Perioperative management - Right Hemihepatectomy, Robotically Assisted

A right hemihepatectomy is considered a  defined as the removal of at least four liver segments. Indications span malignancies, benign tumors, non-tumorous diseases, and liver transplantation (living donor).

1. Malignancies

Primary Liver Cancers:

• Hepatocellular carcinoma (HCC)
• Intrahepatic cholangiocellular carcinoma (iCCC)
• Cystadenocarcinoma

Metastases:

• Often from colorectal, breast, or neuroendocrine tumors.

Direct Tumor Invasion:

• E.g., invasion into adjacent structures requiring en bloc resection.

2. Benign Diseases

Liver Tumors:

• Adenoma: Particularly β-catenin-mutated subtype in male patients or when larger than 5 cm due to the risk of rupture or malignancy
• Focal nodular hyperplasia: Resected if diagnostic uncertainty or symptoms from compressive growth are present
• Hemangioma: Indications include vascular or biliary compression (Budd-Chiari-like syndrome) or Kasabach-Merritt syndrome
• Cystadenoma: Removed due to potential for complications or diagnostic uncertainty

Criteria for Benign Tumor Resection:

• Diagnostic uncertainty despite extensive evaluation
• Clinical symptoms: Upper abdominal pain, nausea, or cholestasis caused by tumor size or growth
• Rupture/bleeding risk (adenoma > 5 cm)
• Malignant transformation risk (e.g., β-catenin-mutated adenomas)

3. Non-Tumorous Diseases

Liver Cysts/Polycystic Liver Disease:

• Indications include rapid progression, symptoms (e.g., pressure, pain, dyspnea), or infection

Parasitic Liver Cysts:

• Caused by echinococcal infection

Intrahepatic Stones/Caroli Syndrome

Recurrent Liver Abscesses

Liver Trauma

4. Living Liver Donation

• Requires careful evaluation of donor anatomy and liver function to ensure postoperative safety and sufficient residual liver volume

Key Considerations for Liver Resection

• Oncological and Surgical Feasibility:
  • Requires precise understanding of liver functional anatomy, segmental divisions, and vascular/lymphatic variations
  • Multidisciplinary assessment and perioperative planning are crucial for optimal outcomes in major liver resections

Oncological and Functional Aspects of Liver Resection

Oncological Aspects

• R0 Resection: The goal of surgical treatment for liver malignancies is achieving an R0 resection, meaning complete removal of the tumor macroscopically and microscopically
• R2 Resection: For symptomatic neuroendocrine liver metastases, an R2 resection (incomplete tumor removal) may be indicated. In such cases, debulking over 90 % of the tumor mass can achieve symptom relief (“cytoreductive surgery”)
• iCCC: Resection for intrahepatic cholangiocarcinoma (iCCC) is indicated if the tumor is technically resectable and distant metastases are excluded

Functional Aspects

• Perioperative Mortality and Liver Failure:
  • Liver failure is the leading cause of mortality after liver resection, highlighting the importance of risk assessment
• Factors associated with postoperative liver failure include:
  • Volume and quality of the residual liver tissue (e.g., cirrhosis, steatosis, fibrosis)
  • Presence of cholestasis or cholangitis
  • Extent of surgical trauma (size of resection area, blood loss, duration of hilar occlusion)
  • Comorbidities (e.g., medication use)
  • Postoperative complications (e.g., bile leakage, infections)
• Minimum Residual Liver Volume:
  • In a non-damaged liver with normal synthesis and excretory function, 25 – 30 % of functional liver volume must remain after resection. This requires adequate arterial and portal venous blood supply, as well as unobstructed hepatic venous and biliary drainage.
  • In a damaged liver (e.g., cirrhosis, fibrosis), a higher residual volume is required (> 40 %). Assessing functional reserve in cirrhotic livers is particularly challenging.
  • If resection threatens to leave insufficient liver volume, preconditioning techniques to induce hypertrophy of the remaining liver should be considered.

Augmentation Techniques

Portal Vein Embolization (PVE)/Portal Vein Ligation (PVL):

• Selective embolization of the portal vein branch supplying the liver lobe to be resected
• This induces atrophy in the embolized lobe and hypertrophy in the contralateral lobe, optimizing liver function post-resection

In-Situ Split Concept/ALPPS (Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy):

• A two-stage procedure:
  • Step 1: Ligate the right portal vein and devascularize Segment IV while dividing the liver along the ligamentum falciforme. Segments IV–VIII remain arterialized but portal-devascularized in situ. This rapidly induces hypertrophy of the left lateral lobe, enabling it to assume liver function.
  • Step 2: Perform an extended right hemihepatectomy within approximately two weeks.

 Two- or Multi-Staged Resection:

• In the first stage, perform atypical resection of all tumors in the future residual liver
• After hypertrophy of this residual lobe, remove remaining tumors in a second operation

 Additional Options:

• Combined with Ablative Procedures: For example, radiofrequency ablation (RFA) can complement surgery
• Neoadjuvant Chemotherapy: Followed by secondary surgical resection (currently limited to colorectal metastases)

By integrating oncological precision and functional safety through techniques like preconditioning or staged resections, surgical outcomes can be significantly improved for liver malignancies and complex cases.

Liver Resection in Cirrhosis

Challenges in Assessing Functional Reserve

• Evaluating the functional reserve of a cirrhotic liver is complex. Key factors include:
  • General physical condition
  • Child-Pugh Score: Categorizes liver dysfunction into Child A (mild), B (moderate), and C (severe)
  • Severity of portal hypertension, a critical determinant of postoperative outcomes

Indicators of Portal Hypertension

• Normal bilirubin levels
• Hepatic venous pressure gradient (HVPG) < 10 mmHg
• Other markers include:
  • Splenomegaly
  • Esophageal varices
  • Thrombocytopenia (< 100,000/µl, warning for severe portal hypertension)

Resection Guidelines for Cirrhotic Livers

• Limited resection:
  • Only wedge resections or mono-/bisegmentectomies are recommended
• Hemihepatectomy:
  • Possible only in Child-A patients without significant portal hypertension
  • Child-C cirrhosis is an absolute contraindication for liver resection due to the high risk of liver failure
• Risks:
  • Portal hypertension increases complications during hilar dissection

Liver Transplantation for Cirrhotic Livers with HCC

• Liver transplantation is the treatment of choice for hepatocellular carcinoma (HCC) in cirrhotic livers within defined criteria (e.g., Milan Criteria):
  • Addresses both the tumor and underlying liver disease
  • 5-year survival rates of up to 70 % or more
• Exclusion Criteria:
  • Macrovascular invasion
  • Lymph node involvement
  • Distant metastases
  • Despite organ shortages, liver resection remains a valid alternative in cirrhotic patients with adequate liver function, thanks to improved surgical outcomes

Technical Demands of Right Hemihepatectomy

• Right hemihepatectomy is among the most challenging procedures in robotic liver surgery
• Surgeons should gain experience with:
  • Minor resections (e.g., atypical resections, left lateral sectionectomy involving Segments 2 and 3)
  • Left hemihepatectomy before attempting robot-assisted right hemihepatectomy

By adhering to these guidelines, surgical outcomes can be optimized while minimizing risks in patients with cirrhosis.

General Contraindications

• General inoperability due to underlying conditions
• Severe heart failure or significantly reduced renal and/or lung function

Oncological Contraindications

• Diffuse tumor involvement of the left liver lobe:
  • Evaluate multi-step strategies like ALPPS (Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy), PVE (Portal Vein Embolization), or HVE (Hepatic Vein Embolization) alongside radiofrequency ablation (RFA) to achieve tumor clearance
• Infiltration into:
  • Diaphragm
  • Ligamentum hepatoduodenale
  • Vena cava or hepatic vein confluence
• Distant metastases:
  • Exception: Resectable lung metastases
  • Uncontrolled primary tumor in metastatic disease
• Hepatocellular carcinoma (HCC) in cirrhosis with small tumor burden:
  • While liver transplantation is the preferred treatment under Milan criteria, limited organ availability may preclude this option

Functional Contraindications

• Impaired liver function with insufficient residual function:
  • Child-B/C cirrhosis
• Insufficient residual liver volume:
  • < 20 % in a healthy liver
  • < 30 % in damaged liver (e.g., chemotherapy, cholestasis)
  • < 40 % in cirrhotic or fibrotic liver
• Postoperative liver failure:
  • Major cause of perioperative mortality with limited therapeutic options for recovery
• Klatskin tumors (hilar cholangiocarcinomas):
  • Residual liver volume of at least 30% is required due to cholestatic liver damage
• Preconditioning for hypertrophy:
  • Evaluate hypertrophy techniques for the planned residual liver
  • Hypertrophy can be expected within 12 days to 5 weeks, but may take significantly longer in cholestatic or cirrhotic livers

Method-Specific Contraindications

• General contraindications for robot-assisted procedures align with those for minimally invasive surgery:
  • Inability to tolerate pneumoperitoneum due to severe systemic disease, such as advanced heart failure
  • Severe intra-abdominal adhesions (“hostile abdomen”)

By thoroughly evaluating these contraindications, surgeons can minimize risks and optimize outcomes for liver resections, especially in challenging cases involving oncological and functional complexities.

The early detection of malignancy through imaging and histological confirmation via biopsy is critical for curative treatment of liver lesions.

Initial Assessment

• Patient History: Focus on symptoms (e.g., pain, B-symptoms), previous malignancies, travel history, and risk factors such as:
  • Oral contraceptives, alcohol/drug abuse, viral hepatitis (HBV, HCV)
  • Cirrhosis, metabolic syndrome
• Risk Factors for Malignancy:
  • Liver cirrhosis
  • Chronic hepatitis B or C
  • History of tumors

Clinical and Laboratory Tests

• Comprehensive Surgical Panel:
  • General parameters and liver-specific markers
     
• Liver Function Tests:
  • Coagulation factors, cholinesterase (CHE), albumin, and cholestasis markers
  • Advanced liver function tests:
    • Indocyanine Green (ICG) Clearance Test (e.g., LiMON)
    • 13C-Methacetin Breath Test (LiMAx, Humedics GmbH)
    • Hepatobiliary Scintigraphy (HBS) for segmental liver function
       
• Tumor Markers:
  • Alpha-fetoprotein (AFP)
  • Carbohydrate Antigen 19-9 (CA 19-9)
  • Carcinoembryonic Antigen (CEA)
     
• Infections/Parasitic Diseases:
  • Blood cultures for liver abscesses
  • Serology for echinococcosis or other parasitic diseases

Imaging Techniques

• Ultrasound (US):
  • Backbone of primary imaging diagnostics and screening
  • Native B-mode and color Doppler ultrasound can classify up to 60 % of focal liver lesions (e.g., cysts, hemangiomas, fatty distribution changes)
     
• Intraoperative Ultrasound:
  • Standard during liver resections
  • Identifies additional lesions and evaluates:
    • Vascular architecture
    • Resectability and extent of resection
       
• Contrast-Enhanced Ultrasound (CEUS):
  • Gold standard for diagnosing benign liver lesions
  • Assesses vascular architecture and contrast dynamics in real time during arterial, portal venous, and late venous phases
  • Advantages: 
    • Independent of renal and liver function
  • Disadvantages: 
    • Operator-dependent and limited comparability
       
• 3(4)-Phase Contrast CT (arterial, portal venous, venous):
  • Standard for surgical planning and resectability assessment
  • Provides high-resolution imaging of arterial, portal venous, and hepatic venous structures
  • Advantages:
    • Broad availability and short duration
    • Tumor, total liver, and residual liver volume estimation
  • Disadvantages:
    • Radiation exposure, limited biliary visualization, and reduced sensitivity in steatotic livers
       
• MRI with Liver-Specific Contrast Agents:
  • Uses hepatobiliary contrast agents (e.g., Gd-EOB)
  • Superior differentiation between benign and malignant tumors
  • Enhanced accuracy for lesion characterization in cirrhosis
  • Advantages:
    • Non-invasive bile duct visualization (MRCP)
    • 3D sequences enable precise volumetry and virtual resection planning
  • Disadvantages: 
    • Limited use in patients with implants, claustrophobia, or renal impairment
       
• PET-CT:
  • Useful for systemic staging and detecting occult metastases
  • Less sensitive for individual lesion detection than MRI
  • Best for colorectal cancer metastases in preoperative staging
     
• Endoscopic Retrograde Cholangiopancreatography (ERCP):
  • Rarely used for HCC or colorectal metastases diagnosis
  • Diagnostic and therapeutic use for cholangiocarcinoma (CCC): Tumor localization, biopsy, and stent placement

Liver Biopsy

• Indications for Biopsy:
  • Suspicion of HCC in lesions 1 – 2 cm in diameter with inconclusive imaging
  • Lesions > 2 cm with AFP < 200 ng/mL if imaging lacks typical features
  • Biopsy for extrahepatic CCCs via ERCP using brushing, forceps, or bile aspiration for cytology
     
• Guidelines for HCC Biopsy:
  • Follow AASLD recommendations for diagnostic accuracy

Preoperative diagnostics provide a detailed roadmap for treatment planning, ensuring accurate lesion characterization, staging, and resection feasibility while minimizing unnecessary procedures.

Summary: Preoperative Diagnostics and Preparation for Liver Resection

Preoperative Imaging Requirements

Accurate preoperative imaging is critical for developing a curative treatment plan. The imaging modalities must provide:

• Clear visualization of all tumors to be resected
• Assessment of their relation to vascular and biliary structures
• Detection of anatomical variations in vascular supply, such as:
  • A right hepatic artery arising from the superior mesenteric artery
  • A left hepatic artery arising from the left gastric artery
  • Differentiation of benign liver lesions
  • Measurements of tumor, total liver, and residual liver volumes
  • Evaluation of total and residual liver function, combining volumetry (via CT or MRI) with functional tests (e.g., LiMAx, LiMON)

Laboratory Workup:

• Complete surgical panel including blood typing
• Cross-matching of 4 – 6 erythrocyte concentrates
• Fresh frozen plasma (FFP) and thrombocyte concentrates (if indicated)
• Stabilization of coagulation (e.g., with Konakion®)

Nutritional Support (if necessary):

• For reduced general and nutritional status:
  • High-calorie diet for 3 days preoperatively
  • Human albumin, iron (e.g., Ferrinject), Vitamin B12, folic acid

Hygiene and Thrombosis Prevention:

• Showering the evening before surgery
• Shaving: From the jugulum to the symphysis; include legs if vein harvesting is planned for vascular reconstruction
• Thrombosis prophylaxis:
  • Follow VTE prophylaxis guidelines (e.g., Clexane 40 mg)
  • Compression stockings (anti-thrombosis, AT-strümpfe)

Other Preparations:

• Epidural catheter (PDK)
• Schedule intensive care unit (ICU) bed and central venous catheter (ZVK)
• Administer antibiotics in the operating room (e.g., Cefuroxime 1.5 g)
• Enema the evening before surgery for bowel clearance

Anticoagulation Adjustments

Perioperative Management of Anticoagulants:

• Aspirin: Can generally be continued
• Clopidogrel (ADP-inhibitor): Discontinue at least 5 days before surgery
• Vitamin K antagonists (e.g., warfarin): Stop 7 – 10 days before surgery, monitoring INR
• Direct Oral Anticoagulants (DOACs/NOACs): Discontinue 2 – 3 days before surgery

Bridging Therapy:

• For Vitamin K antagonists: Use short-acting heparins if INR is out of target range
• For DOACs: Bridging is usually unnecessary due to their short half-life. In cases of high thrombotic risk, UFH bridging may be required in a hospital setting

Critical Caveats:

• Coordinate anticoagulation adjustments with the patient’s cardiologist if necessar
• Ensure all preoperative preparations are optimized to reduce risks and improve postoperative outcomes.

This structured approach ensures that patients are thoroughly assessed and prepared for liver resection, maximizing surgical safety and efficacy.

Preoperative Functional Diagnostics and Special Preparation for Liver Resection

Functional Diagnostics

• Routine Evaluations:
  • ECG
  • Lung function tests
  • Chest X-ray (Rö-Thorax)
     
• High Cardiopulmonary Risk:
  • Additional assessments to determine operability:
    • Stress ECG
    • Cardiac echocardiography
    • Coronary angiography
    • Advanced lung function tests
       
• Further Diagnostics:
  • Tailored based on comorbidities

Special Preparation

• Endoscopic Drainage to Improve Liver Function (if necessary):
  • Indications for preoperative bile drainage:
    • Acute cholangitis
    • Cholestasis
    • Malnutrition caused by hyperbilirubinemia
    • Pre-portal vein embolization or neoadjuvant chemotherapy
• Key Considerations:
  • Avoid stents where possible due to the risk of:
    • Bacterial contamination of the biliary system
    • Cholangitis and perioperative infections
    • Stents may still be unavoidable if cholestasis worsens liver dysfunction, increasing morbidity and mortality
    • Focus drainage on the bile ducts of the residual liver
• Endoscopic drainage is preferred over percutaneous transhepatic drainage to reduce risks of:
  • Bacteremia
  • Tumor cell dissemination
  • Trauma to the remaining liver
  • Complete all necessary imaging to assess resectability before stent placement, as stents complicate intraoperative evaluation of resectability

Preoperative Preparation in the Operating Room

• Placement of Essential Lines:
  • Urinary catheter
  • Epidural catheter (PDK)
  • Central venous catheter (ZVK): Usually inserted during anesthesia induction
  • Arterial line: Inserted during anesthesia induction
• Perioperative Antibiotics:
  • Administer 30 minutes before incision.

This protocol ensures thorough functional evaluation and optimal preparation for liver resections, minimizing perioperative risks while enhancing surgical outcomes.

Patient Education and Consent Process

• Use standardized consent forms with accompanying anatomical illustrations to document findings and planned procedures
• Discuss treatment alternatives and additional procedures (e.g., intervention measures or extended surgical steps) as part of the informed consent
• Specifically inform the patient about the potential for a cholecystectomy during liver resection

General Risks

• Bleeding and rebleeding
• Hematoma
• Need for blood transfusions and associated risks
• Thromboembolism
• Wound infection or abscess formation
• Injury to adjacent organs or structures (e.g., stomach, esophagus, spleen, diaphragm)
• Wound dehiscence (Platzbauch)
• Incisional hernia
• Risk of reoperations
• Mortality

Specific Risks

• Conversion to open surgery
• Liver parenchymal necrosis
• Bile leakage (bile fistula) or bilioma
• Hemobilia or biliary peritonitis
• Bile duct strictures
• Pleural effusion
• Air embolism from inadvertent opening of liver veins
• Portal vein thrombosis
• Hepatic artery thrombosis
• Chronic liver insufficiency or liver failure with coma
• Tumor recurrence