Liver Surgery at the Sachsenhausen Clinic, Germany, Frankfurt

Liver Surgery

The liver is the most important organ for storing and detoxifying our body. The organ weighs about 1.5 kg and is located in the upper right part of the abdomen, just below the diaphragm. It is divided into two parts which in turn are divided into 8 segments.

All the blood that absorbs food components and contaminants, dead cells, digestive enzymes, etc. in the stomach, the intestines, the spleen and the pancreas passes through the portal vein into the liver, which in turn can store or process the sugar and fats out of the bile that produces them, or restore them if necessary. It is also responsible for the production of blood-clotting enzymes.

The liver possesses an excellent regenerative capacity and can reproduce the missing number of new healthy liver cells. However, there are some diseases that cause liver damage and require surgery.

What Liver Diseases Exist?

The detoxification function produces and stores large amounts of harmful substances in the liver, making it more susceptible to damage. For this reason, the liver is always targeted by numerous pathogens such as viruses and parasites. Besides, it receives double blood supply and nutrient-rich blood from the gastrointestinal tract passes through the liver, which puts it at risk of penetration of metastases in case of gastrointestinal tumors.

Common diseases:

  • Fatty liver
  • Inflammation (hepatitis) caused by viruses or alcohol
  • Fibrosis and cirrhosis (connective tissue remodeling)
  • Liver cancer
  • There are also rare liver metabolic diseases and autoimmune diseases

What are the Symptoms of Liver Diseases?

Liver diseases do not always have a clear symptomatology. For example, fatty liver may not be detected for a long time.

There may be nonspecific symptoms:

  • Fatigue
  • Loss of appetite
  • Pressure in the upper abdomen

The classic signs of a worsening liver disease are:

  • Jaundice, i.e. changes in the color of the skin and eyes resulting from elevated concentrations of bilirubin
  • Itching is possible
  • Stool and urine color change
  • Ascites (water)
  • A decrease in the hair on the chest and belly in men (due to estrogen disturbance in the liver)
  • Brain diseases including coma

What Diseases May Require Liver Surgery?

Liver surgery is necessary in the case of the following benign and malignant liver tumors and biliary tract tumors:

  • liver abscess
  • liver cysts
  • hemangiomas
  • liver adenoma
  • liver cancer
  • bile duct cancer
  • metastases to the liver

What Operations are Performed on the Liver and In What Cases?

Before every surgical procedure, a comprehensive diagnosis is made. In this way, the visceral surgeon can collect all the data necessary for the operation on the liver and plan the operation as accurately as possible.

Minor interventions, such as the insertion of a drainage catheter (a plastic tube through which pus can flow) into the liver abscess, are performed under local anesthesia.

Liver cysts (blisters filled with fluid) can be removed by a visceral surgeon, usually by laparoscopy or by using an open abdominal incision when the cysts are opened and aspirated. The enveloping layer of the mucous membrane is removed and the opening is closed with the peritoneum, which prevents the formation of a new cyst.

Echinococcosis sometimes requires a partial resection of the liver in cases of serious infestations. However, the decision is made on an individual basis.

Benign liver adenomas are usually removed via minimally invasive laparoscopy. For this purpose, the affected liver segment is removed through small incisions in the skin performed with special instruments and a camera.

Treatment of malignant tumors, such as liver cancer, bile duct cancer or metastases to the liver, often involves a combination of different treatments.

For example, before a tumor is removed, the visceral surgeon can cut off the blood supply to the cancer area, thus making it smaller. At the same time, healthy tissue is stimulated to grow. Thus, in some cases, large tumors can be removed without leaving insufficiently functional liver tissue.

When the liver is transplanted, the donor organ is connected to the blood vessels in the patient’s body. The operation can last about 4-8 hours and is associated with lifelong immunosuppression to avoid rejection of the foreign organ.

What is Liver Resection?

Liver resection is a partial removal of the liver. The liver which performs important functions in the body during metabolism of fats, sugar and protein, as well as during detoxification is capable of regeneration. This means that partial resection can lead to the reproduction of liver tissue. However, only healthy liver tissue has this ability. If the patient has cirrhosis, this is not possible.

The liver is in the upper right part of the abdomen and is attached to it with various ligaments (at the lower edge of the diaphragm). They are divided into visible (separated by a strip of connective tissue) right and left liver lobes and are anatomically based on blood supply in the eight segments.

These divisions also provide two options for orientation during the operation. Thus, a distinction is made between the resection of the flap and the resection of the segment. In addition, one half of the liver (not identical to the lobes!) can be removed (hemigepatectomy). During atypical resection, no one pays attention to these divisions and resects directly only small individual pieces.

The maximum type of liver resection used during transplantation is the removal of the entire liver (hepatectomy). The type of the operation depends on the patient’s individual characteristics.

When is Liver Resection Required?

There are several reasons to perform liver resection. They are benign tumors such as liver abscess (pus accumulation), liver cyst (water bubble) and tapeworm infection and malignant tumors such as liver cancer or metastases to the liver from other affected organs.

The need and possibility of removing cancer surgically is always determined by an interdisciplinary team together with the patient. In rare cases, an accident can lead to a rupture in the liver, which requires liver resection.

What Surgical Methods are Available?

There are two different surgical techniques for liver resection. On the one hand, it is possible to perform an “open surgery” using an abdominal incision along the lower edge of the right rib arch, and on the other hand, by means of a “keyhole technique” (laparoscopy).

Which method will be chosen depends on the type and degree of the disease severity (e.g. complete liver removal or liver transplantation can only be performed using the open surgery). The patient’s general condition and previous diseases also play a role in decision-making.

Liver Cancer

The most common type of liver cancer is hepatocellular carcinoma (HCC). It occurs in 6% of men and 3% of women.

Mutations occur in the cells of the liver, causing them to grow uncontrolled. The risk factors most commonly associated with this type of cancer include hepatitis B, liver cirrhosis or hemochromatosis.

As the liver is the main metabolic organ, its functional insufficiency is incompatible with life.

Symptoms of Liver Cancer

Signs of the disease are rather unspecific. Patients usually complain about:

  • Weakness
  • Loss of weight
  • Pressure in the abdomen
  • Convexities in the abdominal wall
  • Yellowing of the skin (jaundice)

How is Liver Cancer Diagnosed?

The disease usually worsens very quickly. Tumors are diagnosed by using ultrasound, CT or MRI. The most accurate diagnosis of the disease is a liver biopsy (taking some tissue through the abdominal wall with a special needle).

What Types of Liver Tumors Exist?

Besides hepatocellular carcinoma (HCC), there is cholangiocarcinoma, hepatoblastoma, sarcoma or cystadenocarcinoma, which are extremely rare.

Metastases to the liver, i.e. tumor deposits of remote liver neoplasms (malignant secondary liver tumors), are even more frequent than HCC (liver cell cancer). These can be, for example, colon cancer or breast cancer metastases. Since the liver, as the main metabolite, is supplied with blood perfectly well, it is most often affected by tumor deposits.

Benign liver tumors are liver cell adenomas, focal nodular hyperplasia, cavernous hemangiomas or liver cysts.

How is Liver Cancer Treated?

The best survival rates for malignant liver tumors are achieved by complete surgical removal (resection) of the neoplasm. Also, liver transplantation is effective for severe liver cirrhosis.

Life-extension through palliative care (measures that do not cure but facilitate and possibly prolong survival) is limited. However, the quality of life can be significantly improved by using such measures as instilling alcohol into the tumor, chemotherapy or improving the bile outflow.

Alternative Ways to Treat Liver Cancer to Reduce Tumor

If the tumor cannot be surgically removed, alcohol can be administered into the tumor or the tumor can be reduced by heat (e.g. radiofrequency ablation). Tumor shrinkage can “compress” the inoperable tumor to an operable state.

In the case of a more common disease, the tumor can also be reduced by using selective internal radiation therapy (SIRT, radioembolization). This technique reduces the size of the tumor and protects the adjacent tissue.

Another option for tumor reduction is the use of transarterial chemoembolism (TACE). The chemotherapeutic agent is administered directly into the cancerous tissue through a vascular catheter. These tumor-reducing measures can be used up to liver transplantation, resection or palliative surgery.

A recent option for tumor reduction is HIFU therapy (highly intensive focused ultrasound). With this approach to treatment, the tumor is “treated with ultrasound” from the outside by using high-energy ultrasound waves. The tumor cells heat up and are “welded together”, so the tumor shrinks. This technique is still being tested, but numerous studies have shown that it is a successful therapeutic approach with few side effects.

After Liver Resection Surgery

Post-treatment is highly dependent on the disease that led to the resection of the liver. For example, cancer treatment requires, as a rule, a more careful follow-up and treatment (e.g. metastases to the liver can be treated with chemotherapy). On the other hand, a cyst does not usually require special follow-up treatment.

Life Expectancy After Liver Resection

Life expectancy after this procedure depends on the disease that led to the operation. In the case of cancer, the spread of the tumor and its type are important prognostic factors, as well as previous diseases and the patient’s general condition.

In general, however, there is no limited life expectancy after liver resection (e.g. cyst surgery), as the remaining liver components (and growing liver cells) can perform their functions well.

What are the Prognoses after Liver Surgery?

Prognoses and case records are highly dependent on the underlying disease and its progression.

For example, there are excellent prognoses for liver adenomas after surgical removal. In rare cases, a new adenoma may appear over time, but it can be treated in the same way.

However, in the case of malignant tumors, the prognosis is worse. 30-50% of patients will continue to live over 5 years if the operation is performed in an experienced liver surgery center.

Due to the combination of different procedures (chemotherapy, radiation therapy, chemoembolization, surgery) and the excellent regenerative capacity of the liver, in recent years an increasing number of patients with large liver tumors or metastases to the liver have been cured completely.

In any case, the visceral surgeon will discuss the options and alternatives in detail with the interdisciplinary team and, of course, with the patient before starting treatment.

Prof., Dr. med. Plamen Staikov

Prof., Dr. med. Plamen Staikov

Medical Director, Head physician

Holger Bahn

Holger Bahn

Senior physician

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