Liver Procedures

Open Liver Resection

Liver resection is the removal of part of the liver during an operation. The body can cope with removal of up to two-thirds of the liver. The liver also has the ability to grow back. Within 3 months from your operation, the remainder of your liver will have grown back to near normal size.

Liver resection is a curative management for primary liver tumors (hepatocellular carcinoma, cholangiocarcinoma, gallbladder cancer (+/- involving the liver), liver angiosarcoma, etc) and it is the only hope for cure in many metastatic liver tumors (metastatic colorectal cancer, neuroendocrine carcinoma, sarcoma, ovarian cancer, kidney cancer, etc). In the past decade, safety of liver resection has significantly improved with better understanding of liver anatomy, improved surgical instrumentation, and more sophisticated postoperative care. Mortality rate from a major liver resection is now less than 1%. Today, liver resection has become a safe and routine operation.

More than 70% of liver resections in Europe and the United States are undertaken using the traditional open technique. Most patients spend 5-7 days in hospital after the operation. In an effort to further decrease the postoperative complications and to facilitate a shorter recovery, minimally invasive liver surgery technique was developed. In 1992, laparoscopic liver resection was first described for a small peripherally located liver tumor. Laparoscopic liver resection technique gradually evolves to enable completion of major liver resections (removing 3 or more liver segments) for liver cancers. However, not all patients are candidates for the minimally invasive liver surgery based on their tumor characteristics. About 20% of patients presenting to our liver surgery center require an open liver resection due to tumor size, tumor proximity to major biliary and vascular structures, and the need for a vascular resection with reconstruction. For example, if the liver tumor involves a major blood vessel feeding the liver (main portal vein, hepatic artery, and inferior vena cava) where a vascular resection is needed to achieve cure, then this operation is performed using the traditional open technique.

For open liver resection, a surgical retractor is placed to properly expose the liver and the tumor, away from other abdominal organs such as stomach, intestines, and colon. The blood vessels feeding the lobe of the liver to be resected are carefully isolated and ligated. The line of demarcation on the liver surface is then identified. Liver ultrasound is routinely used to mark the border between the tumor and healthy liver parenchyma. A careful review of the intrahepatic anatomy to map the location of major vessels is crucial for a safe liver surgery. A computerized assessment of the liver volume (to be resected and to be preserved) is equally important to avoid a postoperative liver failure from not having adequate liver tissue after the resection. An experienced liver surgeon determines whether a preoperative portal vein embolization or portal vein ligation to induce future liver remnant hypertrophy is necessary in cases of marginal liver volume. Other factors such as history of chemotherapy, background liver cirrhosis, degree of liver steatosis, obesity, portal hypertension, ongoing biliary obstruction, and prior liver resections are all taken into consideration. This evaluation process is highly complexed, specialized and only available in dedicated liver surgery centers.

Intraoperative bleeding is carefully managed and minimized to achieve superior outcomes. The resected specimen is finally sent to pathology laboratory for a frozen section examination, in order to confirm absence of tumor cells at the liver resection margins. Once the open liver resection is complete, your liver surgeon may leave a small drain, which is later removed in a few days after the liver operation. Open liver resection is technically challenging and physically demanding for the liver surgeon. It is therefore very important to see a liver specialist or liver surgeon with significant experience in liver resections, especially for the major liver resections.

Most patients stay in the hospital for 5-6 days after open liver resections. We only admit patients to the intensive care unit when it is clinically necessary. Nearly all our postoperative liver surgery patients are admitted to a regular surgical floor. Our team of highly-trained nurses, physical therapists, respiratory therapists, and nutritionists will work with you to speed up your postoperative recovery. We also employ an enhanced recovery protocol after Open Liver Surgery to facilitate recovery and shorten the hospital stay.

Laparoscopic Liver Resection

Laparoscopic liver resection (LLR) is safe, feasible and is rapidly being adopted by the majority of advanced high volume liver centers worldwide.

The vast majority of our liver resections are performed using state of the art, pure laparoscopic techniques. As a national leader in minimally invasive Laparoscopic liver surgery, Dr Michail Papoulas is able to remove small to large liver tumors through small incisions instead of an open large incision by utilizing Laparoscopic Liver resection techniques.

Advantages of Minimally Invasive Laparoscopic Liver Resection:

1. Faster Postoperative Recovery – Most patients leave the hospital within 3-4 days following major Robotic liver resection and within 2 days following minor liver resections. Cardiac and pulmonary complications are significantly reduced with minimally invasive liver surgery techniques. Faster recovery from liver resections translates into an earlier administration of systemic chemotherapy in patients who need additional systemic chemotherapy afterwards.

2. Reduced Blood Loss – Most laparoscopic liver resections we have performed result in less than 100 cc of blood loss. Blood transfusion is rarely needed, even for major liver resections.

3. Less Pain – Most patient experience minimal pain and require minimal narcotics, even after major liver resections.

4. Minimal Risk for Wound Infection – The probability of having surgical wound infection is significantly lower, less than 1% when compared to open liver resection.

5. Minimal Risk for Hernia Formation – Small incisions heal with significantly lower chance of developing incisional hernias. The best way to prevent hernia formation after surgery is to avoid creating a large incision.

6. Better Cosmetic Outcome – Small incisions healed with minimal, often nearly invisible scars

7. Less intra-abdominal adhesions – Laparoscopic liver surgery creates less scars (adhesions) around the organ thus allowing an easier access and approach to the liver in case future liver surgery is required.

How Laparoscopic Liver Operations for Benign and Malignant Liver Tumors are Performed?

Laparoscopic liver resection is performed through 4 or 5 small incisions (5 to 12mm) in the upper abdomen. The liver is visualised and magnified via a High Definition camera. It can be fully mobilised in order to identify and visualise lesions even in the most posterior and superior aspects of the liver. The steps of liver resection follow the same principles with the open technique. The specimen is usually extracted from a small incision in the lower abdomen (pfannenstiel incision).

Robotic Liver Resection

Robotic liver resection is a form of minimally invasive liver surgery, similar to laparoscopic liver resection. Robotic and laparoscopic liver resection display similar safety and feasibility for hepatectomies. In experienced hands, outcomes of robotic and laparoscopic liver surgery are similar, while recent studies showed no inferiority of one approach over the other. Robotic liver surgery offers some technical advantages compared to laparoscopic surgery including ease of dissection and suturing. On the contrary, robotic liver surgery is associated with a longer operative time and significantly higher cost compared to the laparoscopic approach. In our practice, we opt for a robotic approach only when a biliary reconstruction is planned requiring delicate suturing using the robotic-platform.

Laparoscopic Liver Cyst Fenestration (Unroofing)

When a large hepatic cyst becomes symptomatic, patients often present with right upper quadrant pain, shoulder discomfort, nausea, epigastric fullness, and acid reflux-like feelings. The symptoms are caused by a mechanical stretch to the Glissonean capsule covering the liver or mechanical compression to the surrounding organs such as stomach, diaphragm, intestines, and chest wall. In this situation, a surgical unroofing or fenestration of the large liver cyst is necessary. Presence of liver cyst is generally not associated with liver dysfunction.

A diagnosis can be easily made based on a CT scan or MRI. It is important to rule out a premalignant cystic mass/lesion of the liver such as mucinous cystic neoplasm or parasitic hydatid cyst, which should instead be resected. A percutaneous liver cyst aspiration by an interventional radiologist is commonly discussed and falsely performed, however it is well known to fail in more than 95% of patients due to rapid fluid re-accumulation within the hepatic cyst. The futile percutaneous liver cyst aspiration is therefore, not recommended.

In the modern era of liver surgery, laparoscopic liver cyst fenestration has become the standard treatment for symptomatic large hepatic cysts. It is a technically straightforward operation with excellent efficacy and long-term outcomes. An open liver operation is now obsolete for this disease.

To definitively treat symptomatic large hepatic cysts, removal/resection of a large portion of the cyst wall is mandatory. This may include partial liver resection of adjacent attenuated liver parenchyma. When the operation is performed properly, the incidence of cyst recurrence is minimized. Recognition of the intrahepatic biliary and vascular anatomy is important to avoid bile leak or bleeding intraoperatively. The resected cyst wall is then sent to pathology for a frozen-section evaluation to identify or rule out presence of any premalignant/malignant cells. When premalignant or malignant cells are identified, a formal oncologic liver resection is needed to gain negative margins.

Most patients can be discharged to home on the same day of the operation. Placement of an abdominal drain is usually not needed after this procedure. A small percentage of patients require an overnight stay in the hospital mainly due to medical problems. It is important to see an experienced liver surgeon to treat large symptomatic hepatic cysts. Dr. Michail Papoulas and his team perform this operation frequently. Even in patients with prior multiple abdominal operations (including open operations), minimally invasive technique can still be offered safely with excellent outcomes.

Repeat Liver Resection

New tumors can arise after a liver resection either via open, laparoscopic, or robotic liver surgery method during the surveillance phase. New liver cancers are usually found in different locations in the liver, away from the area of prior liver resections. Each type of liver cancer is different in term of recurrent potentials. Metastatic colon and rectal cancers to the liver can recur several years after the initial liver surgery. It is important to detect an early tumor recurrence using imaging modalities such as CT scan or MRI, in addition to following the level of tumor markers. Liver biopsy is often necessary to confirm the liver cancer recurrence. A PET scan is useful to rule out other distant metastases such as brain, lung, bone or retroperitoneal lymph nodes metastasis. Once the liver cancer recurrence is diagnosed, immediate consultation with a liver surgeon or liver specialist is necessary.

Management of recurrent liver cancer has evolved significantly in the last decade. Improvement in safety profile of liver resection/liver surgery and perfection in minimally invasive liver surgery technique extend the indication of repeat liver resection. Many patients with recurrent liver tumors are candidates for a repeat liver resection in combination with liver ablation and systemic chemotherapy administration. For colorectal cancer with liver metastases, repeat liver resection has been well documented to increase long-term overall survival and it is safe. Some patients achieve survival more than a decade after the index metastatic diagnosis and the initial liver resection.

A preoperative evaluation for a repeat liver resection is essentially similar to one for the initial liver resection. A higher technical challenge is expected with a repeat liver resection, mainly related to volume of liver remnant and scar tissue formation around the liver, diaphragm, and intestines. However, in experienced hands of a liver surgeon, repeat liver resections can be done safely with similar short- and long-term outcomes as those of initial liver resections. The use of minimally invasive liver surgery approach during the initial liver resection facilitates easier repeat liver resections. This is secondary to the less scar tissue formation associated with minimally invasive liver surgery. The repeat liver resections can also be safely performed using the minimally invasive surgery method by experienced liver surgeons.

In our liver surgery unit, we offer both laparoscopic and robotic liver resection for patients with recurrent liver tumors/liver cancers. Minimal invasive liver surgery allows for the repeat liver resection to be done without the need to create a large open incision, thus minimizing potentials for postoperative complications and facilitate faster recovery. It also creates significantly fewer intra-abdominal adhesions, allowing for future repeat operation to be done also minimally invasively if other new tumor reoccurs in the liver. Parenchymal sparing liver surgery is followed in each liver resection to preserve as much non-cancerous liver parenchyma as possible. Advanced interventional radiology technique such as preoperative portal vein embolization or portal vein ligation to induce hypertrophy of the future liver is also frequently applied in this circumstance. Liver transplant does not play role in patients with recurrent metastatic cancer to the liver.

Repeat liver resections may also be combined with liver tumor ablation (radiofrequency ablation or microwave ablation), depending on the tumor location, number, and proximity to major biliovascular structures. This will be determined by the liver surgeon after reviewing CT and/or MRI scan prior to the operation. Patients with metastatic liver cancers who achieve tumor-free status experience significantly longer overall survival benefits. Dr. Michail Papoulas has significant experience in performing minimally invasive robotic liver resection for patients who had undergone prior liver resection at other institutions, including those with open abdominal operation(s) previously.

Laparoscopic & Robotic Bile Duct Repair

Bile duct leak can be caused by many reasons such as an inadvertent injury of the bile duct during a difficult laparoscopic cholecystectomy, abdominal trauma (stab or gunshot wound), or a large gallstone impinging on the bile duct wall causing a pressure necrosis phenomenon (called Mirizzi syndrome). However, the most common reason for bile duct leak is iatrogenic laparoscopic cholecystectomy.

Biliary surgery is a highly specialized procedure, which requires training and experience. Most general surgeons do not have adequate technical expertise in biliary surgery. Biliary tract anatomy can vary among patients and recognition of this anomaly is crucial in undertaking bile duct surgery. Understanding of subsegmental biliary anatomy is gained by liver surgeons from performing bile duct cancer resection (Klatskin tumor resection). Accessory branches from perihilar liver segments can be found without warnings, and they can be easily injured when not carefully identified.

Interventional radiologists and advanced endoscopists are parts of the multidisciplinary team treating bile duct leak. Many patients with bile duct injury are recognized during the gallbladder removal surgery, but a significant percentage is recognized several days following the gallbladder surgery. Patients usually develop fever, abdominal pain, nausea/vomiting, jaundice (yellowing of skin and eyes), or failure to thrive from the bile duct leak.

Whenever possible, bile duct leak/injury is managed non-operatively using an endoscopic placement of biliary stent or via a percutaneous transhepatic approach. For certain types of bile duct leak/injury, such as a complete transection of the bile duct, a surgical intervention is necessary from the index diagnosis.

Majority of biliary surgeries for any reasons are still performed with the traditional open operation. Whenever technically feasible, minimally invasive bile duct repair (laparoscopic or robotic) is preferable due to the lower rate of postoperative complications, less pain, shorter recovery, and earlier return to work. A closed suction drain is routinely placed for all bile duct repairs. This is removed at a later time prior to hospital discharge or in the office during the first follow-up visit.

Dr. Michail Papoulas has a significant expertise in robotic minimally invasive bile duct repair/reconstruction. Long-term patency of the biliary system greatly depends on the experience/expertise of the liver surgeon or bile duct surgeon. High-volume centers produce superior/better outcomes when compared to low-volume centers. This fact has been well documented in the surgical literatures, similar to other complex liver and pancreas operations. In the past several years, our team had presented methods and outcomes of robotic bile duct repair at several national academic surgical meetings.

Laparoscopic Bile Duct Exploration

Surgical exploration of the bile duct to remove debris or stones causing obstructive jaundice is needed when endoscopic or percutaneous approach fails. Traditionally, this operation is done through an open approach. In the area of minimally invasive surgery, Robotic Bile Duct Exploration can be done without creating a large open incision to minimize postoperative complications.

During Bile Duct Exploration , a small endoscope is inserted into the bile duct to visualize the debris or stones. Once the debris or stones are visualized, a retrieval basket can be inserted through this small endoscope to remove them. This procedure requires advanced surgical and endoscopic skills, often not available in many community hospitals.

Dr. Michail Papoulas has significant experience in performing Bile Duct Exploration using minimally invasively techniques with excellent outcomes.

Two Stage Extended Liver Resection

Some patients are referred to our practice with very large liver tumors or multiple liver tumors occupying/replacing most of the liver, requiring resection of more than 70% of the total liver volume. These patients are at risk of developing postoperative liver failure because they will not be left with an adequate functioning liver parenchyma to support their metabolism after the extended resection.

To avoid postoperative liver failure, at least 30% of healthy functioning liver parenchyma must remain after resection. Traditionally a portal vein embolization by an interventional radiologist is done to embolize the ipsilateral portal vein going into the tumor side. This maneuver will induce contralateral liver hypertrophy (growth) in about 6-8 weeks. This procedure is successful in about 70% of cases. In the other 30%, the contralateral liver fails hypertrophy. To mitigate this, we have adopted a technique of two-stage extended liver resection, known as ALPPS procedure (Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy).

During the first stage, a laparoscopic diagnostic examination of the abdominal cavity and the liver is undertaken. After exclusion of tumor spread within the abdomen, we undertake a laparoscopic portal vein ligation and liver partition (partial or full). In about 2 weeks later, the contralateral liver segments hypertrophy significantly to greater than 30%, which reduces the chance of having liver failure after extended resection.

A special CT scan protocol with volumetric rendering method is obtained to document the percentage of liver hypertrophy. At the second stage, the extended liver resection removing the liver tumor(s) with curative intent is then completed.

Laparoscopic Liver Ablation

Local therapy with thermal ablation is a secondary alternative treatment option for various tumors in patients who are not suitable for liver resection. Marginal liver reserve, the need to remove excessive amount of normal liver in order to clear a small tumor (<3cm), and patient’s inability to tolerate major operation due to medical issues are the most common reasons to recommend ablation instead of liver resection.

Dr. Michail Papoulas utilizes a microwave energy system to ablate and eliminate tumors. This procedure is performed via laparoscopic tiny incisions (1-3). Using a videoscopic camera, we are able to visualize the liver surface directly and undertake the tumor ablation under a real-time ultrasound guidance. The ablation probe is carefully inserted into the center of the tumor avoiding the surrounding organs such as diaphragm, stomach, kidney, main bile duct, major vessels, small intestine, and colon to prevent injury to those structures.

Laparoscopically delivered liver ablations are associated with lower tumor recurrence when compared to those delivered percutaneously by an interventional radiologist (6% vs 14%). The laparoscopic or robotic approach also provides the opportunity to perform a direct inspection of the entire abdominal cavity and liver surface for small metastatic tumors otherwise not detected on high quality CT/MRI scans (18%). Many patients can be discharged after 6-12 hours observation.

Liver ablation is also frequently done in combination with tissue preserving liver resection to achieve tumor free status when additional tumors are present on the other liver lobe. Dr. Michail Papoulas and his team frequently perform combined minimally invasive liver resection and liver ablations for primary and metastatic tumors with excellent outcomes.

Extended Hepatectomy for Hilar Cholangiocarcinoma

Detection of hilar cholangiocarcinoma in extrahepatic bile duct strictures is a continuing challenge in clinical practice. Most cholangiocarcinomas become symptomatic when the tumor obstructs the biliary drainage system, causing painless jaundice (yellow discolouration of eyes and skin). Because of its wide availability, computed tomography is one of the first studies obtained in patients with suspected biliary tract obstruction. Currently, a good quality MRI/MRCP is an optimal investigation tool for suspected hilar cholangiocarcinoma. Most patients undergo biliary drainage prior to referral for resection. Ideally, biliary stents should not be inserted before resectability is assessed.

Hilar cholangiocarcinoma continues to be a complex challenge for the surgeon. The only curative treatment for patients with this condition is surgery, which should be attempted only in specialized centers. Recent advances in surgical treatment have led to a more aggressive approach. An additional hepatic resection is defined as essential for a radical surgical approach.

For hilar cholangiocarcinoma, the Bismuth-Corlette (and/or Blumgart T-staging) classification is a guide to the extent of surgery required.

• In type I and II: en-bloc resection of the extrahepatic bile ducts and gallbladder with 5–10 mm bile duct margins and regional lymphadenectomy with Roux-en-Y hepatico-jejunostomy.
• In type III: hilar resection plus right or left hepatectomy or trisegmentectomy.
• In type IV: right or left

The need for vascular reconstruction of the portal vein is not uncommon in Type III and IV hilar cholangiocarcinomas. Additionally, preoperative planning and volume manipulation techniques are required for these type of major liver surgeries in order to induce hypertrophy of the future liver remnant, perform a radical resection with clear margins and avoid post-hepatetomy liver failure.

Dr. Michail Papoulas has a great experience managing patients with hilar cholangiocarcinoma. He has presented in the Annual Meeting of the Israeli Surgical Society the contemporary surgical approach to hilar cholangiocarcinoma.