Perioperative management - Right hemihepatectomy

Indication for liver resection

The indications for liver resection are diverse. The main focus is on malignant liver tumours. Further indications include benign tumours, non-tumorous diseases and living liver donation.

1. Malignancies

• Primary
  • Hepatocellular carcinoma (HCC)
  • Intrahepatic cholangiocarcinoma (iCCA)
  • Cystadenocarcinoma
• Metastases

2. Benign diseases

• Liver tumours
• Adenoma (β-catenin-mutated subtype, male patient)
• Focal nodular hyperplasia (in cases of diagnostic uncertainty or complications due to expansile growth)
• Haemangioma (in cases of compression of vessels (Budd-Chiari-like syndrome) and bile ducts; Kasabach-Merritt syndrome (uncontrolled coagulation within a giant haemangioma with consumption of platelets and clotting factors, resulting in a bleeding tendency).
• Cystadenoma (mucinous cystic neoplasm [MCN]) DD simple hepatic cyst; septa alone, without wall thickening or nodules, are not diagnostic of an MCN.

Remarks
The surgical treatment of benign liver tumours requires a high degree of critical indication assessment and arises from:

• uncertain malignant potential despite exhaustive diagnostic workup
• Clinical symptoms, e.g. upper abdominal pain, nausea, or cholestasis due to tumour size, compression phenomena, or significant growth in size
• risk of rupture and bleeding in adenomas larger than 5 cm
• Risk of malignant transformation in hepatocellular adenoma (beta-catenin-mutated subtype, male patient)
• potential for malignant transformation or tendency to recurrence in hepatic cystadenoma

3. Non-tumorous diseases

4. Living liver donation

Operative planning and strategies to extend resectability

In operative planning, both oncological and technical surgical aspects must be taken into account.

Advances in perioperative medicine, preoperative conditioning and systemic therapy have fundamentally changed the management of primary and secondary liver tumours. The aim is to optimise resectability while at the same time minimising the risk of post-hepatectomy liver failure. In addition to neoadjuvant chemotherapy, interventional and surgical procedures are now standard to ensure a sufficient functional liver remnant volume.

A prerequisite is precise knowledge of the functional and segmental anatomy of the liver as well as of its vessels and their branching variants.

1. Oncological aspects

• The aim of surgical treatment of liver malignancies is R0 resection, i.e. macroscopically and microscopically complete tumour removal.
• Exception: In symptomatic neuroendocrine liver metastases, an R2 resection may also be indicated, since debulking of more than 90% of the tumour mass leads to freedom from symptoms ("cytoreductive surgery").
• Entity-specific: In iCCA, resection is the only curative option after exclusion of distant metastasis, as there is no established transplantation indication and no effective alternative. The liver is usually healthy, so the limit is purely technical – unlike in HCC with cirrhosis, where liver function is the limiting factor.

2. Functional aspects

Liver failure [post-hepatectomy liver failure (PHLF)] is the most important cause of perioperative mortality after liver resection. Since the treatment options for postoperative hepatic insufficiency are very limited, preoperative risk evaluation is of crucial importance.

The risk of PHLF correlates with:

• Size and quality of the remaining liver tissue (cirrhosis, steatosis, fibrosis)
• cholestasis or cholangitis
• extent of the operative trauma (resection surface, blood loss, duration of hilar occlusion)
• pre-existing conditions and medication use
• postoperative complications (bile leaks, infections, etc.)

minimum liver remnant volume to be retained (FLR = future liver remnant)

• In general, with otherwise unimpaired liver parenchyma, an FLR of approximately 25% is considered sufficient.
• If liver function is impaired, for example after hepatotoxic chemotherapy or in hepatic steatosis, the FLR should be approximately 30%.
• In cases of known liver cirrhosis or cholestasis, an FLR of at least 40% is necessary.
• A prerequisite in each case is impeccable arterial and portal-venous supply as well as unimpeded hepatic venous and biliary drainage of the liver remnant.

If this volume is likely to be undershot, preconditioning (preoperative hypertrophy induction) should be considered.

Measures to extend resectability

1. General measures

• Discontinue hepatotoxic noxae
• Fully treat infections
• Drain cholestasis

2. Augmentation techniques (hypertrophy induction)

Portal vein embolisation/ligation (PVE/PVL)

• Principle: Selective occlusion of the portal vein branches of the liver half to be resected later. This causes atrophy of the affected segments and compensatory hypertrophy of the remaining liver. Liver infarctions do not occur, as the liver is additionally supplied arterially (dual perfusion via the portal vein and hepatic artery).
• PVE is the less invasive standard procedure, achieving more complete occlusion of even the small branches; PVL is used primarily when surgery is being performed anyway, for example in two-stage hepatectomy or ALPPS.
• A standard for decades with proven safety.
• Limitation: In approximately 20% of patients, resection is not possible after 4–6 weeks due to insufficient hypertrophy or tumour progression.

Liver venous deprivation (LVD)

• First described in 2016: PVE combined with embolisation of the ipsilateral hepatic vein.
• Simultaneous blockade of portal inflow and venous outflow leads to faster and stronger hypertrophy than PVE alone, with comparable safety.

ALPPS ("Associating Liver Partition and Portal vein ligation for Staged hepatectomy", in-situ split)

• Two-stage procedure:
  • 1st step: Ligation of the right portal vein branch, portal devascularisation of segment 4, and transection of the liver along the falciform ligament. Segments 4–8 remain in situ with arterial supply. The left lateral lobe hypertrophies very rapidly.
  • 2nd step: Usually within 1–2 weeks, extended right hemihepatectomy.
• Advantages: fastest hypertrophy of all procedures; both interventions possible within a single hospital stay; completion rate of the second operation nearly 100% (vs. a 4–6-week interval in classic two-stage hepatectomy).
• Disadvantage: high morbidity and mortality, therefore strict patient selection is required.

Selective internal radiotherapy (SIRT, "radiation lobectomy")

• Transfemoral intra-arterial administration of yttrium-90 microspheres into the tumour-bearing liver lobe.
• Achieves tumour control in the irradiated area and simultaneously hypertrophy of the FLR.
• Prospective comparative studies are lacking to date.

3. Two-/multi-stage resection (two-stage hepatectomy, TSH)

In a first operation, the future residual liver is rendered tumour-free by parenchyma-sparing resections and/or ablation. To induce hypertrophy, portal vein ligation is performed intraoperatively or portal vein embolisation postoperatively. After sufficient hypertrophy, usually after 4–8 weeks, the tumour-bearing liver half is resected in a second operation, usually as an (extended) hemihepatectomy. Due to tumour progression or insufficient hypertrophy, approximately 25–35% of patients do not reach the second operation. The main indication is bilobar colorectal liver metastases.

4. Combination with ablative procedures [e.g., radiofrequency ablation (RFA)]

5. Neoadjuvant systemic therapy / conversion therapy and secondary resection

• Systemic therapy can reduce the size of primarily unresectable liver metastases to the extent that secondary resection becomes possible (conversion). This is established above all for colorectal liver metastases.
• Therapy is guided by molecular markers (RAS, BRAF, MSI) and the location of the primary tumour: intensified chemotherapy (e.g., FOLFOX, FOLFIRI, FOLFOXIRI) plus anti-EGFR antibodies or bevacizumab. Conversion rates approximately 20–40%.
• Regular re-evaluation in the tumour board; operation as soon as resectability is achieved, since prolonged chemotherapy damages the liver and increases the risk of postoperative liver failure.

Liver resection in cirrhosis

1. Assessment of operability

• The extent of resection is guided by:
• Liver function: Child-Pugh, MELD and ALBI score, and if applicable functional tests (ICG clearance or LiMAx test)
• Degree of portal hypertension
• Volume of the residual liver
• Reliable parameters for adequate postoperative liver function:
  • normal bilirubin
  • hepatic venous pressure gradient (HVPG) < 10 mmHg
• Indicators of portal hypertension:
  • splenomegaly
  • oesophageal varices
  • thrombocytopenia (caution: < 100,000/µl)

2. Extent of resection

• Parenchyma-sparing and minimally invasive procedures are preferred.
• Child A: Without relevant portal hypertension and with sufficient residual liver, major resections are also possible. Enlargement of the residual liver by PVE or ALPPS may also be employed.
• Child B: This is not an automatic exclusion from surgery. In a well-compensated liver, small resections may be possible under certain circumstances in experienced centres.
• Child C: Contraindication to resection; here, if at all, liver transplantation is an option.
• In portal hypertension, there is a significantly increased risk due to the inherently complication-prone dissection in the liver hilum.

3. Liver transplantation vs. resection in HCC

• Liver transplantation: From an oncological perspective, within defined limits (including the Milan criteria), the treatment of choice for HCC in the cirrhotic liver, as it treats both the HCC and the underlying liver disease.
  • 5-year survival rates of up to 70% and higher
  • Prerequisite: exclusion of macrovascular invasion, lymph node and distant metastases
• Partial liver resection: Due to the organ shortage in Germany and the improved outcomes of liver surgery, including in the cirrhotic liver, a legitimate alternative provided that liver function is adequate.

General:

• General inoperability of the patient due to underlying conditions
• Marked cardiac insufficiency, impaired renal and/or pulmonary function

Oncological:

• Diffuse involvement of the liver lobe to be preserved after exhausting the methods for extending resectability (see above)
• Infiltration into the diaphragm or the hepatoduodenal ligament
• Infiltration of the vena cava or the confluence of the hepatic veins
• Further distant metastases (except resectable pulmonary metastases)
• Uncontrolled primary tumour in the presence of metastases
• For HCCs with a small tumour burden in liver cirrhosis, liver transplantation is considered the treatment of choice, but this is qualified by the lack of organ availability (Milan criteria).

Functional:

• Impaired liver function with insufficient residual function, Child-B/C cirrhosis
• Insufficient residual liver volume (< 25–30 % in a healthy liver, < 40 % in a damaged liver)
• The most important cause of perioperative mortality after liver resection is liver failure. Risk evaluation is therefore of decisive importance, as the therapeutic options in the case of postoperative hepatic insufficiency are very limited.
• Evaluation of hypertrophy conditioning on the side to be preserved. Depending on the method, corresponding hypertrophy can be expected after 12 days to 5 weeks, but may take considerably longer in a cholestatic or cirrhotic liver.

For liver masses, the early detection of malignancy by means of imaging and, where applicable, histological confirmation by biopsy is the prerequisite for curative therapy.

An initial assessment is obtained from the history: pain, B symptoms, previous malignant diseases, travel history, oral contraceptives, alcohol abuse, drug abuse, viral hepatitis, metabolic syndrome, liver cirrhosis. Risk factors for a malignancy are liver cirrhosis, chronic hepatitis B or hepatitis C virus infection, and a history of tumour.

Clinical examination and laboratory tests:

• General: full laboratory panel
• Liver function: Important parameters of liver function:
• Tumour markers: alpha-fetoprotein; CA 19-9 (carbohydrate antigen 19-9); CEA
• In liver abscesses: fever, positive blood cultures, travel history
• In case of suspected parasitic diseases, e.g. echinococcosis → serology

Ultrasound:

• Backbone of primary imaging diagnostics (= screening).
• The assessment of focal liver lesions with native B-mode ultrasound and colour-coded duplex ultrasound allows for a reliable classification in up to 60% of cases (e.g., cysts, typical haemangiomas, focal fat distribution disorders).

Intraoperative ultrasound examination:

• Standard during every liver resection
• Detection of additional foci
• By assessing the vascular architecture and especially the contrast agent dynamics in the tissue, a differential diagnostic classification of the lesion(s) is often possible.
• Assessment of the positional relationship to vessels and bile ducts, of resectability, and of the extent of resection

For a more detailed assessment of a liver space-occupying lesion, a dynamic examination with assessment of the contrast agent behaviour in the various perfusion phases of the liver is necessary.

Contrast-enhanced ultrasound: CEUS (contrast-enhanced ultrasound):

• Contrast-enhanced ultrasound represents the gold standard in the diagnosis of benign liver changes.
• Contrast-enhanced ultrasound enables the depiction of liver perfusion in "real time". The contrast agent behaviour of a liver space-occupying lesion can be observed in the arterial, portal venous, and late venous phases. The different entities display characteristic patterns in this process.
• The advantage is its independence from renal and liver function; the disadvantage is its operator dependence and the lack of objective comparability.

3(4)-phase i.v. contrast-enhanced CT (native, arterial, portal venous, venous)

• The standard procedure for operative planning and clarification of resectability is multiphase contrast-agent (CA)-enhanced rapid thin-slice spiral computed tomography (CT)
• This achieves a high-resolution depiction of the arterial, portal venous, and venous structures. Most liver lesions can already be classified in this way with high sensitivity and specificity.
• The advantages of CT are its wide availability and the short examination time. The disadvantages are radiation exposure and the situation in thyroid diseases or renal functional impairment.
• With appropriate analysis software, the tumour volume, the total liver volume, and the remaining remnant liver volume after resection can be estimated.
• With regard to liver function, CT provides only indirect indications: enlarged spleen, recanalised umbilical vein, prominent caudate lobe, dilated bile ducts.
• In the presence of steatosis, the informative value regarding liver foci is limited.
• A disadvantage is the poor depiction of the biliary duct system.

MRI (magnetic resonance imaging)

• Use of liver-specific, predominantly biliary-excreted contrast agents (Gd-EOB = biliary-excreted contrast agent)
• The advantage of MRI is the good differentiability of benign and malignant liver tumours.
• The detection accuracy and characterisation of lesions in cirrhosis also appears to be increased compared with conventional contrast agents.
• Limitations arise with implants, claustrophobia, or renal functional impairment.
• With the possibility of 3D sequences, exact volumetry of the liver and virtual resection planning can be performed through anatomical depiction of the liver vessels, as with CA-enhanced CT.
• MRCP (magnetic resonance cholangiopancreatography) is the ideal instrument for the non-invasive depiction of the biliary duct system.
• In iCCC, MRI with cholangiography (MRI/MRCP) based on a liver-specific contrast agent with depiction of the intra- and extrahepatic bile ducts represents the gold standard.

3D planning and intraoperative navigation (AI and augmented reality)

Liver anatomy, particularly the branching of vessels and bile ducts, varies greatly between individuals. For an oncologically safe and at the same time parenchyma-sparing resection, the position of the tumour in relation to these structures must be precisely known.

• Artificial intelligence: AI-assisted software creates three-dimensional models of the liver, tumour, vessels, and bile ducts from CT and MRI data. This allows the supply and drainage territories to be delineated and the volume of the remnant liver (FLR) to be calculated precisely.
• Augmented reality: The 3D model is superimposed onto the camera image or into data glasses during the operation. In this way, the surgeon can see where the tumour and larger vessels lie beneath the surface. The difficulty is that the liver deforms due to respiration, positioning, manipulation, and pneumoperitoneum. The model must therefore be continuously adapted.
• Clinical relevance: The aim is more R0 resections with maximal parenchymal preservation. Whether this improves patient outcome is still the subject of studies.

PET-CT (positron emission tomography in combination with CT)

• Positron emission tomography (PET) in combination with CT and F18-fluorodeoxy-D-glucose (FDG) as a radiopharmaceutical is suitable for detecting most hepatic metastases, particularly in colorectal carcinoma.
• Due to the poorer single lesion detection compared to MRI, it has a role in whole-body staging when a comprehensive staging workup is required for both intrahepatic and extrahepatic primary tumours, i.e., even before concrete surgical planning.
• Detection of occult distant metastasis.

Endoscopic retrograde cholangiopancreatography

• ERCP plays a rather minor role in the diagnosis of HCC or colorectal metastases. Therapeutically, stent placement via ERCP is used for tumour obstruction of the ductus hepatocholedochus.
• In CCC, ERCP is used both diagnostically and therapeutically: in proximal/perihilar (Klatskin tumour) and distal localisation, the tumour can be localised very well, and ERCP also allows sampling for cytological examination.

Liver biopsy

• If HCC is suspected, there is an indication for biopsy under certain conditions. This should be performed according to the guidelines of the American Association for the Study of Liver Diseases (AASLD) in cases of:
• If imaging findings are characteristic of HCC, a biopsy can be dispensed with.
• An intrahepatic tumour with a diameter > 2 cm should be biopsied if the space-occupying lesion does not present typically on imaging and the AFP is < 200 ng/ml.
• In extrahepatic CCCs, histological confirmation can be obtained during an ERCP. For this purpose, brush cytology, forceps biopsy and bile aspiration are available, whereby sensitivity can be increased by a combination of these methods.

Summary:

• Correct preoperative imaging depiction of the exact extent of the tumour burden is crucial for a curative treatment concept.
• The following requirements must be placed on the imaging methods:

General preoperative preparation

• Comprehensive surgical laboratory work-up, blood group determination
• In case of increased cardiopulmonary risk, clarification of operability by further diagnostics (exercise ECG, cardiac echo, coronary angiography, pulmonary function test)
• Provision of 4–6 cross-matched packed red blood cell units at the surgeon's discretion
• If necessary, FFP and platelet concentrates
• In case of reduced general and nutritional status (e.g. albumin < 30 g/l), deficiencies should be corrected preoperatively: high-calorie nutrition, in severe malnutrition over 7–14 days, treatment of anaemia with intravenous iron as well as substitution of vitamin B12 and folic acid in case of proven deficiency.
• An enema the evening before for bowel emptying is recommended
• Preoperative antibiotic administration as a single shot (second-generation cephalosporin ½ h before skin incision)

Preoperative review and adjustment of therapy with anticoagulants/platelet aggregation inhibitors

• Platelet aggregation inhibitors
  • ASA: In secondary prevention, for example after myocardial infarction, stent or stroke, ASA is usually continued perioperatively. If it is taken only for primary prevention, it can be discontinued about 7 days beforehand.
  • P2Y12 inhibitors (ADP receptor antagonists) are paused before the procedure:
    • Clopidogrel: 5 days
    • Ticagrelor: 3–5 days
    • Prasugrel: 7 days
  • Dual antiplatelet therapy after coronary stenting: The treatment must not be discontinued without consulting a physician. Elective procedures should be postponed if possible until the recommended minimum duration of dual therapy has been reached. The decision is made jointly with cardiology.
• Vitamin K antagonists
  • Phenprocoumon (Marcumar®): discontinue 7–10 days beforehand. The long pause results from the long half-life.
  • Warfarin: discontinue about 5 days beforehand.
  • INR before the procedure: the target is a value below 1.5.
  • Bridging with low-molecular-weight heparin is only necessary in case of high thromboembolic risk, for example in:
    • mechanical heart valve
    • thromboembolism within the last 3 months
    • atrial fibrillation with high stroke risk
• DOACs (direct oral anticoagulants, formerly NOACs)The pause depends on the active substance and renal function. For a procedure with high bleeding risk, the following applies:

Preoperative biliary drainage in biliary obstruction prior to liver resection

Preoperative biliary drainage is only an option in biliary obstruction with bile stasis. This mainly concerns perihilar CCC, gallbladder carcinoma with infiltration of the hepatic hilum and tumours that compress the central bile ducts. In most liver resections, for example for liver metastases or HCC, there is only rarely an obstruction, and the question does not arise.

If bile stasis is present, drainage is nevertheless not performed routinely. Any intervention on the bile duct system, especially with contrast medium administration, leads to bacterial contamination. This increases the risk of cholangitis and perioperative infections. On the other hand, persistent cholestasis impairs liver function and increases morbidity and mortality. The indication must therefore be assessed on an individual basis.

Indications
In the presence of obstruction, drainage is generally indicated in:

• acute cholangitis, additionally with antibiotic therapy
• pronounced hyperbilirubinaemia, especially when a major resection with a small remnant liver is planned
• cholestasis-related malnutrition
• planned portal vein embolisation (PVE)
• planned neoadjuvant chemotherapy
• a foreseeably longer time until surgery

Timing
Before drainage, imaging to assess resectability should be completed, ideally with MRI/MRCP. Indwelling stents and drains make radiological as well as intraoperative assessment more difficult.

Procedure

• Primarily, the remnant liver is drained, i.e. the portion of the liver that remains after resection.
• Endoscopic drainage (ERCP with stent) is generally preferable to percutaneous transhepatic drainage (PTCD). PTCD increases the risk of bacteraemia, tumour cell dissemination along the puncture tract, and injury to the remnant liver. In the randomised DRAINAGE trial on perihilar CCC, mortality after PTCD was higher.
• In complex hilar strictures (Bismuth III/IV) or when endoscopic drainage fails, PTCD remains an alternative.

After drainage
Prior to an elective major liver resection, one should wait until cholestasis and inflammatory parameters have normalised. A bilirubin below approximately 2–3 mg/dl is frequently targeted. There is no uniform fixed time requirement; the decision is made individually.

Evidence
A 2025 meta-analysis on hilar CCC (21 studies, over 3000 patients) revealed the following picture: preoperative drainage did reduce postoperative liver failure. However, it increased morbidity, infections, cholangitis, and bile leaks, and prolonged the hospital stay. Overall mortality did not differ. The authors do not recommend routine drainage, but see advantages in cases of very high bilirubin, planned PVE, and malnutrition.

Source: Chen X et al., Int J Surg 2025;111(5):3543–3560.

Standardised consent forms are recommended for patient information, in whose anatomical sketches the findings can be drawn in. Patients should also be informed about alternatives and complementary treatments, in particular about interventional procedures and possible extensions of the procedure. Before every liver resection, it is advisable to obtain consent for a cholecystectomy.

General risks

• Bleeding
• Secondary haemorrhage
• Haematoma
• Need for transfusions with the associated transfusion risks
• Thromboembolism
• Wound infection
• Abscess
• Injury to adjacent organs/structures (stomach, oesophagus, spleen, diaphragm)
• Burst abdomen
• Incisional hernia
• Follow-up procedure
• Mortality

Specific risks

• Hepatic parenchymal necrosis
• Bile fistula
• Biloma
• Haemobilia
• Biliary peritonitis
• Bile duct stenosis
• Pleural effusion
• Air embolism (due to inadvertent or unnoticed opening of hepatic veins)
• Portal vein thrombosis
• Hepatic artery thrombosis
• Chronic hepatic insufficiency
• Hepatic insufficiency with hepatic coma
• Tumour recurrence