الفهرس 
Surgical Anatomy of the LiverOnly 14 pages are availabe for public view
 |  | from | 169 |  |  |
| | | from | 169 | | |
Abstract
The liver is the largest internal organ in the body. Liver plays a key role in major metabolic activities andbreakdown of many drugs and toxins. Cirrhosis is the end result of chronic liver damage caused by chronic liver diseases. It’s scaring of liver. Most common cause is hepatitis C infection, other causes are hepatitis B infection, alcohol abuse, autoimmune inflammatory liver disease, biliary stasis, medications, metabolic, NASH, etc..
Hepatocellular carcinoma (HCC) almost always arises in the context of chronic liver disease, usually in patients with cirrhosis. (HCC) is a primary malignancy of the liver, representing the 5th most common cancer in the world.
The presence of underlying hepatic parenchymal disease is critically important in determining both treatment options and outcome. The extent of the underlying hepatic dysfunction often dictates the therapeutic options may well be more important than cancer extent in determining survival.
Portal hypertension is one of main sequences of liver cirrhosis.Two important factors exist in the pathophysiology of portal hypertension, increase in vascular resistance and increase in portal blood flow. Presence and degree of portal hypertension influence the treatment plans of patients. Hepatic venous pressure gradient measurement together with platelet count can offer an objective way to assess portal hypertension. Clinically significant portal hypertension is defined as an increase in HVPG to 10 mmHg.
The ability to evaluate its functional mass is a very important parameter.For many years, the most common tool for gauging prognosis in cirrhosis was the Child-Turcotte-Pugh (CTP) system. Another scoring system is model of end stage liver disease(MELD) score. It is superior to CTP system because it uses objectiveparameters (bilirubin, INR and creatinine); less subjected tocenter-to-center variability;and the MELD score increases as the three constituentparameters deteriorate.
Hepaticreserve is the combined functions of the liver as determined byhepatic parenchyma, the reticuloendothelial system, unique cells in the liver(i.e., Ito cells) and hepatic blood flow, including major arterial, portal venous,hepatic venous; and microvascular blood flow in the spaces of Disse. Although severalmethods have been used to quantitatively evaluate thereserve capacity of the liver no definitivemethod has been established as yet.
Clearance/tolerance tests (like 13C breath tests and Indocyanine green (ICG) retention test), Functional imaging and blood flow as well as liver volumetry can together present a rational approach to assess the liver reserve.
Remnant livervolume (RLV)should be always ≥25% and ≥40 % in cirrhotic, of the estimated standard liver volume. The rational way to utilize hepatic volume isto have the liver volume measured by the same surgeon. Which is feasible by the use of Adobe Photoshop®or ImageJon personal computers.
Liver resection has been the primary treatment for HCC in selected patients with limited disease. Resection is more widely applicable, because there are no restrictions on tumor size, number or macrovascular invasion, which often preclude orthotopic liver transplantation (OLT) and ablation, respectively. Unlike OLT, there is also no obligatory waiting time.
To lead your patient safely throughout the journey of liver resection, careful preoperative assessment and preparation, meticulous operative technique and close postoperative monitoring should be adopted.
Good selection of patients is the largestcontributor to improved survival after hepatectomies. At least there are eight different staging systems, none of them with universal acceptance. But three of them (BCLC, CLIP and JIS score) have been validated in different cohorts of patients.
According to the most popular one BCLC, liver resection is preferably done to patients BCL stage 0 (Performance status test:0, CTP score: A) with single tumor <2cm, withnormal portal pressure and billirubin.
Preoperative elevation of general condition, good nutritional suppoort, good glycemic control and administration of methylprednisolone, single-dose antibiotic prophylaxis, synbiotic treatment and thromboprophylaxis are highly recommended.
Short duration, blood less surgeries is the best method to achieve best results. This can be acquired by optimizing the work field by using self retaining retractors and the use of efficient tools to transect the liver with the use of Pringle maneuver together with maintaining low CVP during surgery.
Intraoprative Ultra-sound is a very useful facility to manipulate the plan of surgery.
Laparoscopic resection provides a good alternative for open resection.
Close postoperative monitoring can be done at first day(s) in the ICU. Fluid and electrolytes should be supplied to correct post operative imbalance (eg hypophosphatemia). Early ambulation and early oral feeding should be encouraged. Tight glycemic control, as well as good analgesia should be started immediately post surgery. Early administration of pharmacologic thromboprophylaxis is recommended.