Far Eastern University

Nicanor Reyes Medical Foundation

Institute of Medicine • Blood supply of the liver:
Section 3E Batch 2020 o Left and Right Hepatic artery- supplies 25% of
the blood in the liver
o Hepatic vein- majority of the blood supply
would come from the hepatic vein
• Portal vein:
o Very important anatomical structure especially
LIVER DISEASE for surgeons
o It rests at the base of the liver
Dr. M ichael L. Capulong • Has a remarkable regenerative capacity
28 September 2018 o Regeneration follows the size of the area of the
liver you are removing, if a big portion is
removed, you won’t expect that portion to
*Some information about the anatomy part is lifted from regenerate totally or entirely
Schwartz.
*Source: PPT, lecture, Schwartz
*No proofreading done. Malaki na kayo kaya niyo na yan

LIVER ANATOMY

• The liver is held in place by several ligaments:
o Round Ligament- is the remnant of the
obliterated umbilical vein

§ Enters the left liver hilum at the front
• Liver is the largest solid organ in the body
th edge of the falciform ligament
• By weight it only takes about 5 of the body weight
o Falciform Ligament- separates the left lateral
o Less than 1 kg for a 50kg individual
and left medial segments along the umbilical
• Weighing approximately 750 g to 1000g (Schwartz: fissure
1500 g) § Unequally divides the liver
• Functions of the organ: § Anchors the liver to the anterior
o Filtering mechanism abdominal wall
o Processing several types of enzymes o Fibrous ligamentum venosum (Arantiu’s
o Accessory GIT organ ligament)- located deep in the plane between
• It resides in the RIGHT upper abdominal cavity the caudate lobe and the left lateral segment
• Protected by the rib cage o Left and Right Triangular ligaments- secures
• Reddish brown in color the two sides of the liver to the diaphragm.
• Surrounded by a fibrous sheath known as Glisson’s o Coronary ligaments
capsule § Right CL anchors the liver to the right
• The right side of the liver is bigger than the left retroperitoneum.
• The falciform ligament and the gallbladder divides • These ligaments can be divided in a bloodless plane
the liver to fully mobilize the liver to facilitate hepatic
o Gallbladder and caudate lobe of the liver is also resection.
used as a marker to known which side of the • Hepatoduodenal ligament (porta hepatis)-
liver you’re dealing with o Supports the liver
o Gallbladder is connected via the cystic duct and o contains the:
the common bile duct which will eventually § Common bile duct
nd
drain to the 2 portion of the duodenum § Hepatic Artery
• Functional division is more important which divides § Portal vein
the liver into smaller areas o It also serves as a guide in locating these
structures

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 • Foramen of Winslow (epiploic foramen) INCIDENTAL LIVER MASS
o Located from the right side and deep (dorsal) • A liver mass often is identified incidentally during a
to the porta hepatis radiologic imaging procedure performed for another
o This allows complete vascular inflow control to indication
the liver when the hepatoduodenal ligament is o A liver mass may be discovered during
clamped using the Pringle maneuver. evaluation for gallbladder disease or kidney
o Used as a guide to the retroperitoneal area stones
§ Especially if there are problems in the o Usually incidental unless if it is due to
posterior wall of the abdomen and for infectious causes (most common is hepatitis)
any pathologies in the common bile duct • With advances in imaging technology, previously
undetected lesions are now identified.
HISTORY OF LIVER SURGERY o Although many of these lesions are benign and
• The ancient Greek myth of Promethues reminds us will require no further treatment.
that the liver is the only organ that regenerates o Most common tumor is that of metastatic
• The first recorded elective hepatic resection was tumors
done in 1888 in Germany by Langenbuch. • The evaluation of an incidental liver mass begins
with:
SEGMENTAL ANATOMY 1. History
• The liver is grossly separated into the right and left 2. Contrast helical CT and MRI
lobes by the plane from the gallbladder fossa to the 3. Measurement of levels of the tumor markers
inferior vena cava (IVC), known as Cantlie’s line carcinoembryonic

• The right lobe typically accounts for 60-70% of the
ALGORITHM FOR DIAGNOSTIC WORK-UP OF AND
liver mass, with the left lobe (and caudate lobe)
INCIDENTAL LIVER LESION
making up the remainder.
• The caudate lobe lies to the left and anterior of the
IVC.
• Couinaud
o Divided the liver into eight segments,
numbering them in a clockwise direction
beginning with the caudate lobe as segment I.
o Segments II and III comprise the left lateral
segment
o Segment IV is the left medial segment.
o The Right lobe is comprised of segments V, VI,
VII, and VIII
§ Segments V and VIII making up the right
anterior lobe
§ Segments VI and VII making up the right
posterior lobe.
o These are functional segments useful when
resecting a liver
§ Through these you can freely remove
one segment without affecting the entire
function of the liver
§ 1 full segment includes the vascular
bundle and the biliary drainage of that
liver
§ Also useful in doing biopsy, draining the
liver with hepatic cyst, and abscess via

percutaneous drainage to easily identify • Very good history and physical exam is very
the exact segment of the liver involve important especially in knowing that in most
cases, these are secondary to metastatic disease
and the origin is difficult to determine
• Prolonged estrogen use predisposes a woman to
adenoma formation
o Intake of OCP for >10 years increases
the chance for adenoma formation

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 • Take note of signs and symptoms of portal • 2 general classifications: Benign and Malignant
hypertension o Most common benign: Hepatic cyst
• Coagulation factors- most of the coagulation • Amebic liver abscess
factors are produced in the liver and a • Radiologic Imaging
derangement in the function of the liver can o Radiologic imaging results are classic for
result to prolongation of bleeding parameter benign hemangioma or Focal nodular
result and even a decrease in the concentration hyperplasia (FNH), liver biopsy is not indicated.
of the clotting factors § There is a differentiating point in the
• 20% of those who undergo screening of hepatitis result of your imaging study that would
will be positive since hepatitis exposure in the tell you that you are dealing with these
Phils is very rampant particular disease
• If you are (+) for the antigen/antibody titers then o Biopsy would actually increase the risk for
there is no need for you to be vaccinated, hemorrhage, because both lesions are
however, that increases your chance for having a hypervascular
full-blown hepatitis later on. That’s why close o Observation is warranted as long as the patient
monitoring and follow-up is important for these is asymptomatic
people since they can be carriers § Period of observation: 3-6 months
• Tumor markers: § Regular follow-up and ultrasound to
o CEA: Colon monitor if there is increase in the size of
o AFP: Liver the hepatic cyst
o CA 19-9: Pancreas § If there is a steady increase in size
o CEA and CA 19-9 are not specific tumor accompanied by pain then this warrants
markers and they overlap so that in liver a surgical procedure (drainage or
pathology these markers may also excision)
increase. This can also help you in your § If there is no changes in size and there is
differential diagnosis since most of the no pain: observe only
time we are dealing with a metastatic • Biopsy
tumor o If all imaging studies are inconclusive, then an
o An increase in CEA and AFP may indicate image-guided percutaneous liver biopsy should
that the primary tumor that metastasized be considered.
to the liver is colonic in origin o If the lesion is too small to biopsy or cannot be
• Percutaneous biopsy is a risky procedure well visualized or targeted for percutaneous
especially if there is a lot of neovascularization biopsy, then options are either close follow-up
since this can cause a lot f bleeding imaging to document stability or laparoscopic
• Screening for other GIT organs may also be done liver biopsy.
• All the major disease in the top three list for § Do close monitoring and follow-up and
both male and female will ultimately have ideally the person who did the first US
metastasizing tumor in the liver but this should should also be the one to do the
not prevent you from doing a curative surgery. succeeding US for uniformity sake
• Curative surgery is possible as long as the o If biopsy demonstrates adenocarcinoma, the
nodules or tumors are confined in one area only differential diagnosis narrows to:
in the liver (segments) § Metastatic adenocarcinoma from an
o Limiting factor for curative surgery is unknown or occult primary
when tumor is multiple and in different § Primary liver adenocarcinoma, which
areas of the liver also is known as cholangiocarcinoma

CLASSIFICATION OF LIVER LESIONS BENIGN HEPATIC CYSTS/ LESIONS

1. CONGENITAL CYSTS
• Practically present for the entire life of the
individual, silent, benign, and not even
increasing in size
• Majority of hepatic cysts are asymptomatic
• They are usually identified incidentally and can
occur at any time throughout life
• Congenital or Simple cyst- most common
benign lesion found in the liver
o Female:Male ration is approximately 4:1

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 o Hepatic imaging studies: thin-walled, • Preferred mode of treatment: SURGICAL
homogenous, fluid structures with few or RESECTION
no septations. • If aspiration is done, it usually contains bile due
§ You see septations if the cyst is to the egress of bile into the hepatic ducts
chronic. This happens when the
cyst becomes infected and fibrosis 3. POLYCYSTIC LIVER DISEASE
occurs • Adult Polycystic Liver Disease (ADPCLD)
§ But for non-infected cysts, typically • Presence of multiple hepatic cysts
they are not septated • Autosomal Dominant Disease
o Cyst epithelium is cuboidal and secretes a • Third decade of life
clear serous fluid. • Prevalence and number of hepatic cysts are
• Treatment: higher in females
o Aspiration (CT or US guided) followed by • Increase with advancing age
SCLEROTHERAPY. • Increasing severity of renal cystic disease and
§ If it becomes symptomatic renal dysfunction.
§ Sclerotherapy is done when there is • At age 60 years old, approximately 80% of
recurrence of the cyst. Done by ADPCLD patients will have hepatic cysts, with
injecting a chemical (alcohol) in the women having more and larger cysts
cavity resulting to the collapse of
• This gender difference may be due to the
the wall of the cyst
effects of estrogen
o This approach is approximately 90%
o Estrogen also promotes formation of
effective in controlling symptoms and
hepatic cysts
ablating the cyst cavity.
• Patients with a small number of cysts or with
o If percutaneous treatment is unavailable
small cysts (<2 cm) usually remain
or ineffective, treatment may include
asymptomatic
either laparoscopic or open surgical cysts
o Asymptomatic: observe only
fenestration.
• In contrast, patients who develop many or
§ If it keeps on coming back or if the
large cysts, with a Cyst:Parenchymal Volume
cyst is too large
Ratio of >1, usually develop clinical symptoms,
§ Leaving the capsule behind
including:
increases the risk for recurrence
o Abdominal pain
o The laparoscopic approach is being used
o Shortness of breath
more frequently and is 90% effective
o Early satiety
o The excised cyst wall is sent for
o These are due to compression of organs
pathologic analysis to rule out carcinoma,
(stomach) around the liver
and the remaining cyst wall must be
• Progressive ADPCLD will result in renal failure
carefully inspected for evidence of
and the need for hemodialysis
neoplastic change.
o If such change is present, complete • In most patients, the liver parenchymal
resection is required, either by volume is preserved despite extensive cystic
enucleation or formal hepatic resection. disease.
• Most common hepatologic complications
2. BILIARY CYSTADENOMA associated with ADPCLD:
• Slow-growing, unusual, benign lesions that 1) Intracystic hemorrhage- bleeding within
most commonly present as large lesions in the the cyst
right lobe of the liver. 2) Infection- due to long-standing fluid
within the cyst
• Although these lesions are usually benign, they
3) Post-traumatic rupture- occurs when
can undergo malignant transformation.
trauma is sustained in the abdomen (he
• Usually presents as abdominal pain
fell down, vehicular accidents)
• An abdominal mass occasionally can be
• Modestly elevated gamma-glutamyltransferase
identified on physical examination.
(GGT) level
• In contrast to simple cyst, biliary cystadenoma
• CT scanning of the abdomen
have walls that appear thicker with soft tissue
• Other conditions that may be associated with
nodules and the cyst’s septations usually
ADPCLD includes:
enhance.
o Cerebral aneurism
• The protein content of the fluid can be variable
o Diverticulosis
and can affect the radiographic images on CT
o Mitral valve prolapse
and MRI.
o Inguinal hernia

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 • Treatment: possibly in the patient with a small (T1 or
o Cyst aspiration and sclerosis may be T2) cholangiocarcinoma
considered if the patient has one or a few
dominant cysts 5. HEMANGIOMA
o Most patients have multiple cysts and do • Also referred to as hemangiomata
not improve when this technique is used • Most common solid benign masses that occur
o The only definitive therapy for patients in the liver
with symptomatic ADPCLD is • They consist of large endothelial lined vascular
ORTHOTOPIC LIVER TRANSPLANTATION spaces
§ Do a liver and at the same time • They are more common in women and occur in
kidney transplant to address the 2 to 20% of the population
renal and hepatic failure. • They can range from small (<1 cm) to giant
o If the patient has renal involvement cavernous hemangioma (10 to 25 cm)
(polycystic kidney disease) with renal • Most common symptom is pain (main
failure, consideration should be given to indication of resection)
combined liver-kidney transplantation o Often occurs with lesions larger than 5 to
6 cm due to the stretching of the walls of
4. CAROLI’S DISEASE the hemangioma
• A syndrome of congenital ductal plate • Spontaneous rupture (bleeding) is rare
malformations often intrahepatic bile ducts o The bigger the hemangioma the higher
o There are cystic dilatations of the bile the spontaneous rupture à bleeding
ducts within the liver o Monitoring is important
• Caution should be exercised in ordering a liver
biopsy if the suspected diagnosis is
hemangiona because of the risk of bleeding


from the biopsy site
o Especially if the lesion is at the edge of
the liver


• CT-scan: asymmetrical nodular enhancement

6. HEPATIC ADENOMA
• Benign solid neoplasm of the liver
picture from google
• Most commonly seen in young woman (aged
• Characterized by segmental cystic dilation
20 years to the forties)
(often intrahepatic)
• Prior or current use of estrogens (oral
• Associated with an increased incidence of
contraceptives) is a clear risk factor for
biliary lithiasis, cholangitis, and biliary abscess
development of liver adenomas
formation.
o If a woman in the OPD came with a solid
• Usually occurs in the absence of cirrhosis and is
nodule in the liver, the first thing to ask is
associated with cystic renal disease
history of OCP use to rule out adenoma
• Most common presenting symptoms including
o Next, ask about any abnormality in any of
fever, chills, and abdominal pain
the other GI organs
o Signs and symptoms of infection due to
• With venous phase contrast, they can look
cholangitis
hypodense or isodense
• Most patients present by the age of 30
• A significant risk of spontaneous rupture with
• Diagnosis: MRCP, ERCP, and percutaneous
intraperitoneal bleeding
transhepatic cholangiography (provides more
• Clinical presentation: abdominal pain, and in
detailed imaging of the biliary tree and confirm
10 to 25% spontaneous intraperitoneal
communication of the intrahepatic cysts with
hemorrhage
the biliary tree, which is necessary to solidify
• Risk of malignant transformation to a well-
the diagnosis)
differentiated HCC.
• Treatment:
o Recommended to be surgically resected.
o Biliary drainage, with ERCP and

percutaneous transhepatic
7. FOCAL NODULAR HYPERPLASIA (FNH)
cholangiography as first-line modalities
• Another solid, benign lesion of the liver
o Liver resection- can be considered in the
patient with hepatic decompensation or • Similar to adenomas, they are more common
unresponsive recurrent cholangitis and in women of childbearing age, although the

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 link to oral contraceptive use is not as clear as o Because ultimately the drainage of the
with adenomas colon will pass through the liver.
• A good quality biphasic CT scan usually is
diagnostic: a typical central scar in the nodule 1. HEPATOCELLULAR CARCINOMA
• They show intense homogeneous • Fifth most common malignancy worldwide
enhancement on arterial phase • Major risk factors:
o Color flow studies: Shows you the o Viral hepatitis (B or C)
pattern of blood supply and allows you to o Cirrhosis
visualize neovascularization that should o Hemochromatosis- uncommon in the
make you suspicious of malignancy Philippines
o Cold nodule: benign • In a person with cirrhosis, the annual
o CT score: it will indicate if the area is conversion rate to HCC is 3-6%
blood filled or fluid filled depending upon • In patients with chronic hepatitis C virus
the score infection, cirrhosis usually is present before the
• The fibrous septa extending from the central HCC develops; however, in cases of hepatitis C
scar are more readily seen with MRI virus infection, HCC tumors can occur before
• If CT or MRI scans do not show the classic the onset of cirrhosis
appearance radionuclide sulfur colloid imaging • HCCs are typically hypervascular with blood
may be used to diagnose FNH based on select supply predominantly from the hepatic artery.
uptake by Kupffer cells o Lesion often appear hypervascular during
• Unlike adenomas they do not rupture the arterial phase of CT studies
spontaneously o Relatively hypodense during the delayed
• No significant risk of malignant transformation phases due to early washout of the
• Main indication for surgical resection is contrast medium by the arterial blood.
abdominal pain • MRI also is effective in characterizing HCC
• Oral contraceptive or estrogen use should be • HCC has a tendency to invade the portal vein,
stopped when either FNH or adenoma is and the presence of an enhancing portal vein
diagnosed thrombus is highly suggestive of HCC
o For the hepatobilliary system, the portal
vein is the limiting structure for the
surgeon. Meaning its involvement will
indicate that, the tumor cannot be
resected anymore
• Treatment:
o Complex and is best managed by a multi
disciplinary liver transplant team
o For patients without cirrhosis who
develop HCC, resection is the treatment
of choice
o For those patients with Child’s class A
cirrhosis with preserved liver function
8. BILE DUCT HAMARTOMA and no portal hypertension, resection is
• Typically small liver lesions (2-4 mm in size), also considered.
visualized on the surface of the liver at o If resection is not possible because of
laparotomy poor liver function and the HCC meets
• They are firm, smooth, and whitish yellow in the Milan criteria (one nodule <5 cm, or
appearance two or three nodules all < 3 cm, no gross
• They can be difficult to differentiate from small vascular invasion or extrahepatic spread),
metastatic lesions, and excisional biopsy often liver transplantation is the treatment of
is required to establish the diagnosis choice
o It is better to freeze the tumor first
MALIGNANT LIVER TUMORS before excising to prevent bleeding
Ø Malignant tumors in the liver can be classified as: o Living-donor liver transplant is also an
o Primary: cancers that originate in the liver or alternative for patients with HCC
o Metastatic: cancers that spread to the liver awaiting transplantation to avoid
from an extrahepatic primary site dropout due to tumor progression
Ø Most common tumor seen in the liver is metastatic
colorectal cancer

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 o There should be negative lines of resection
so you remove the entire thing. If there are
adherent structures you have to go back
and continue to excise until there is
negative margins
o In the absence of associated primary
sclerosing cholangitis (PSC), surgical
resection is the treatment of choice for
hilar cholangiocarcinoma. However,
approximately 10% of patients with
cholangiocarcinoma have PSC
§ Sclerosing cholangitis means that
there is a global narrowing of the bile
ducts because of cholangiocarcinoma
§ Instead of having a dilated bile ducts,
• ALGORITHM FOR THE MANAGEMENT OF HCC what happens is they collapse
because of fibrosis
§ In the presence of this, resection of
the cholangiocarcinoma will not
improve because the liver will go into
decompensation simply because the
bile is not draining due to the close
intrahepatic bile ducts
• Cholangiocarcinoma in the setting of PBS is
frequently multicentric and often is associated
with underlying liver disease, with eventual
cirrhosis and portal hypertension. As a result,
experience has shown that resection of
cholangiocarcinoma in patients with PSC yields
dismal results
− Child’s classification is based from the liver • Because the growth of hilar
function cholangiocarcinoma indicates that this disease
− The challenge in liver transplant is looking spreads in a locoregional manner, a rationale
for a matching donor and the post-op for the use of neoadjuvant chemoradiation was
recovery developed by the transplant team at the
University of Nebraska in the late 1980
2. CHOLANGIOCARCINOMA (BILE DUCT CANCER) o Hilar cholangioCA is harder to manage
• The second most common primary malignancy because it is located in the (take off
within the liver point) of the common hepatic ducts
• Always an incidental finding and usually post-op and very near the intrahepatic ducts
cholecystectomy o Hindi ko naintindihan si take off point
• Sub classified as: pero sabi ni Schwartz about hilar
o Peripheral (intrahepatic) bile duct cancer cholangioCA “it preferentially grows
(in the liver bed) along the length of the bile ducts,
o Central (extrahepatic) bile duct cancer often involving the periductal
(common duct) lymphatics with frequent LN
• A biopsy specimen from the cholangiocarcinoma metastases.”
will show adenocarcinoma but the pathologist is o It typically presents as a stricture of the
often unable to differentiate metastatic proximal hepatic duct causing painless
adenocarcinoma to the liver from true primary jaundice
bile duct adenocarcinoma. Therefore a search o The easier conditions to treat are those
for a primary site should be undertaken located distally since they are the ones
• Treatment: amenable to resection and
o Histologically negative margins, anastomosis.
concomitant hepatic resection, and well-
differentiated tumor histology were
associated with improved outcome after
resection

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 • Factors predictive of poor survival included: 5. NEUROENDOCRINE CANCER (CARCINOID TUMOR)
o Vascular invasion • Tumors usually coming from the GIT
o Histologically positive margins • Hepatic metastases from neuroendocrine
o Multiple tumors tumors have a protracted natural history and
o Absence of mucobilia commonly are associated with debilitating
o Nonpapillary tumor endocrinopathies
o Tumor of advanced stage • Several groups have advocated an aggressive
o Nonhepatectomy surgical approach of cytoreductive surgery
o Lack of postoperative chemotherapy both to control symptoms and to extend
survival
3. GALLBLADDER CANCER o Cytoreductive surgery is done because
• Rare aggressive tumor with a very poor typically there are multiple type of
prognosis metastasis coming from neuroendocrine
• Over 90% of patients have associated tumors
cholelithiasis • There was no difference in survival between
• Diagnosis is found to be made preoperatively patients with carcinoid tumors and those with
in 57%, intraoperatively in 11%, and islet cell tumors
incidentally after cholecystectomy in 32%
• Surgical approaches can be classified into: HEPATIC RESECTION
a) Reoperation for an incidental finding of Ø For primary liver cancers or hepatic metastases,
gallbladder cancer after cholecystectomy hepatic resection is the gold standard and
b) Radical resection in patients with treatment of choice
advanced disease Ø Although there are anecdotal reports of long-
− The results are dismal for radical term survival after ablation and other regional
resection in patients with advanced liver therapies, liver resection remains the only
disease and positive hilar LN. real option for cure
Ø For HCC in the setting of cirrhosis, liver
4. METASTATIC COLORECTAL CANCER transplantation also offers the potential for long-
• Over 50% of patients diagnosed with colorectal term survival, albeit with the consequence of
cancer will develop hepatic metastases during immunosuppression
their lifetime o You delay the progression of the cirrhosis
• The tumors can be in a form of solitary or because you infuse new viable hepatic
multiple nodules tissue
o If the tumor is small, this can be resected o Limiting factor: donor
• Traditional teaching suggested that hepatic Ø Many large series of patients undergoing major
resection for metastatic colorectal cancer to hepatectomy now report mortality rates of <5%
the liver, if technically feasible, should be
performed only for fewer than four
metastases. However, recent studies have
challenged this paradigm
• Many groups now consider volume of future
liver remnant and the health of the
background liver, and not actual tumor
number, as the primary determinants in
selection for an operative approach.
• Resectability is no longer defined by what is
actually removed, but indications for hepatic
resection now center on what will remain after
resection
• Use of neoadjuvant chemotherapy, portal vein
embolization, two-stage hepatectomy,
simultaneous ablation, and resection of
extrahepatic tumor in select patients have
increased the number of patients eligible for a
surgical approach

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