artery. LHA: left hepatic artery. MHA: middle hepatic artery. RHA: right hepatic artery. B: portal trifurcation (pink), cranial-right view. RPSPV: right posterior sectorial portal vein. RASPV: right anterior sectorial portal vein. LPV: left portal vein. C: variants of hepatic veins (blue) with right accessory hepatic vein, cranio-posterior view. RAHV: right accessory hepatic vein. RHV: right hepatic vein. MHV: middle hepatic vein. LHV: left hepatic vein.

Figure 3.

Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS), Volume rendering reconstructions (VR). Hepatic artery: red. Hepatic veins: blue. Portal vein: pink. Red lesion: tumor. Green lesion: cyst. A: Baseline CT before step 1: simulation of right hepatectomy extended to segment 4. Green liver: Remnant Liver Volume (RLV) including Couinaud’s segments 1, 2, 3. Brown Liver: resected liver (segments 4, 5, 6, 7, 8). The RLV had a volume of 242 ml and 230 ml without the cyst. The calculated future liver remnant was 21% (fraction of RLV on Functional Liver), below the safe threshold for resection (FLR>=25%). The patient was candidate to ALPPS. B: follow-up CT on 7° post-operative day after ALPPS step 1. The RLV (brown liver) increased from 242 ml to 337 ml (equal to 325 ml without the cyst). The calculated FLR was 28%, and the patient underwent to right hepatectomy extended to segment 4 on the following day. The procedures performed in step 1 can be observed: the right portal vein was ligated (not visible in b, pink arrows), and the in-situ splitting was performed (empty white arrows).