Liver cancer surgery, hepatic resection

Surgery is considered when imaging and workup confirm that:

• The tumour can be removed completely with a clear margin
• There is enough healthy liver remaining to support normal function
• The remaining liver works well (no advanced cirrhosis or severe portal hypertension)
• The cancer has not spread beyond the liver (or any extrahepatic disease is controllable)
• The patient is fit for major abdominal surgery

When surgery is not safe, other options include radiofrequency or microwave ablation, transarterial chemoembolisation (TACE), targeted therapy, or liver transplantation in selected HCC patients. The right path is decided at the tumour board.

• Wedge resection: a small non anatomical piece of liver is removed, often for small peripheral tumours
• Segmentectomy: one of the eight liver segments is removed (anatomical resection)
• Sectionectomy: two adjacent segments are removed
• Hemihepatectomy: the right or left half of the liver is removed
• Extended hepatectomy: more than half the liver is removed, used for large or central tumours
• Laparoscopic resection: for selected smaller or peripheral tumours in suitable patients

The extent of resection is planned on cross sectional imaging and sometimes liver volumetry, which estimates how much functioning liver will remain after surgery.

Before any liver resection, the team will arrange:

• Triphasic CT or MRI of the liver to map tumours and blood vessels
• PET CT in selected cases to check for spread
• Liver function tests and assessment for cirrhosis or hepatitis
• Blood tests including tumour markers (AFP for HCC, CEA for colorectal metastases)
• Cardiac and pulmonary clearance
• Tumour board review to confirm surgery is the right next step

For patients with hepatitis B, hepatitis C, or alcohol related liver disease, additional assessment of liver reserve is essential before deciding on resection.

1. 01 General anaesthesia, central line, and arterial line for close monitoring
2. 02 Open or laparoscopic access depending on tumour and patient
3. 03 Intraoperative ultrasound to map tumour, vessels, and bile ducts
4. 04 Mobilisation of the liver and control of inflow and outflow vessels
5. 05 Parenchymal transection with energy devices, ensuring clear margins
6. 06 Careful management of bile duct branches and bleeding points
7. 07 Inspection of the cut surface and the rest of the abdomen
8. 08 Drain placement and closure

Operative time ranges from 3 to 8 hours depending on the extent of resection.