Liver Surgery

The liver is located in the upper right quadrant of the abdomen and is the largest organ, weighing ~1.5 kilograms. It is a major metabolic organ regulating various bodily functions and supports the function of other organs as well. The liver has two major blood supplies – the hepatic artery and the portal vein. The artery carries oxygen-rich blood to the liver, whereas the portal vein carries blood rich in nutrients from the gastrointestinal tract, spleen, and pancreas. The majority of the blood supply to the liver is derived from the portal vein (70%), while the blood supply to the bile ducts is derived from the artery. The hepatic vein is the major outflow of blood vessels from the liver into the inferior vena cava.

The most commonly used system to describe liver anatomy is the Couinaud system. The liver is divided into a right and left lobe. Within each lobe, the liver is further divided into segments, based on the division of the blood vessels within the liver. There are eight segments and are numbered in Roman numerals. The left lobe consists of segments II to IV, while the right lobe consists of segments V to VIII. The caudate lobe is labelled as Segment I.

From the surface, it is impossible to determine the boundaries between the segments. Pre-operative imaging (USS, CT, MRI) is used to delineate the anatomy, while intra-operative USS is used directly on the liver to aid in further defining the anatomy. The knowledge of the segmental anatomy determines the plane of transection during liver surgery.

Liver (hepatic) surgery involves surgical procedures on the liver for a variety of reasons. Liver resection surgery is the most common procedure performed on the liver. Liver surgery aims to remove the diseased area (most commonly cancer) with preservation of as much normal liver as possible.

Initial assessment will include blood tests and imaging of your liver (USS, CT, MRI and/or PET-CT) to assess the extent of the liver disease. These are performed to determine your suitability for liver surgery. The results of these investigations will be discussed with you, and treatment options will be outlined.

Once a decision has been made to proceed with surgery, you will be requested to fill out an anaesthetic questionnaire. This will be reviewed by the anaesthetist who will be responsible for your care, and you may be required to see the anaesthetist in person or sent for additional tests. Once you have completed the anaesthetic review, the date of surgery will be confirmed with you.

Liver resection is commonly performed by an open procedure (laparotomy). In certain cases, it is feasible to perform liver resection laparoscopically (keyhole). The preferred approach for major liver resection is a laparotomy, especially for tumors in difficult areas to access.
 
The principles of liver resections are:

• Mobilisation of the liver
• Intraoperative Ultrasound is performed to confirm the location of the cancer and the anatomy of the major blood vessels
• The blood vessels to the planned resected liver are controlled.
• The liver parenchyma (substance) is transected (cut), and meticulous care is taken to seal off the small blood vessels and bile ducts that traverse across the surgical plane of transection

An incision is made in the right upper quadrant of the abdomen and the abdominal cavity is entered into carefully. The incision can be a straight midline wound or, more commonly, a “Reverse-L incision”.

A laparoscope (camera) is introduced via a small incision and three further small wounds are used to allow the utility of laparoscopic surgical instruments. Once the liver resection has been completed, the wound for the laparoscope is extended to allow the removal of the resected liver.

There are risks with any surgery, and they can be divided into “General” or “Procedure-specific risks”. Complications occur in ~20-30% of all cases and are usually mild. If you are overweight or smoke, there is an increased risk of post-operative complications.

There are some rare but specific complications related to liver resection:

• Liver failure

This is one of the most feared and severe complications following liver surgery. It occurs if the future liver remnant (remaining volume of liver tissue) is insufficient to maintain normal liver synthetic, excretory and detoxifying function.

The symptoms of liver failure include:
- Progressive jaundice
- Ascites (fluid build-up in the abdominal cavity)
- Coagulopathy (abnormal blood clotting)

Liver failure can lead to death if the liver is unable to regenerate sufficiently post-liver resection. During the work-up for liver surgery, Dr. Michael Chu will estimate the volume of the future liver remnant and provide an approximate risk of liver failure post-liver resection. If pre-operative work-up was performed cautiously, post-liver resection liver failure is a rare complication.

• Bile leak

There is a 5-10% chance of bile leak from the liver cut surface following liver resection. This can usually be treated with percutaneous aspiration under ultrasound guidance and is normally self-limiting. If the bile leak does not settle spontaneously, an endoscopic procedure (ERCP) may be required to decompress the bile ducts and encourage bile flow towards the duodenum rather than the cut surface. On rare occasions, a re-operation may be required to deal with the bile collection.

• Post-Operative bleeding

The liver is a very vascular organ, and bleeding may occur at the time of resection or post-operatively. In the majority of patients, it settles without requiring further intervention, but some patients may need blood transfusion. Rarely, patients may require a re-operation.

• Liver abscess

A liver abscess is defined as an infection within the liver itself. This occurs as a result of transection through the liver, but in the absence of pre-operative infection, this is a rare complication. This complication is more common post-liver ablation as the destructed liver tissue is left in-situ (it is not removed) and can be a nidus (source) of infection.

All patients undergo a thorough assessment before deciding whether to proceed with liver surgery. This will include clinical examination, blood tests, and advanced imaging (CT or MRI Liver). Dr. Michael Chu will work alongside you at each step of the assessment and make sure you have a thorough understanding. If the potential benefit from surgery is less than the risks of surgery, surgery would not be recommended.

Depending on the extent of liver resection, you may be required to be admitted to the High Dependency Unit (HDU) for the night of your surgery. Most patients stay in the HDU for one night, and you will be cared for on the ward after your HDU stay. There will be several routine checks performed by the nursing staff, including overnight.

During your hospital stay, Dr. Michael Chu will review you twice a day, and the anaesthetist will review you at least once a day. The ward staff are very experienced in caring for post-liver surgery patients and will be responsible for your care.

Patients are allowed to eat and drink as tolerated following surgery. On the night following surgery in HDU, patients are allowed to drink oral fluids as tolerated and then progress to a full diet as tolerated in the next 24-48 hours. Please ensure that you listen to your body with regards to appetite/hunger and if you feel full/bloated, do not try and push more oral intake. If required, a dietitian will visit you on the ward to advise you about post-operative dietary requirements and prescribe supplemental nutrition drinks as needed.

In the initial stages, you may find that eating small meals regularly throughout the day may be more tolerable than three large meals a day. As you improve, you will be able to adjust your dietary intake to suit your body. If you are really struggling with your oral intake, there are dietary supplements available, and this can be liaised with a dietitian.

Alcohol should be avoided for at least three months following liver surgery to allow full liver regeneration.

You will be encouraged to mobilise as much as possible during your hospital stay to reduce the risk of post-operative lung complications and DVT. In the first post-operative day (this may be in HDU), you will be encouraged and assisted to mobilise into a chair, and sometimes for a short distance.

The majority of patients will have mild discomfort post-operatively; liver surgery is not routinely considered a painful operation. Pain management will be managed between Dr. Michael Chu and the anaesthetist. It usually consists of regular paracetamol with the addition of stronger analgesia (in the form of opioids) on an “as required” (PRN) basis.

​To prevent VTE, patients will require a daily injection to be self-administered subcutaneously in the abdomen. This will be for 28 days post-operatively and patients will be instructed how to administer this prior to their discharge.

The surgical incision will be sutured with dissolvable sutures and do not require removal. Steristrips (thin-adhesive bandages) are placed over the incision to support the skin edge and reduce the tension on the wound and are usually left on the wound for 10 days. On top of the Steristrips, a waterproof dressing is placed and should stay for at least 3-5 days. You can shower with this dressing, and it should be pat dry afterwards. Some patients prefer to leave the waterproof dressing for a bit longer, and that is okay. If the Steristrips fall off earlier than 10 days, it is acceptable.

Once the dressing is removed and the wound appears clean and dry, the wound does not need further dressings. Occasionally, the wound may leak some “dark-ish” fluid or look a little red, which is not unusual. The staff will keep a close eye on the wound. If staples or non-dissolvable sutures are used to close the wound, these will need to be removed after 10-14 days. The district nurse will be able to do this for you. If you would like to use Vitamin E or Bio-Oil on the wound to reduce scar prominence, please do so after the first week.

The majority of patients spend 4-6 days in hospital before discharge. The general criteria for discharge are:

• Mobilising independently
• Having an adequate oral intake (fluids and food),
• Being able to perform the majority of self-care
• Only requiring oral analgesia.  

• Activity & Work

​Patients are allowed to perform their regular activities as long as it is not too uncomfortable for them. However, it is recommended to stray from heavy lifting or activity for 4-6 weeks. Most patients do return to work after this period, but some may take longer to do so. Irrespective of the surgical approach (open or laparoscopic), it normally takes ~3 months to return to normal activities. Additionally, most patients experience reduced energy levels post-operatively for a few weeks and can be up to 6-8 weeks. Please be patient and give yourself time to recover.​

• Driving

It is recommended that patients not drive for a minimum of 3 weeks post-liver surgery. When you get home and feel ready to drive, sit in the car seat and ensure you can perform a full emergency stop/brake before you start driving. It is also advisable that you have the strength to control the car and respond quickly before you start driving.
 
Importantly, please check with your insurance policy and company to ensure you do not invalidate your insurance policy by driving post-operatively.

On rare occasions, patients may have a drain or feeding tube in the post-operative period.

• Feeding Tube

The feeding tube passes through the nose into the stomach and allows supplementary nutrition to be administered in the post-operative period in conjunction with a dietitian.

• Drain

In the case where a drain is inserted, it allows drainage of any fluid (blood or bile) that may leak off the cut surface and will generally be left for 2-3 days.

• Urinary Catheter

A catheter is placed in the urinary bladder in the operating theatre to monitor urine output (kidney function) during the post-operative period. This is usually removed on post-operative day 2.

If you or your family have any concerns, please contact Dr. Michael Chu directly or his rooms, or the hospital. If it is a medical emergency, please dial 111 for an ambulance to take you the nearest acute hospital.
 
If you have any of these symptoms, please let Dr. Michael Chu know:

• Fever over 38.5 C
• Vomiting or diarrhoea
• Wound infection or discharge of blood/pus from the wound
• Lack of bowel movement after 3-4 days
• Persistent abdominal pain not controlled by prescribed analgesia
• Persistent abdominal distension (bloating)
• Becoming jaundiced (yellow-tinge to the eyes or skin)

Dr. Michael Chu will send a letter to your GP summarising your hospital stay and a copy of your operation note to keep your GP up to date with your status. It is advisable that you make an appointment with your GP a few days after your discharge so they can physically assess your clinical status.

Dr. Michael Chu is happy to be contacted by your GP if they have any questions or concerns.

• Pain or discomfort

After an operation, a degree of discomfort is expected and usually improves over the first two weeks. In some patients, the discomfort may last for a few weeks. The prescribed analgesia aims to ensure that the discomfort is manageable so that you can continue to improve physically. However, if the pain is worsening or you have any concerns regarding its duration (greater than two weeks), please contact your GP or Dr. Michael Chu.

• Bruising

There is usually bruising around the incision, and it may extend up to the ribs. The bruising may appear within 24-48 hours after surgery. If you feel that the bruising is worsening, becoming painful, or there is discharge of pus from the wound, please contact Dr. Michael Chu.

• Right shoulder pain

Due to the location of the liver and its proximity to the diaphragm, the irritation of the diaphragm may lead to right shoulder pain. This can last for a few days and should slowly improve. Heat packs can often alleviate shoulder pain. However, if it lasts greater than 2 days or worsens, please contact Dr. Michael Chu, as it may also indicate the development of a collection around the liver.

• Constipation

This is a common occurrence following any abdominal surgery. It is usually related to the opioids during general anaesthetic or those given post-operatively for analgesia. There are a few laxatives that can be obtained over the counter at the pharmacy or by prescription. Similarly, natural dietary supplements such as kiwi fruit are also quite effective. Importantly, please drink plenty of fluid.

Yes, the liver is able to regenerate and is the only organ in the body that can regenerate. When part of the liver is resected, the remnant liver hypertrophies (grow) to the volume of the original whole liver. However, bile ducts and the blood vessels in the liver do not re-grow; only the hepatocytes (liver cells) in the remnant liver grows. This process takes 8-12 weeks and allows major liver resection to proceed. 

This depends on the quality of the liver in the patient. For a healthy liver, up to 70% can be removed, leaving 30% behind. In a patient with chronic liver disease or following chemotherapy, a larger volume of remnant liver is required, and the amount of liver that can be removed safely is reduced.

This is dependent on the reason for the liver resection and your clinical status following surgery. In patients with colorectal (bowel) cancer, chemotherapy is generally given before and after resection of the metastatic liver disease. However, for many other cancers, liver resection alone is adequate. Each case is unique and will be discussed with an oncologist (medical cancer specialist), who is the specialist providing the chemotherapy.

With any operation, there is a risk of death from the surgery and its complications.
Specifically for liver resection, the risk is dependent on:

• Extent of liver resection
• Condition or quality of the liver
• Medical co-morbidity

​Within the peri-operative period, the estimated risk of death as a result of a complication is around 2% of all patients that undergo liver resections. It is important to note that it is extremely rare to die in the operating theatre. As liver resection is usually performed for a cancer, the risk and benefit of surgery is balanced against the risk of not undergoing surgery. You are encouraged to discuss your risks and your operation with the surgeon and anaesthetist before the operation.

Once a proposed date for surgery has been set, you will need to follow these instructions:

• Blood tests are taken 1-2 days prior to the day of surgery. This ensures that blood is available if you require a blood transfusion.
• Specific instructions will be given on where and when to present for surgery.
• Specific instructions will be given on when to stop drinking and eating. It is important that you follow these instructions as it will pose an anaesthetic risk, and we may have to cancel or delay your surgery.
• You do not need to shave before coming into the hospital.
• You will be advised on what normal medications to take on the day of surgery, but only take them with a small amount of water.
• If you are on any blood thinners that affect clotting, please inform Dr. Michael Chu during your consultation, as they may need to be stopped well in advance before the day of surgery. If you are unsure about any medications, please ask Dr. Michael Chu and the anaesthetist.

Learn more about preparing for surgery.

A follow-up will be arranged for you after you have been discharged from the hospital. Dr. Michael Chu’s PA will get in contact with you, and the follow-up is usually 1-2 weeks after leaving the hospital.

At the follow-up consultation, Dr. Michael Chu will go through with you:

• How you are recovering
• Operative findings
• Pathology report from the surgery

Depending on your recovery and the pathology result, Dr. Michael Chu may recommend additional investigations, treatment, or follow-up reviews. Dr. Michael Chu will ensure you are fully aware of the plan and answer any questions that may arise during the consultation.

If you have any questions or concerns during your post-operative period, please contact Dr. Michael Chu at +64 27 216 7288.