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Liver Disease: Schwartz Principles of Surgery2010
Liver Disease: Schwartz Principles of Surgery2010
Dr.Ahmad Kachooyi
SHAHID BEHESHTI hospital
HISTORY OF liVER SURGERY
Liver anatomy
History of liver surgery
The ancient Greek myth of Prometheus reminds
us that the liver is the only organ that
regenerates.
The first recorded elective hepatic resection was
done in 1888 in Germany by Langenbuch.
The liver is the largest organ in the body, weitghing
approximately 1500 g.
The hepatoduodenal ligament is known as the porta
hepatis and contains the common bile duct, the hepatic
artery, and the portal vein.
From the right side and deep (dorsal) to the porta hepatis is
the foramen of Winslow, also known as the epiploic
foramen.
Segmental Anatomy
The liver is grossly separated into the right and left lobes by
the plane from the gallbladder fossa to the inferior vena
cava (IVC), known as Cantlie‘s line.
The right lobe typically accounts for 60 to 70% of the liver
mass, with the Ieft lobe (and caudate lobe) making up the
remainder.
The caudate lobe lies to the left and anterior of the IVC .
Couinaud
Divided the liver into eight segments,numbering them in a clockwise
direction beginning with the caudate lobe as segment I.Segments
IIand III comprise the left lateral segment, and segment IV is the left
medial segment
The right lobe is comprised of segments V, VI, VII, and VIII, with
segments V and VIII making up the right anterior lobe, and
segments VI and VII the right posterior lobe.
Couinaud's liver segments (I through VIII) numbered in a clockwise manner. The left lobe
includes segments II to IV, the right lobe includes segments V to VIII, and the caudate
lobe is segment I. IVC = inferior vena cava.
INCIDENTAL LIVER MASS
A liver mass often is identified incidentally during a radiologic
imaging procedure performed for another indication' For example
a liver mass may be discovered during evaluation for gallbladder
disease or kidney stones.
* The most common presenting symptoms include fever, chills, and abdominal
pain
* Most patients present by the age of 30
*dx:MRCP,ERCP, (provide more detailed imaging of the biliary tree(
* Treatment: biliary drainage, with ERCP and PTC serving as first-line. Liver
resection can be
considered in the patient with hepatic decompensation or unresponsive
recurrent cholangitis and
possibly in the patient with a small T1 or T2 cholangiocarcinoma.
Hemangioma
The fibrous septa extending from the central scar are also more readily seen with MRI.
If CT or MRI scans do not show the classic appearance radionuclide sulfur colloid
imaging may be used to diagnose FNH based on select uptake by Kupffer cells.
HCCs are typically hypervascular with blood supplied predominantly from the
hepatic artery. Thus, the lesion often appears hypervascular during the
arterial phase of CT studies and relatively hypodense during the delayed
phases due to early washout of the contrast medium by the arterial blood.
MRI imaging also is effective in characterizing HCC
HCC has a tendency to invade the portal vein, and the presence of an enhancing portal
vein thrombus is highly suggestive of HCC
The treatment of HCC is complex and is best managed by a multi disciplinary liver
transplant team.
For patients without cirrhosis who develop HCC, resection is the treatment of choice. For
those patients with Child's class A cirrhosis with preserved liver function and no portal
hypertension, resection also is considered.
If resection is not possible because of poor liver function and the HCC meets the Milan
criteria (one nodule <5 cm, or two or three nodules all <3 cm, no gross vascular
invasion or extrahepatic spread), liver transplantation is the treatment of choice
.
Living-donor liver transplantation is also an alternative for patients with HCC awaiting
transplantation to avoid dropout due to tumor progression.
.
Cholangiocarcinom (Bile Duct Cancer)
Cholangiocarcinoma is the second most common primary malignancy
within the liver
subclassified:
1.peripheral (intrahepatic) bile duct cancer
2.central (extrahepatic) bile duct cancer
A biopsy specimen from the cholangiocarcinoma will show
adenocarcinoma but the pathologist is often unable to differentiate
metastatic adenocarcinoma to the liver from true primary bile duct
adenocarcinoma .Therefore a search for a primary site should be
undertaken .
Histologically negative margins, concomitant hepatic resection, and
well-differentiated tumor histology were associated with improved
outcome after resection.
the results are dismal for radical resection in patients with advanced
disease and positive hilar lymph node.
Metastatic Colorectal Cancer
Over 50% of patients diagnosed with colorectal cancer will develop hepatic
metastases during their lifetime.
Many groups now consider volume of future liver remnant and the health of the
background liver, and not actual tumor number, as the primary determinants
in selection for an operative approach. Resectability is no longer defined by
what is actually removed, but indications for hepatic resection now center
on what will remain after resection.
For HCC in the setting of cirrhosis, liver transplantation also offers the
potential for long-term survival, albeit with the consequence of
immunosuppression .