Chapter 124: Anatomic Considerations, Operative Techniques, and Perioperative Management of Hepatobiliary Malignancies

INTRODUCTION

Surgical resection is the first-line treatment for selected patients with hepatobiliary malignancies. With refinements in surgical techniques and perioperative patient care, the safety of liver resection has improved dramatically over the decades. Indeed, the mortality rate after major hepatectomy has been reported to be less than 5% in recent years at high-volume hepatobiliary centers.^1-3 The most important factor influencing outcomes after liver resection is the surgeon’s knowledge of the relevant anatomy and of basic principles pertaining to the surgical procedure. In this chapter, we review the general principles of hepatobiliary surgery and describe current approaches for safe liver resection.

PREOPERATIVE ASSESSMENT

Adequate surgical planning is required for safe and curative resection of hepatobiliary malignancies. Preoperative assessment should include evaluation of the resectability of the disease and prediction of surgical risk, which allows surgeons to minimize perioperative morbidity in patients undergoing liver resection.

Evaluation of Tumor Extent

Imaging studies are used to detect and characterize hepatobiliary lesions. For liver lesions, computed tomography (CT) and magnetic resonance imaging (MRI) have been reported to be the best methods of detecting lesions.^4-6 Contrast enhancement with a quadruple-phase liver protocol (i.e., plain CT followed by a three-phase dynamic study comprising an arterial phase, a portal phase, and a late phase) can be used to accurately evaluate the extent of the disease and characterize tumor vascularity for precise mapping of lesions and accurate diagnosis. For biliary lesions, high-resolution CT also accurately predicts resectability.⁷ However, endoscopic retrograde or percutaneous transhepatic cholangiography is helpful for determining the longitudinal distribution of such lesions, permitting sampling of bile for cytology as well as step biopsy, intraductal ultrasonography, and/or biliary drainage simultaneously.

In addition to assessment of the main hepatobiliary lesions, screening of distant metastases or extrahepatic disease is also inevitably required to determine the oncological resectability of the tumor. Chest CT is the preferred modality for identifying lung metastases. Patients with metastatic liver lesions from the gastrointestinal tract additionally require pelvic CT to exclude peritoneal dissemination and primary status or local recurrence of the primary. In selected patients, positron emission tomography combined with CT (PET-CT) is useful for screening distant metastases and determining the metabolic characteristics of an equivocal lesion detected by CT or MRI. However, routine use of PET-CT is not recommended owing to its cost, the need for local expertise, and its limited sensitivity in detecting small lesions and tumors treated with chemotherapy.⁸ Additionally, a recent randomized controlled trial showed no benefit of PET-CT in the preoperative assessment of patients with hepatic colorectal metastases compared to standard, high-quality CT imaging.⁹

Surgical Planning Based on the Anatomy

To determine the technical resectability of the disease and permit an efficient surgical approach, anatomical characteristics should be evaluated in detail prior to surgery. In general terms, ...