Liver surgery pdf - د. مؤيد

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SURGERY

LEC.13

Dr. Muayad Abbas
Lec.1

LIVER SURGERY
Tues. 3 / 11 / 2015

DONE BY : Mustafa Naser

مكتب اشور لالستنساخ

2015 – 2016

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LIVER SURGERY

Anatomy:

 The liver is the largest

organ in the body, weighing

5.1

in the

average

kg man

 The liver parenchyma is

entirely covered

thin capsule

and by

visceral peritoneum

on all but the posterior

surface of the

liver, termed the

‘

bare area

.’

 The liver is divided into a

large right lobe

which constitutes

three-quarters

of the

liver parenchyma, and a smaller

left lobe

Surgical resection of these

lobes would

be termed a

right or

left lobectomy

Ligaments and peritoneal reflections:

 left triangular ligament

 The right triangular ligament

 falciform ligament

(

remnant of the umbilical

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vein), which runs from the umbilicus to the

liver between them right and left

lobes, passing into the interlobar fissure

Liver blood supply:

 The blood supply to the liver

is unique

being derived from the

portal

vein

and

from the

hepatic artery

 The arterial blood supply in

most individuals is derived from the

coeliac

trunk

of the aorta, where the

hepatic artery

arises along with the

splenic

artery

After supplying the

gastroduodenal artery

it branches at a very

variable level to produce the

right and left hepatic arteries

 The blood supply to the right

lobe of the liver may be partly or completely

supplied by a right hepatic

artery arising from the

superior

mesenteric

artery

 Similarly, the arterial blood

supply to the left lobe of the liver may be

derived from the coeliac trunk via

its

left

gastric branch

 The hepatic artery, portal

vein and bile duct are present within the free edge

of the lesser omentum or

the

‘

hepatoduodenal

ligament

.’

 The usual anatomical

relationship of these structures is for the bile duct to

be within the free

edge, the hepatic artery to be above and medial, and the

portal vein to lie

posteriorly

 Within this ligament, the

common hepatic duct is joined by the cystic duct at

a varying level to form the

common bile duct

 The

common hepatic artery

branches at a variable level

within the ligament

to form two, or often three, main arterial branches to the

liver

The right

hepatic artery

often crosses the bile duct

either anteriorly or posteriorly

before giving rise to the

cystic artery



Multiple small hepatic arterial

branches

provide blood to the

bile duct

principally from the

right hepatic artery

 The

portal vein

arises from the confluence of

the

splenic

vein

and the

superior mesenteric vein

behind the neck of

thepancreas. It has some

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important tributaries, including the left gastric vein

which joins just above

the pancreas

Venous drainage of the liver:

 The

venous drainage

of the liver is via the

hepatic veins into the IVC

 The

inferior hepatic veins

are short vessels that pass

directly between the

liver parenchyma and the anterior wall of the IVC

 The

major venous drainage

is through

three large veins that join the

IVC

immediately below the diaphragm

. .

 The

right hepatic

vein can be exposed fully

outside the liver



but the

middle and left veins

usually join within the liver

parenchyma

Main functions of the liver:



■

Maintaining

core body temperature



■

pH balance

andcorrection

of lactic acidosis



■

Synthesis of

clotting factors



■

Glucose

metabolism, glycolysis and gluconeogenesis



■

Urea

formation from protein catabolism



■

Bilirubin

formation from haemoglobin degradation



■

Drug and

hormone metabolism



■

Removal of

gut endotoxins and foreign antigens



Liver function test :

USED TO

 Detect presence of liver

disease

 Distinguish among different

types of liver diseases

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 Gauge the extent of known

liver damage

 Follow the response of

treatment

Tests based on detoxification

excretory

functions:

 Serum bilirubin

 Urine bilirubin

 Blood ammonia

 Serum enzymes : AST, ALT

GGT, 5’Nucleotidase,ALP

Tests that measure Biosynthetic function of

liver:

 Serum Albumin

 Serum Globulins

 PT ,INR

Liver function test:

 Bilirubin

is synthesised in the liver

and excreted in the bile. Increased levels

may be associated with: 1

increased haemoglobin breakdown

hepatocellular dysfunction

resulting in impaired

bilirubin transport and

excretion, or

biliary obstruction

Serum Bilirubin:

 A break down product of

porphyrin ring of heme – containing proteins

 found in blood in 2 fractions

–

conj/unconj

 Conjugated

water soluble , so excreted

by kidneys

 Unconjugated

insoluble in water , bound

to albumin in blood

 About

377

mg of bilirubin

is formed per day

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 Normal total serum bilirubin

7.3

–

5.3

mg/dl

 Direct/conjugated bilirubin

7.5

–

7.0

mg/dl

 Indirect/unconjugated

bilirubin: 0.2 – 0.9mg/dl

Urine Bilirubin:

 Unconj bilirubin – binds to

albumin in serum

not filtered by kidneys

 Any bilirubin in urine is

conj.bilirubin, the presence of bilirubinuria – liver

 In acute viral hepatitis

–

bilirubin appears in urine before urobilinogen and

jaundice

 Undiagnosed febrile illness

with

bilirubinuria - hepatitis

Blood Ammonia:

 Produced by

normal protein metabolism

by intestinal bacteria in colon

 Liver – detoxification

–

converting into urea which is excreted by kidneys

 Pts with advanced liver

diseases contributes to hyperammonemia

 The serum

alkaline phosphatase

is particularly elevated with

cholestatic

liver

disease

biliary

obstruction

 The

transaminase levels [aspartate

transaminase (AST

)

and

alanine

transaminase (ALT

])

reflect acute

hepatocellular damage, as does the

gamma-glutamyl transpeptidase

(

GGT) level, which may be

used to detect

the

liver

injury associated with acute alcohol ingestion

 The synthetic functions of

the liver are reflected in the ability to synthesise

proteins (albumin level

)

and clotting factors (prothrombin time

 The

standard method

of monitoring

liver function in patients with

chronic

liver disease is serial measurement of bilirubin, albumin and

prothrombin

time

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Alanine transaminase(SGPT)

 Normal : 7 – 41 U/L

 ALT found primarily in liver

Aspartate transaminase (SGOT

Normal

–

U/L

 AST – liver , cardiac

muscles, skeletal muscle, kidneys, brain, pancreas,

lungs, leucocytes, RBC in

decreasing order

Serum Enzymes – that reflect cholestasis:



enzymes

 Alkaline Phosphatase



’

Nucleotidase

Alkaline Phosphatase:



fold rise can be seen

in many types of liver ds ( infective, alcoholic

hepatitis, HCC

)



times – cholestatic

liver ds, infiltrative liver ds, bone ds with rapid bone

turnover

 In absence of

jaundice/elevated aminotransferases – elevated ALP of liver

– often early

cholestasis and less often infiltrative hepatic ds

 Isolated rise of ALP

–

hodgkins lymphoma

diabetes

hyperthyroidism

CHF

amyloidosis

inf.bowel

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▪ Not helpful in diff b/w

intrahep

extrahep cholestasis

’

Nucleotidase:

 Normal :2 – 10 U/L

 Moderate elevated – hepatitis

 Highly elevated – biliary obs

 Unlike ALP , the level is

unrelated with osteoblastic activity ie.. Unaffected

by bone ds

 Test Normal

range

 Bilirubin 5–17 μmol l–1

 Alkaline phosphatase (ALP

)

–

241

IU l–1

 Aspartate transaminase (AST

)

–

IU l–1

 Alanine transaminase (ALT

)

–

IU l–1

 Gamma-glutamyl transpeptidase

(

GGT) 10–48 IU l–1

 Albumin 35–50 g l–1

 Prothrombin time (PT) 12–16 s

Imaging of the liver:

Ultrasound:

 This is the

first-line test

owing to its

safety

and

availability

 It is entirely

operator dependent

 It is useful for determining

bile duct dilatation

the

presence of gallstones

and the

presence of liver tumours

 Doppler ultrasound

allows flow in the hepatic

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artery, portal vein and hepatic veins to be

assessed



In some countries, it is used as a

screening test

for the development of

primary liver cancers in a high-risk population

 Ultrasound

is useful in guiding the

percutaneous biopsy of a liver

lesion

Computerised tomography:

 The current

‘

gold standard

’

for liver imaging is

triple-phase, multislice,

spiral computerised tomography (CT

 This provides fine detail of

liver lesions down to

less

than 1 cm

in diameter

and gives

information on their nature

 Oral contrast

enhancement allows

visualisation of the stomach and

duodenum in relation to the liver hilum

 The

early arterial phase

of the intravenous contrast

vascular enhancement

is particularly useful for detecting small liver cancers

owing to their

preferential arterial blood supply

 The

venous phase

maps the branches of the

portal vein within the liver

and the drainage via the hepatic veins

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

Inflammatory liver lesions

often exhibit

rim enhancement

with

intravenous contrast

whereas the common

haemangioma

characteristically shows late venous enhancement

 The

density of any liver lesion

can be measured, which can be

useful in

establishing the presence of a

cystic lesion

Magnetic resonance imaging:

 Magnetic resonance imaging

(

MRI

)

would appear to be as effective an

imaging modality as CT in the majority of patients with liver disease



It does, however, offer

several advantages

 First

the use of

iodine-containing intravenous contrast agents is

precluded in many patients

because of a history of allergy.Those patients

should be offered MRI rather

than contrast CT

 Second

magnetic resonance

cholangiopancreatography (MRCP) provides

excellent quality, non-invasive

imaging of the biliary tract

 It is useful for diagnostic

questions when

ERCP has

failed or is impossible

due to previous surgery



Magnetic resonance angiography

(

MRA) similarly provides

high-quality

images of the hepatic artery and portal vein, without the need for

arterial

cannulation

 It is used as an alternative

to selective hepatic angiography for diagnosis

 It is particularly useful in

patients with

chronic

liver disease

and a

coagulopathy

in whom the

patency of the portal vein

and its branches is in

question

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Endoscopic

retrograde

cholangiopancreatography:

 ERCP is required in patients

with obstructive jaundice who cannot

undergo MRCP because of

claustrophobia

 or where an

endoscopic intervention

is anticipated based on

previous

imaging [endoscopic removal of common bile duct (CBD) stones or

insertion of a palliative biliary tract

stent.

 A preoperative check of

coagulation

is essential, along with

prophylactic

antibiotics

and an

explanation of the main

complications

which

include

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pancreatitis

cholangitis

and

bleeding or perforation

of the duodenum

related to

sphincterotomy

Percutaneous transhepatic cholangiography:

 PTC is indicated where

endoscopic cholangiography has

failed

impossible

e.g. in patients with

previous pancreatoduodenectomy or Pólya

gastrectomy

 It is often required in

patients with

hilar bile

duct tumours

guide

external

drainage

of the

bile ducts to

relieve

jaundice

and to

direct

stent

insertion

Angiography:

 Selective visceral

angiography may be required for diagnostic purposes

but, with improving

cross-sectional imaging (CT and MR angiography), is

usually employed for

therapeutic intervention



Prior to liver resection

it may be used to visualise

the anatomy of the

hepatic artery to the right and left sides of the liver and

to confirm patency

or tumour involvement of the portal vein

 It can also provide

additional information on the

nature of a liver nodule

primary liver tumours have a well developed arterial blood supply



Therapeutic interventions

include the

occlusion of arteriovenous

malformations

the

embolisation of bleeding sites

in the liver

and the

treatment of liver tumours

(

transarterial embolisation

TAE

Nuclear medicine scanning:

 Radioisotope scanning can

provide diagnostic information that cannot be

obtained by other imaging

modalities

 Iodoida is a technetium-99m

(

mTc)-labelled radionuclide

that is

administered

intravenously, removed from the circulation

by the liver

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processed by hepatocytes and excreted in the

bile

 Imaging under a gamma camera

allows its uptake and excretion to be

monitored in real time

 These data are particularly

useful when a

bile leak

or biliary obstruction is

suspected and a non-invasive screening test is

required



sulphur colloid liver scan

allows Kupffer cell activity

in the liver to be

determined



This may be particularly

useful to confirm the nature of a liver lesion

;

 adenomas and haemangiomas lack

Kupffer cells and hence show no

uptake of sulphur colloid

Laparoscopy and laparoscopic ultrasound:

 Laparoscopy is useful for the

staging of

hepatopancreatobiliary cancers



Lesions overlooked by

conventional imaging are mainly peritoneal

metastases and superficial liver

tumours



Laparoscopic ultrasound

provides additional information for liver

tumours on their proximity to the major vessels and bile duct branches

Imaging modality Principal indication:

 Ultrasound :Standard

first-line investigation

 Spiral CT :Anatomical

planning for liver surgery

 MRI :Alternative to spiral CT

 MRCP: First-line

non-invasive cholangiography

 ERCP :Imaging the biliary

tract when endoscopic

intervention

is anticipated (e.g. ductalstones

)

 PTC :Biliary tract imaging

when ERCP impossible or failed

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 Angiography :To detect

vascular involvement by tumour

 Nuclear medicine :To quantify

biliary excretion and tumour

spread

 Laparoscopy/Laparoscopic US

To detect peritoneal tumour spread and

superficial liver metastases

LIVER TRAUMA:

 Liver trauma can be divided

into

blunt

and

penetrating

injuries

 Blunt injury

produces

contusion

laceration

and

avulsion injuries

to the

liver, often in

association with

splenic

mesenteric or renal injury

 Penetrating injuries, such as

stab

and

gunshot wounds

are often

associated

with chest or pericardial involvement

Diagnosis of liver injury:

 Clinical diagnosis

 suspicion of a possible liver

injury is essential



All lower chest and upper abdominal stab wounds

should be suspect,

especially

if considerable blood volume replacement has been required



Similarly

severe crushing injuries to the lower chest or upper

abdomen

often combine rib fractures, haemothorax and damage to the spleen

and/or liver

 Patients with a penetrating

wound will require a laparotomy and/or

thoracotomy once active resuscitation is

under way

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 Owing to the opportunity for

massive on-going blood loss and the rapid

development of a coagulopathy, the

patient should be directly transferred

to the operating theatre while blood

products are obtained and volume

replacement is taking place

 Patients who are

haemodynamically stable should have an oral and

intravenous contrast-enhanced CT scan

of the chest and abdomen

 This will demonstrate

evidence of parenchymal damage to the liver or

spleen as well as associated

traumatic injuries to their

feeding vessels

 Free fluid can also be

clearly established and a

diagnostic

aspirate

performed

 Additional investigations

that may be of value include

peritoneal lavage

which can confirm the presence of

haemoperitoneum, and

laparoscopy

which can demonstrate an

associated diaphragmatic rupture

Initial management of liver injuries

 Penetrating

 The initial management of a

patient with an upper abdominal penetrating

injury is the basis of

resuscitation



The initial survey assesses the patient’s

airway patency, breathing

pattern and circulation

 Peripheral venous access is

gained with two large-bore cannulae and

blood sent for cross-match of 10 units

of blood

Full blood count, urea and

electrolytes, liver function tests, clotting

screen,

glucose and amylase

 Initial volume replacement

should be with colloid or O-negative blood if

necessary

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

Arterial blood gases should

be obtained and the patient intubated and

ventilated if the gas exchange is

inadequate

 Intercostal chest drains

should be inserted if associated pneumothorax or

haemothorax is suspected

 Once initial resuscitation

has commenced

the

patient should be

transferred to the operating theatre, with further

resuscitation performed

on the operating table



The necessity for

fresh frozen plasma

and

cryoprecipitate

should be

discussed with the

blood transfusion service immediately the patient

arrives, as these patients

rapidly develop

irreversible

coagulopathies

due to

lack of

fibrinogen and clotting factors

 Blunt trauma

 With severe blunt injuries

the plan for resuscitation and management is

as outlined above for penetrating

injuries

 For the patient who is

haemodynamically stable, imaging by CT should be

performed to further evaluate

the nature of the injury

 The basic surgical management

differs between penetrating and blunt

injuries thought to involve the liver

;

penetrating injuries should be

explored

whereas

blunt

injuries can be

treated conservatively

 The indication for

discontinuing conservative treatment for blunt trauma

would be

evidence of on-going blood loss

despite correction of any

underlying coagulopathy

and the

development of signs of generalised

peritonitis

The surgical approach to liver trauma

 A

rooftop incision

gives excellent visualisation

of the liver and spleen and,

if necessary, can be extended upwards for a median

sternotomy

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 A stab incision in the liver

can be sutured with a fine absorbable

monofilament suture



If necessary, this may be

facilitated by producing vascular inflow

occlusion by placing an atraumatic

clamp across the foramen of Winslow

(the

Pringle manoeuvre

(

 Lacerations to the hepatic

artery should be identified by placing an

atraumatic bulldog clamp on the

proximal vessel prior to repair with 5/0 or

6/0 Prolene suture

 If unavoidable, the hepatic

artery may be ligated, although parenchymal

necrosis and abscess formation will

result in some individuals



Portal vein injuries should

be repaired with 5/0 Prolene, again with

exposure of the vessel being

facilitated by the placement of an atraumatic

vascular clamp

 Diffuse parenchymal injuries

should be treated by

packing the liver to

produce

haemostasis

 This is effective for the

majority of liver injuries if the liver is packed

against the

natural contour of the diaphragm by packing

from below



Large abdominal packs should be used to ease

their removal, and the

abdomen closed to facilitate compression

of the parenchyma

 Necrotic tissue should be

removed, but poorly perfused, though viable,

liver left

in situ

If packing is necessary, the patient

should have the packs removed

after 48

hours, and usually no further surgical intervention is required

Antibiotic cover

is advisable, and full reversal of any coagulopathy is

essential

Other complications of liver trauma:

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 A

subcapsular or intrahepatic

haematoma

requires

no specific

intervention and should be allowed to resolve spontaneously

 Abscesses

may form as a result of

secondary infection of an area of

parenchymal ischaemia, especially after

penetrating trauma

 Treatment

is with

systemic antibiotics

and

aspiration under ultrasound

guidance once the necrotic tissue has

liquefied



Bile collections

require aspiration under

ultrasound guidance or

percutaneous insertion of a pigtail drain

 The site of origin of a

biliary fistula

should be determined by

endoscopic

or percutaneous

cholangiography, and biliary decompression

achieved by

nasobiliary or percutaneous transhepatic

drainage or stent insertion

 Late vascular complications

include hepatic artery

aneurysm and

arteriovenous or arteriobiliary fistulae



These are best treated

nonsurgically by a specialist hepatobiliary

interventional radiologist

The feeding vessel can be embolised

transarterially

 Hepatic failure

may occur following extensive

liver trauma

This will usually reverse

with conservative supportive treatment if the blood

supply and biliary drainage

of the liver are intact

Management of liver trauma:



■

Remember

associated injuries



■

At-risk

groups

 Stabbing/gunshot

in lower chest or upper abdomen

 Crush injury

with multiple rib fractures

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

■

Resuscitate

 Airway

 Breathing

 Circulation



■

Assessment

of injury

 Spiral CT

with contrast

 Laparotomy

if haemodynamically unstable



■

Treatment

 Correct

coagulopathy

 Suture

lacerations

 Resect if

major vascular injury

 Packing if

diffuse parenchymal injury

Other complications of liver trauma:

 Other

complications of liver trauma



■

Intrahepatic

haematoma



■

Liver

abscess



■

Bile

collection



■

Biliary

fistula



■

Hepatic

artery aneurysm



■

Arteriovenous

fistula



■

Arteriobiliary

fistula



■

Liver

failure

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Pyogenic liver abscess:

 The aetiology of a pyogenic

liver abscess is

unexplained

in the majority of

patients

 It has an increased incidence

in the

elderly

diabetics

and the

immunosuppressed

who usually present with

anorexia

fevers

and

malaise

accompanied by

right upper quadrant

discomfort



The

diagnosis is suggested

by the finding of a

multiloculated cystic mass

on ultrasound or CT scan

 And

confirmed by aspiration for culture and sensitivity

END of this lecture …