What is the Liver?
The liver is the largest solid organ in the body. It is located in the right upper part of the abdominal cavity, below the breathing muscle (diaphragm), and behind the rib cage. It is surrounded by multiple vital organs. The stomach lies on its left, the gallbladder sits just below the edge of the liver on the right, and the small and large intestines travel along its lower border.The liver is made of two parts, a bigger right lobe and a smaller left lobe.
The liver is connected to the intestines through a conduit called the common bile duct. The gallbladder stores bile made by the liver and is connected to the common bile duct via the cystic duct.The liver is responsible for a plethora of vital functions, including but not limited to detoxifying body wastes, producing essential nutrients for body function, producing bile to help with fat digestion, playing an important role in immunity, and making clotting factors to prevent bleeding.
The liver is the only visceral organ that has the ability to regenerate. After liver surgery the remaining liver portion will grow in volume as to assume the function of the liver portion that was surgically removed. In healthy livers, we only need 20-25% of our liver to survive.Therefore, if needed, 75-80% of the liver can be surgically resected. That is not the case in livers that are diseased, such as in fatty liver and cirrhosis patients. In these types of livers about 30-50% of the whole liver is needed for survival.
External Anatomy of the Liver
Internal Anatomy of the Liver
The liver gets its blood supply though two sources: the hepatic artery and the portal vein. Blood, after circulating through the substance of the liver and being detoxified, drains into the hepatic veins that direct blood back to the heart. These blood vessels and bile ducts divide into smaller branches that supply individual segments of the liver. Based on the organization of these branches there are 8 defined segments in a human liver.
Liver surgery is mainly based on this internal liver anatomy. The aim of surgery is the remove as little liver substance as possible while maintaining adequate blood supply and drainage of the remaining portion of liver.
Common Symptoms of Liver Diseases
Liver diseases vary between benign diseases and cancerous diseases. Common symptoms depend on the nature of the problem but in general include:
- Abdominal pain: depending on the size and location of a liver tumor, that might cause abdominal pain is different areas of the abdomen, most commonly in the right upper side.
- Jaundice: liver diseases can present very late where jaundice (yellowing of the skin and mucous membranes) happens.
- Weight loss, poor appetite and aversion to food.
- Fatigue, depression.
Treating Liver Diseases
Liver diseases that are treated with surgery are usually tumors or masses/cysts. The are divided into three categories:
- Benign liver lesions: These are not cancerous in nature and do not progress into cancers. Examples include liver cysts, hemangiomas, and focal nodular hyperplasia (FNH).Surgery for these lesions is indicated if it cannot be determined if the lesion is benign or malignant based on imaging studies, or if it is causing symptoms such as abdominal pain, or compressing other surrounding organs.
- Pre-cancerous liver lesions: These are benign lesions at the present time but have the risk of becoming cancers. These lesions are usually surgically removed once diagnosed. The most common example is a liver Adenoma. These lesions usually occur in females who are taking birth control pills. Stopping hormonal/contraception medications is the first step in treatment of these lesions and may cause regression in their size. However, they very rarely disappear completely and may still require surgery or close surveillance.
- Cancerous liver lesions: These are malignant lesions either spreading to the liver from other cancers (Colon, rectal, pancreas, breast cancers, etc.), or primarily arising in the liver such as Hepatocellular Carcinoma (HCC) which is a cancer of liver cells; or Cholangiocarcinoma, which is a cancer of bile duct cells that are present in the substance of the liver. The treatment of these cancers and liver lesions are dictated by the stage of the disease and might involve surgery, transplantation, chemotherapy, or radiation therapy.
Surgery of the Liver
The extent of surgery on the liver is dictated by the location of the disease, and whether the lesion is benign, malignant or pre-malignant. Liver surgery is one of the biggest and most involved abdominal surgeries because of its close proximity to other vital organs and blood vessels.
The aim of liver surgery is to remove the diseased fragment of the liver, and leave behind a healthy, disease-free liver portion with adequate blood supply and biliary drainage. This is accomplished through conservation of as many arteries, veins, and bile ducts as possible.
It is not uncommon to have the gallbladder removed at the time of liver surgery for many reasons that your surgeon will explain during the office visit.
Total Hepatectomy and Partial Hepatectomy
Surgery of the liver includes working around large blood vessels, which adds to the risk of the surgery. Because of this, bleeding is always a concern in large liver surgeries where a big portion of the liver needs to be excised. Removing the right lobe of the liver is called Right Hepatectomy, and removing the left lobe of the liver is called Left Hepatectomy. Removal of part of a liver lobe is called Partial Hepatectomy.
Open vs. Laparoscopic Hepatectomy
The patient and their liver surgeon will make a decision whether or not they qualify for minimally invasive liver surgery, versus the usual open liver surgery. Our surgeons are qualified to perform minimally invasive liver surgery using the camera technique (Laparoscopic Hepatectomy), or the robotic technique (Robotic Hepatectomy).
Are you a candidate for laparoscopic surgery? Your surgeon will make this decision with you. Some patients with previous upper abdominal surgery or with preexisting medical conditions may not be candidates for this procedure.
In certain tumors of the liver, the current approach is to burn (ablate) the liver lesion in place, instead of surgically removing it. This approach is used for selected liver tumors to spare patients the morbidity and the complications of a large liver resection. Liver ablation is done on patients that cannot tolerate and will not survive a major liver resection, or in some tumors that are very small thus achieving similar results to liver resection. This procedure can be done through small band-aid sized incisions where a camera is inserted into the belly and an ultrasound probe is used to locate the tumor in the substance of the liver. After the lesion has been located by ultrasound a thin microwave antenna is inserted into the targeted lesion and the lesion is destroyed with microwave technology. This is a very safe and effective procedure. Patients will be discharged home the same day, or will spend one night in the hospital at the most.
Liver Cyst Surgery
Liver cyst marsupialization or unroofing is a procedure done using minimally invasive techniques in cases of liver cysts that are benign in nature, but are causing symptoms of abdominal pain due to their large size, or other symptoms when they are compressing other surrounding organs. This procedure is done through small band aid sized incisions and the front wall of the cyst is taken off. The fluid from inside of the cyst is removed and the remaining back wall of the cyst is burned. This procedure has a very high success rate over other procedures because it both eliminates the cause of symptoms, and prevents recurrence of the cyst.