The liver

Xu Bing, M.D.
Associate Professor

Department of Surgery
The First Affiliated Hospital of Zhengzhou
University
The liver

Anatomy
General anatomic description

♦ Liver is a solid organ (1.5 Kg) occupies the

right upper quadrant of the abdomen.
♦ Covered by the thoracic cage and
diaphragm.
♦ Its posterior surface straddles the inferior
vena cava (IVC).
The anterior surface of the liver
The posterior and inferior surface of the liver
Blood supply of the liver

♦ Dual blood supply.

♦ About 25% of blood and 30% - 50% of

oxygen are supplied by hepatic artery.

♦ About 75% of blood and 50% to 70% of

oxygen are supplied by portal vein.
Hepatic anatomy is defined by its
vascular structure (eight segments
suggested by Couinaud.
♦ Enumeration of the
segments begins left to
right, beginning with
segment Ⅰ(the caudate
lobe).
♦ Remembered by
clockwise from Ⅰto
Ⅷ.
The liver

Physiology
Physiology of the liverⅠ

The liver is the center of metabolism in the

body. The synthesis, modification, storage,
breakdown and excretion of many of
substances upon which life depends occur in
the liver.
Physiology of the liverⅡ
♦ Bile formation and excretion: Bile is
secreted at a rate of 600 to 1000 ml per day.
♦ Metabolism of carbohydrate, fat, protein,
vitamin A,D,E,K, and hormones etc.
♦ Blood coagulation.
Physiology of the liver Ⅲ
♦ Detoxification: The liver is detoxification
center of the body.
♦ Phagocytosis and immunity: The Kupffer
cells have phagocytosis function and
produce γ- globulin, which is involved in
immune mechanisms.
♦ Liver regeneration.
Infectious liver disease

♦ Pyogenic liver abscess

♦ Amebic liver abscess
♦ Hydatid disease of the liver
Infectious liver disease
♦ Pyogenic liver abscess
Pyogenic liver abscess

♦ CT scan demonstrates
multiloculated hepatic
abscess in the right
liver.
Pyogenic liver abscess

♦ CT scan at the time of

percutaneous drainage.
Surgical exploration and drainage
♦ Needle aspiration to empty the
abscess and to obtain organism
culture.
♦ The abscess wall is incised
with electrocautery and the
contents of the cavity must be
fully aspirated and the
loculations broken down with
the index finger.
♦ The cavity should be washed
with betadine and a soft silastic
drain inserted and secured.
Infectious liver disease
♦ Amebic liver abscess
Amebic liver abscess
♦ CT scan of amebic
abscess (A). The
lesion is peripherally
located and round.
Rim is nonenhancing
but shows preipheral
edema (black arrows).
Note the extension
into the intercostal
space (white arrows).
Infectious liver disease
♦ Hydatid disease
Hydatid disease (Echinococcal cysts)
♦ Ultrasound
demonstrating typical
characteristics of
hydatid cyst (daughter
or granddaughter cysts
and typical rosette
appearance).
Benign liver disease

♦ Cavernous hemangiomas

♦ Cysts of the liver

Benign liver disease
♦ Cavernous hemangiomas
CT scan of a giant cavernous hemangioma
Benign liver disease
♦ Cysts of the liver
Giant (fist-sized) solitary cyst in the
right liver lobe
Polycystic liver disease with several
chambers
Hepatocellular
Carcinoma
(HCC)
Geographical areas with a high risk of HCC
♦ HCC is the most
prevalent malignant
disease in the world,
killing up to 1.25
million persons
annually.
♦ HCC is much more
common in sub-
Saharan Africa, China,
Japan and southeast
Asia.
Etiology

♦ Chronic liver disease of any cause plays an

important role in development of HCC in
any part of the world.

♦ Cirrhosis is an etiological factor and it was

believed that a majority of patients having
HCC of the liver had cirrhosis.
Clinical features Ⅰ
♦ Primary HCC may occur at any age. It is more common in
males by a ratio of 4:1.

♦ Anorexia, loss of weight and strength, and abdominal pain

are the most common symptoms.

♦ The most significant physical abnormality is hepatomegaly,

which is present in approximately three fourths of the
patients. The liver may become tremendously enlarged and
nodularity.
Clinical features Ⅱ
♦ Splenomegaly is observed in one third of patients.

♦ Ascites may develop.

♦ The tumors tend to rupture spontaneously and the

symptoms of intra-abdominal hemorrhage with
the development of shock may be the terminal
episode.
Laboratory findings Ⅰ

♦ The most frequent findings is a rise in the

serum alpha-fetoprotein (AFP).

♦ 75% of patients with HCC arising in

association with HBV cirrhosis had AFP
levels above 200-400ng/ml.
Laboratory findings Ⅱ
♦ AFP may return to normal after successful
surgical resection and is a useful level to
follow.

♦ Markedly elevated AFP levels may also be

found in patient with teratocarcinomas, yolk
sac tumors, and, rarely, hepatic metastatic
carcinomas from the stomach or pancreas and
pregnancy obviously.
Hepatic imaging
♦ Ultrasonography.

♦ Computed Tomography.

♦ Magnetic Resonance Imaging.

♦ Hepatic arteriography.
 Ultrasonography
♦ US is relatively inexpensive and portable, and
detects tumor great than 2cm in diameter.

♦ Shows the size, outline, site and its relationship

with vessel.

♦ Identifies the hepatic vessels, and portal

cancerous embolism.
CT
♦ CT has a wide applications in detection of HCC,
it usually shows the tumor size less than 2 cm.

♦ It may detect small HCC by using contrast

materials.

♦ It is the best method for detecting small and micro

HCC.
MRI
♦ Useful for detecting both primary and tumor
spread.

♦ Useful in distinguishing between small

HCC and small hemangiomas uncovered
during surveillance.
Hepatic arteriography

♦ It is the best modality for detecting the

tumor site.

♦ It may show tumor with 0.5~1.0cm size.

Pathology
♦ Gross appearance.

Nodular type
Massive type
Diffuse type
Gross appearance Ⅰ
♦ Nodular type
♦ <5cm, usually
coexists with
cirrhosis.
Gross appearance Ⅱ
♦ Massive type
♦ > or =5cm, most
common form.
♦ most prone to
rupture.
Gross appearance Ⅲ
♦ Diffuse type
♦ It is rare, may be
difficult to
distinguish from
regenerating
nodules of
cirrhosis.
Small HCC
♦ < 2cm
♦ It is based on the histologic finding and
biological characteristic.
♦ Well differentiated, low grade malignancy.
♦ Usually encapsulated.
♦ Cancer embolism rate is low with relative
good liver function.
Metastasis of HCC
♦ Intrahepatic metastasis.

♦ Extrahepetic metastasis.
Five most common sites of HCC metastasis are:
regional lymph nodes
lung
adrenal glands
bone
peritoneal surface
Diagnosis
♦ Hepatic imaging is a critical part of the diagnosis
of HCC.

♦ AFP measurements can be very helpful in the

diagnosis of HCC.

♦ AFP >200-400 ng/mL, exclude chronic active

liver disease, pregnancy, congenital tumors,
suggesting HCC.
HCC
♦ The treatment of HCC
 The pricinple of treatment of HCC is
early found, early diagnosed and early
treated.
♦ The treatment options for HCC:

Hepatic resection.
Ablative procedures (Alcohol injection;
Cryoablation; Radiofrequency or microwave ablation.)
Transarterial chemoembolization.
Liver transplantation.
Indication for resection of HCC
♦ Single tumor ( especially Small HCC )
without severe cirrhosis and distal
metastasis.
♦ The contraindication includes obvious
jaundice, ascites, edema of lower limb,
distal metastasis, general condition at late
stage and so on.
Hepatic resection
♦ The most effective treatment is surgical removal
of the tumor with an appropriate amount of
surrounding normal liver tissue. But The
recurrence rate after resection is high.
♦ Hepatic resections consist of the removal of a lobe
or segment of the liver.

♦ Major lobectomy.
♦ Segmental resection (Wedge resection).
Several anatomic features pose obstacles
to operations on the liver
♦ The liver is prone to fracture and bleeding with
manipulation.
♦ A dual efferent blood supply is intertwined with
delicate afferent biliary ducts in a crowded hepatic
hilum.
♦ The three hepatic veins empty directedly into
inferior vena cava posterior to the liver and are
obscured unless extensive retrohepatic dissection is
performed.
Control of hepatic blood flow

The most common

technique is the pringle
maneuver.

Intermittent inflow
inclusion with 10 to 20
minutes of clamping
followed by interval
declamping for 2 to 5
minutes.
 Positions and incision of liver operation
♦ Supine positions with the
right arm extended are
preferred,with the
abdomen slightly
overstretched.
♦ Laparotomies are
performed through a
bilateral subcostal and
upper abdominal midline
incision.
Hepatic segmental resection
Right hepatic lobectomy and Left hepatic lobectomy
Right trisegmentectomy and Left trisegmentectomy
Left lateral segmentectomy and Median
liver segment dissection
Five classic major hepatic resections based on
the lobar system of anatomy

♦ Right hepatic lobectomy (Ⅴ Ⅵ Ⅶ Ⅷ)

♦ Left hepatic lobectomy (Ⅱ Ⅲ Ⅳ)
♦ Right trisegmentectomy (Ⅳ Ⅴ Ⅵ Ⅶ Ⅷ)
♦ Left trisegmentectomy (Ⅱ Ⅲ Ⅳ Ⅴ Ⅷ)
♦ Left lateral segmentectomy (Ⅱ Ⅲ )

♦ Median liver segment dissection (Ⅳ)

♦ Isolated hepatic caudate lobectomy (Ⅰ)
Segmental resection (Wedge resection)

♦ Segmental resections are performed for

small lesions near the liver surface that do
not require a full lobectomy.
Alcohol injection
♦ Percutaneous ethanol injection (PEI).
♦ PEI is a useful technique for ablating small
tumors.
♦ Most tumors less than 2 cm can be ablated with
a single application of PEI. But large tumors
may require multiple injections.
♦ It carries the risk of disseminating the tumor.
Cryoablation

♦ Cryoablation uses a specialized cryoprobe to

freeze and thaw tumor and surrounding liver
tissue with resulting necrosis.

♦ This technique is effective at local tumor kill.

Radiofrequency or Microwave Ablation

♦ Radiofrequency ablation (RFA) utilizes

high-frequency alternating current to create
heat around an inserted probe, resulting in
temperatures greater than 60℃ and
immediate cell death.
Transarterial Chemoembolization
♦ Transarterial therapy for HCC is based on the fact that the
majority of the tumor’s blood supply is from the hepatic
artery.
♦ In TACE, a chemotherapy agent of choice (usually
doxorubicin, cisplatin, or mitomycin) is injected in
suspension with iodized oil (lipiodol). Lipiodol has a high
affinity for HCC. The drug is slowly released over a
period of weeks after arterial occlusion.
♦ Patients receiving transarterial chemoembolization may
survival longer than untreated patients.
Liver transplatation
♦ Theoretically, liver transplantation is the ideal
treatment for HCC because it addresses both the
liver dysfunction and the HCC.
♦ Patients with advanced cirrhosis ( Child’s B and C
) and early-stage HCC should be considered for
transplant.
♦ The limitations of transplantation are the need for
chronic immunosuppression as well as the lack of
organ donors.
Prognosis

♦ The prognosis for patients with HCC is

extremely poor. The disease progresses
rapidly, and death occurs, on an average,
within four to six months after the onset of
the first symptom.
Prevention of HCC
♦ The outcome of screening to high risk
population, hepatitis history more than 5
years or HbsAg positive.

Pasteur plasma-derived vaccine (5ug IM at

1, 5, and 9 weeks plus a booster shot at 12
months).
Hepatic metastatic
tumors
Hepatic metastatic tumors Ⅰ
♦ Makes up the largest group of malignant tumors
in the liver.

♦ Bronchogenic carcinoma is the most common

primary lesion causing hepatic metastases.
♦ Next in order of frequency are primary tumors in
the prostate, colon, breast, pancreas, stomach,
kidney, and cervix.
Hepatic metastatic tumors Ⅱ

♦ The most common symptoms of

hepatic metastatic disease are pain,
ascites, jaundice, palpable mass,
weight loss, anorexia, fever, and vague
gastrointestinal complaints.
 Hepatic metastatic tumors Ⅲ
♦ Liver metastases from tumors that do not drain into the
portal vein ( breast, lung, melanoma, etc.) are not resected
because of the probability of systemic metastasis.

♦ Only colorectal, pancreatic, and carcinoid tumors are likely

to have liver-only metastases.

♦ Only colorectal cancer has been extensively studied and

carried hepatic resection sometimes.
Metastatic tumor

♦ A tumor of the
descending colon
with hepatic
metastases.
Over !