Liver Resection in a Case of Cavernous Hemangioma

Liver Resection in a case of Cavernous Hemangioma

1. 1 BY UNIT 3 RESIDENTS UNDER THE GUIDANCE OF- DR. PRABHAT B NIHCKAODE (PROFESSOR & HOU) DEPARTMENT OF GENERAL SURGERY TOPIC- LIVER RESECTION PROBLEM BASED LEARNING

2. CASE HISTORY 46 year old male came to OPD with complaints of – Pain in upper right side of abdomen since 3 months 2

3. HISTORY OF PRESENTING ILLNESS Patient was apparently alright 3 months back when he started getting dull aching Pain in right Upper Abdomen , radiating to back on right side, aggravated with intake of food and relieved on lying down. No history of nausea , vomiting , fever. No history of bowel irregularities. No history of jaundice. No history of similar complaints in past. No history of trauma to abdomen. 3

4. PAST HISTORY Not a known case of Diabetes mellitus, hypertension . No past surgical history PERSONAL HISTORY Mixed diet Normal appetite and adequate sleep Bowel and bladder habits are regular and no complaints. Denies history of any addictions 4

5. GENERAL EXAMINATION Afebrile Pulse-100/min Blood Pressure-140/90 mm hg Icterus / cyanosis / pallor/ - absent SYSTEMIC EXAMINATION Per Abdomen- Soft, non distended Tenderness was present in Epigastrium , Right iliac fossa No organomegaly No palpable lump Bowel sounds present in all quadrants Rest of the systemic examination was within normal limits Per Rectal Examination- NAD 5

6. INVESTIGATIONS HB- 14.2 WBC- 9800 PLATELETS- 297000 LFT- TOTAL BILIRUBIN- 0.63 CONJUGATED – 0.25 UNCONJUGATED – 0.38 ALP- 81 Alpha fetoprotein – 34.4 (Normal) CA-19.9 – 2.21 (Normal) CEA- 1.61 (Normal) PT- 11.7 INR – 1.01 6 Sr. Creatinine – 0.91 Sr. Urea- 21

7. USG (ABDOMEN & PELVIS) Liver is 12.5 cm in size & Liver shows mildly coarse echotexture. Left Lobe of the Liver, along its postero -inferior region shows an oval heterogenous hyperechoic mass lesion, measuring around 7x5x3 cm, No obvious e/o focal cystic lesion seen. IHBR are not dilated at present. Hepatic Veins are not dilated. Impressiom - space-occupying lesion pf liver possibility of the atypical hepatic hemangioma / ? Neoplastic etiology. 7

8. CECT (ABDOMEN & PELVIS) Liver is normal in size, attenuation and enhancement. Intrahepatic biliary radicals are not dilated. A well-defined irregularly marginated hypo-to- isodense lesion measuring 42 x 38 x 34 mm (AP & TR x CC) is noted in the segment II of liver. The lesion shows no enhancement in arterial phase with progressive and heterogeneous enhancement in delayed phase. The lesion is seen to cause mass effect in the form of mild compression of the left branch of portal vein. 8

9. Gall bladder is distended and appears normal. No obvious radiodense calculus or mass lesion is seen. No obvious wall thickening or pericholecystic collection is seen. Common bile duct (CBD) is not dilated. Findings- Atypical Hepatic hemangioma. ? Neoplastic Etiology 9

10. MRI (ABDOMEN & PELVIS) A well-defined, lobulated & irregularly marginated, exophytic altered signal intensity lesion measuring 4.4 x 3.3 x 6.6 cm (CC x AP x TR) in its maximum dimensions is noted in left lobe of liver predominantly involving posterior aspect of segment II. It abuts lesser curvature of stomach and caudate lobe with fairly maintained fat planes. 10

11. The lesion exhibits slightly low signal on T1, heterogenous high signal on T2/STIR, patchy areas of restricted diffusion, patchy blooming on GRE images indicating areas of hemorrhage/hemosiderin deposition and no loss of signal in out of phase images. The lesion is hypovascular and shows heterogenous delayed filling in of contrast material with few non-enhancing areas within. Findings likely suggestive of fibrolamellar Hepatocellular Carcinoma. 11

12. After careful assessment ,patient was posted for left hepatectomy with Fibrolamellar hepatocellular carcinoma as diagnosis . Patient underwent left hepatectomy on 29 th December 2023 12

13. INTRAOPERATIVE FINDINGS Midline laparotomy incision taken Liver visualised- right lobe normal Left lobe – segments II & III showed an exophytic mass No evidence of metastasis in peritoneum or any other organ Left lobe of liver mobilized by cutting the triangular ligament upto left hepatic vein 13 Hilum dissected by lowering the hilar plate

14. Left branches of portal vein and hepatic artery identified and looped Left hepatic vein ligated and cut along with left branch of portal vein Line of demarcation seen lateral to segment IV segments II , III & IV dissected and left Hepatectomy done Cholecystectomy done Hemostasis achieved No bile leak comfirmed Abdomen closed in layers 14

15. INTRAOP IMAGES 15

16. AFTER COMPLETEION OF LEFT HEPATECTOMY (SEGMENT II , III & IV ) 16 Raw surface of Right lobe of Liver

17. EXCISED SPECIMEN 17 Cavernous Hemangioma

18. 18 Cavernous Hemangioma

19. POST OPERATIVE PERIOD Patient tolerated the procedure well and was kept in SICU for 4 days for observation and then was shifted back to general ward on POD 5. Input output monitoring was done abdominal drain output charting was done and patient was started on diet was started for the patient on POD 4. Abdominal drain was removed on POD 10 when the output was consistently less than 10ml for 4 consecutive days. Patients sutures were removed on POD 12 following which patient was discharged on POD 13. 19

20. PROBLEMS FACED IN THE CASE Due to confusing impression on all investigations- Biochemical tests- all values were within normal range. Alpha fetoprotein-normal USG (A+P)-suggested- space occupying lesion in liver. CECT(A+P)-suggested- atypical hemangioma in segment II of left lobe of liver. MRI (A+P)-suggested-exophytic growth in segment II of liver with possibility of HCC (fibrolamellar type) 20 DIAGNOSTIC DELIMA

21. SPECIFIC LEARNING OBJECTIVES AT THE END OF THIS DISCUSSION ONE MUST LEARN – 21

22. DISCUSSION Liver is solid gastrointestinal organ mass 1200-1600 g Occupies the right upper quadrant of the abdomen. The costal margin coincides with the lower margin and the superior surface is draped over by the diaphragm. Most of the right liver and most of the left liver is covered by the thoracic cage. The liver extends superiorly to the height of the fifth rib on the right and the sixth rib on the left. 22 Anatomy of Liver

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24. 24 SEGMENTS OF LIVER Couinaud classification – Divides the liver into eight functionally indepedent segments Each segment has its own vascular inflow, outflow and biliary drainage. Middle hepatic vein divides the liver into right and left lobes (or right and left hemiliver ). This plane runs from the inferior vena cava to the gallbladder fossa. Left hepatic vein divides the left lobe into a medial and lateral part. Portal vein – divides the liver into upper and lower segments. – The left and right portal veins branch superiorly and inferiorly to project into the center of each segment.

25. PERITONEAL REFLECTIONS OVER THE LIVER Coronary Ligament- diaphragmatic peritoneal duplications are referred to as the coronary ligament , Right & Left triangular Ligament- lateral margins on either side Bare area of Liver on the Rt. Of IVC Portal vein Hepatic Artery & Bile duct enters the hilum of the liver on its undersurface & these structures are invested in connective tissue that is called as Hilar Plate. 25

26. BLOOD SUPPLY OF LIVER Liver like lungs has dual blood supply. The hepatic portal vein brings 75-80% blood to liver. Portal vein contains 40% oxygen than blood returning to the heart from systemic circuit The hepatic portal vein contains virtually all nutrients absorbed from the alimentary tract to the liver with the exception of lipids which is absorbed through the hepatic artery. 26

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29. LIGAMENTS OF LIVER 29

30. PERITONEAL ATTACHMENTS OF LIVER 30

31. SURGICAL SIGNIFICANCE OF LIGAMENTUM TERES Small para umbilical veins from the portal system to the umbilicus run with the ligamentum Teres Used as a guide to left side of liver Runs through the fissure between Seg3 and 4 to LPV which may be covered by parenchyma The Seg 3 bile duct usually joins the LHD immediately behind and superior to its entry to LPV Used as a guide for doing Seg 3 bypass 31

32. The two layers fan out on the liver surface to blend with peritoneum covering the liver Relatively avascular Posterior most portion of the ligament separates to form the anterior layer of right and left Coronary ligaments The Triangle formed on the posterior part has the common trunk of MHV-LHV as the base A depression of liver tissue in front of IVC on right side contains RHV Falciform artery-originating from middle or left HA runs obliquely forwards towards midline Communicates with superior snd inferior branches of epigastric artery Important in chemoembolization -may lead to cutaneous necrosis in the umbilical region 32

33. CORONARY AND TRIANGULAR LIGAMENTS Coronary ligament attaches the posterior surface of the liver to diaphragm Mainly seen on the right side- a superior leaf running caudally and to the right joining the inferior leaf -forming Right Triangular ligament at the edge of right lobe Inferior leaf passes back and runs behind the IVC to eventually take part in the formation of lesser omentum "Bare area of the liver" bounded by the ligaments and liver is directly in contact with diaphragm IVC and entry of hepatic veins are seen within the bare area For mobilisation of liver these ligaments has to be divided 33

34. THE HILAR PLATE Half cylinder open towards the base Bounded above by segment 4, on the right by the Rouviere's sulcus and cystic plate and on the left continuous with the umbilical plate Anterior Glisson's sheath runs behind the cystic plate and the hilar plate and the posterior Glisson's sheath behind the Rouviere's sulcus The bile ducts and vessels of right side can be easily dissected without widely opening the hilar plate 34

35. A layer of connective tissue that surrounds and accompanies the main liver vessels and bile ducts, separating them from the liver parenchyma "The Plate" is in fact a tube that surgical dissection can transform into a plate 35

36. Lowering of Hilar plate At the hilum the connective tissue is loose and it is possible to separate the PV,HA and BD Beyond the point of bifurcation they are covered by Glissonian sheath and inseparable Helpful in exposing extra hepatic segment of LHD Important for the identification of the LHD during bile duct repair following injury or a palliative LHD to jejunal anastomosis En bloc resection of hilar duct confluence with hilar plate combined with liver resection including Seg 1 is the treatment of hilar cholangio carcinoma 36

37. CYSTIC PLATE 37 Located in the GB bed and is continuous with capsule of Seg 5 and Seg 4b and Glisson's sheath of Right anterior segment. Posterior edge lies above the candies line in the hilar area. In more than 83% posterior edge of the cystic plate is located on the right side of the right portal vein branch

38. UMIBICAL PLATE Located along the inferior edge of the ventral surface of the umbilical fissure Contains the ducts and blood vessels of S2 S3 and S4 Continuous with the round ligament inferiorly At the level of umbilical plate - can distinguish three concentric planes • The upper margin of the umbilical plate can be reached by incising the superior border of round ligament 38

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40. HEPATIC HEMANGIOMA Hepatic hemangiomas are also termed cavernous hemangiomas and account for approximately 70% off all solid benign liver tumors Cavernous hemangiomas have a female predilection, with a female-to-male ratio of 5:1, and are most frequently detected in middle-aged women. They are usually small (<5 cm). Lesions that are larger than 10 cm are termed as giant hemangiomas. Hemangiomas are often solitary, multiple lesions may be present in up to 40% of patients Hemangiomas appear as dark purple, soft, and compressible lesions that are well demarcated and surrounded by a thin capsule 40

41. 41 They arise from endothelial cells that build multiple vascular channels, supported by fibrous septa, resulting in cavernous vascular spaces lined by endothelium and separated by connective tissue. They obtain their blood supply mainly from the hepatic artery and lack biliary or portal structures. typically asymptomatic hepatic lesions that are incidentally discovered at laparotomy, autopsy, or during routine imaging studies for unrelated reasons.

42. PRESENTATION- ASYMPTOMATIC – mostly IF SYMPTOMATIC- Pain in right upper abdomen Decreased appetite Early satiation Nausea , vomitiitng Post prandial bloating 42

43. INVESTIGATIONS BIOCHEMICAL BLOOD INVESTIGATIONS- CBC LFT RFT PT / INR SEROLOGY MARKERS FOR LIVER PATHOLOGY- Alpha-fetoprotein (AFP)- is a protein normally produced by the developing fetus. Elevated levels of AFP in adults can indicate liver cancer, although it can also be elevated in other conditions such as cirrhosis and hepatitis. CarcinoEmbryonic Antigen ( CEA) -is a protein that is elevated in various types of cancer, including liver cancer. Elevated CEA levels may indicate the presence of liver cancer, although it is not specific to liver cancer and can be elevated in other types of cancer as well. 43

44. Cancer antigen 19-9 (CA 19-9 ) -is a tumor marker that is commonly associated with pancreatic cancer, but elevated levels can also be found in liver cancer and other gastrointestinal cancers Glypican-3 (GPC3)- GPC3 is a protein that is highly expressed in liver cancer cells, particularly in HCC. It can be used as a tumor marker for liver cancer, especially in combination with other markers such as AFP  Des-gamma-carboxy prothrombin (DCP) or protein induced by vitamin K absence or antagonist-II (PIVKA-II): DCP or PIVKA- ll is a protein that is produced by liver cancer cells. Elevated levels of DCP are associated with liver cancer, particularly in cases of hepatocellular carcinoma (HCC). 44

45. IMAGING USG(Abdomen & Pelvis) MRI ( Abomen & Pelvis) CECT (Abdomen & Pelvis) triple phase Arterial phase- In the arterial phase hypervascular tumors will enhance via the hepatic artery, when normal liver parenchyma does not yet enhances, because contrast is not yet in the portal venous system. These hypervascular tumors will be visible as hyperdense lesions in a relatively hypodense liver. However when the surrounding liver parenchyma starts to enhance in the portal venous phase, these hypervascular lesion may become obscured 45

46. Portal Venous phase- In the portal venous phase hypovascular tumors are detected, when the normal liver parenchyma enhances maximally. These hypovascular tumors will be visible as hypodense lesions in a relatively hyperdense liver Equilibrium phase In the equilibrium phase at about 10 minutes after contrast injection, tumors become visible, that either loose their contrast slower than normal liver, or wash out their contrast faster than normal liver parenchyma. These lesions will become either relatively hyperdense or hypodense to the normal liver. 46

47. BLOOD POOL AND HEMANGIOMA  Normally when we look at lesions filling with contrast, the density of these lesions is always compared to the density of the liver parenchyma. In hemangiomas one should not compare the density of the lesion to the liver, but to the blood pool. This means that the areas of enhancement in a hemangioma should match the attenuation of the appropriate vessels ( bloodpool ) at all times. So in the arterial phase the enhancing parts of the lesion must have almost the same attenuation value as the enhancing aorta, while in the portal venous phase it must match the enhancement of the portal vein If it does not match the bloodpool in every single phase of contrast enhancement forget the diagnosis of a hemangioma. 47

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50. 50 CAPILLARY HEMANGIOMA Known as fast flow haemangioma . Accounts for 16% of all haemangiomas.42% are under 1cm in diameter. USG: Most often hypoechoic and homogenous(due to predominant fibrous stroma and fast flow). CT : Slightly hpodense in NECT. An early ,intense, homogenous contrast is observed by flash similar to the aortic enhancement in arterial phase.Late,this enhancement follows that of the aorta,without washing. MRI: Homogenous and high intensity signals on T2WI images as well as a contrast kinetics similar to that seen in CT.

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52. Most common sub-type and corresponds to classic description of haemangioma in imaging. Consists of large vascular spaces with a central cavernous zone. In general ,This typical appearance is observed in lesions less than 3cm in diameter. 52 CAVERNOUS HEMANGIOMA

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54. Degeneration with an extensive fibrosis, beginning at the centre of the lesion, at the origin of the obliteration of vascular spaces.Also called thrombosed or hyalinsed haemangioma . USG: Heterogenous lesion with hypoechoic zones that may correspond to sclerotic zone in histology. CT: Focal patches are observed that are more spontaneously hypodense than rest of the lesion,also corresponding to sclerotic zones. MRI:T2W heterogenous signal with central hypointense zone is seen. Enhancement pattern is slow with a peripheral nodular enhancement,similar to cavernous haemangioma . 54 SCLEROSED HEMANGIOMA

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56. TREATMENT 56

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58. HEPATECTOMY 58

59. 59 Functional surgical anatomy Couinaud segments  Understanding the internal anatomy of the liver is essential to performing hepatic resections and, in particular, parenchymal-preserving resections. the three main hepatic veins separate the liver into four sectors, 7 segments, each of which is fed by a portal pedicle that includes a branch of the hepatic artery, portal vein and bile duct. The right and left hemilivers are divided by the main portal scissura , which contains the middle hepatic vein. 

60. Segment II makes up the left posterior angle, whereas segment III constitutes the left anterior angle of the liver. The left lateral sector encompasses segment II and III, whereas the left paramedian sector is made up of segment IV. Removal of the left liver along the main portal fissure entails ligation and transection of the left portal pedicle,LHV , and left-sided tributaries of the MHV. 60 LEFT HEMILIVER (SEGMENTS II, III, IV)

61. The caudate lobe is usually not included when performing a left hepatectomy The left posterior dissection, dividing the left liver from segment I, is limited by the sulcus of Arantius . Approximately 40% of the functional liver mass is represented by the left hemiliver The hilar plate is identified and dissected, ligating and transecting any branches to segment IV. The left portal pedicle is encircled and tied, providing a vascular demarcation of the territory to be resected along the main portal fissure. The left hemiliver is mobilized by transecting its ligaments. As dissection is carried out through the liver parenchyma toward the LHV, collaterals are tied or clipped. A venous branch from segment IV may be encountered posteriorly. The LHV is identified, tied, and transected. 61

62. INDICATIONS OF HEPATECTOMY 62 BENIGN LIVER TUMOURS BENIGN CONDITIONS HEMANGIOMA INTAHEPATIC STONES ADENOMA RECURRENT PYOGENIC CHOLANGITIS CYSTADENOMA CAROLI’S DISEASE MALIGNANT LIVER TUMOURS HYDATID CYST HCC LIVER CYSTS CHOLANGIOCARCINOMA LIVER TRAUMA METASTASIS LIVING DONOR LIVER TRANSPLANTATION CARCINOMA GALL BLADDER

63. PREOPEARTIVE PREPARATION chest physiotherapy, deep breathing exercises, incentive spirometry parenteral or enteral hyperalimentation with high protein content bowel preparation Jaundiced patients are hydrated well with intravenous crystalloids over a period of 2–3 days Prothrombin time is corrected using vitamin K injections A broadspectrum parenteral antibiotic regimen is started on the day of operation, before the patient is shifted to the operating room 63

64. OPERATIVE PROCEDURE The patient should be positioned supine with the right arm extended at a right angle to the body. draping should expose the lower chest up to the nipple line and the entire upper abdomen to below the umbilicus INCISIONS: Bilateral subcostal incision. The midline incision should include excision of the xiphoid process. A J-shaped incision (popularized by M. Makuuchi) facilitates exposure of segments VII, VIII, or the bulky tumor involving the right diaphragm. When the abdomen is opened, the entire peritoneal cavity should be explored. In particular, the structures occupying the free edge of the lesser omentum , lymph nodes related to the hepatic artery and the celiac axis, and supraduodenal nodes should be assessed. 64

65. 65 The ligamentum teres is secured, and division of the falciform ligament is begun. The falciform ligament is divided backward to expose the suprahepatic IVC. Suprahepatic exposure of the major hepatic veins and IVC after division of the upper falciform ligament.

66. 66 Inflow control Pringle Maneuver – Occlusion of the portal triad can be performed prior to the transection of the parenchyma to decrease blood loss. The liver can tolerate up to 1 hour of ischemia but intermittent vascular occlusion with cycles of 15 to 20 minutes on and 5 minutes off will decrease the ischemia/reperfusion injury. Total ischemic time should not exceed 120 minutes. An alternative technique for inflow control includes ligation of the right portal pedicle intrahepatically , either prior to or after transection of the parenchyma.

67. In the Glissonian technique, the pedicle to the right liver is controlled prior to the transection of the parenchyma with two incisions: one incision is made at the left base of the gallbladder fossa just above the hilum and another is made at the junction of segment VII and the caudate process. This second incision is perpendicular to the hilum. A large curved clamp is passed above and behind the right hilar pedicle to emerge in front of the IVC. An umbilical tape encircling the pedicle is drawn to the left and the pedicle is transected with a vascular stapler. 67

68. 68 Outflow control The major danger in controlling hepatic venous outflow is the risk of hemorrhage. Intrahepatic control of the hepatic veins during parenchymal transection is feasible and acceptable for tumors that allow clearance superiorly with adequate tumor margins and with safe intrahepatic access to these vessels. Extrahepatic dissection and control of the major hepatic veins is possible in almost all cases. Extrahepatic venous control necessitates two essential requisites that are applicable for all hepatic resections: (1) maintainence of low CVP below 5 mm Hg and (2) precise extra- hepatic dissection of the major hepatic veins. Dissection should be performed with the patient in a 15 degree Trendelenburg position to minimize the risk of air embolism.

69. 69 Parenchymal Transection Simple crushing technique. The Glisson capsule is scored with diathermy along the line of proposed transection, and a Kelly clamp is used to crush the liver tissue and expose small vessels, biliary channels, and larger pedicles; once exposed, these structures can be secured and divided by using a variety of techniques.The most simple and economic method is to use clips and suture ligation. However, a variety of devices can be used, including computer- controlled bipolar cautery (LigaSure; Valleylab, Boulder, CO), a saline-linked radiofrequency ablation monopolar device (TissueLink;TissueLink Medical, Dover, NH) or bipolar variation (Aquamantys,TissueLink Medical), or a Harmonic Scalpel (SonoSurg; Olympus Key Med, New York). Surgicel or fibrin sealants also may be applied to the cut surface of the liver to achieve final hemostasis after transection is complete.

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71. Softer parenchymal tissue is crushed between surgical clamps to expose more significant vessels, which can be ligated by any variety of method according to their size. This method is quick, cost-effective and remains a reference point from which all other techniques are compared. 71 Finger Fracture or Clamp Crushing

72. Uses a pressurized jet of water to fragment the liver tissue and expose the vascular and ductal structures. This is combined with a suction device which clears the surgical field of blood and hepatocytes. The capsule is incised with a diathermy and the water jet is applied on the liver parenchyma, rapidly moving it along the dissection line. 72 Water jet transection

73. The Cavitron Ultrasonic Surgical Aspirator (CUSA, TycoHealthcare ) is currently the preferred method of parenchymal dissection The device combines ultrasonic energy with continuous suction to disrupt and aspirate susceptible tissue, exposing structures greater than 2 mm for individual control 73 Cavitorn Ultrasonic Surgical Aspirator CUSA

74. The use of energy sealing devices improves surgical results and avoids hepatectomy-related complications. Adequate use of vessel sealers is necessary for safe and rapid completion of hepatic resection. 74 Transection using vessel sealing device The heat generated from the bipolar energy causes the fusion of collagen and elastin in the walls of the vessel with the creation of a permanent sealed zone. An acoustic signal informs the surgeon when the vessel is sealed and it can be divided

75. Vascular staplers make this task safer and faster. It can also be used to divide the liver parenchyma. Care should be taken while applying the vascular stapler at the inflow especially in large tumors close to the confluence. If not applied with care there is a risk of narrowing or occluding the hepatic duct confluence. With staplers there is an increased risk of bile leak because the staples are not very effective in sealing small bile ducts. 75 Vascular stapplers

76. 76 COMPLICATIONS Liver Failure after liver resection is the most critical complication that results in mortality, and several criteria have been proposed to predict it in an early stage. If hyperbilirubinemia or refractory ascites (suggesting liver failure) develops, intensive care should be started, including plasma exchange. However, no effective treatments other than liver transplantation have been established for post- operative liver failure. Thus prevention is extremely important. The liver volume remnant should be kept suitable for a patient’s liver functional reserve. In addition, any other potential causes of liver failure should be avoided, such as excessive blood loss followed by excessive RBC transfusion, bile leakage, sepsis, and hypovolemia.

77. 77 Bile Leakage Remains a major complication (6%-11%). In most cases, postoperative bile leakage will subside with conservative treatments; however, major bile leakage can cause critical liver failure. Postoperative bleeding Approximately 1%, with bleeding occurring within 48 hours after surgery in most cases. Conservative therapies, including transfusion, are the first choice; however, spontaneous hemostasis can be difficult to achieve because of the associated bleeding tendency through thrombocytopenia and decrease in coagulation factors. In such cases, emergent reoperation for hemostasis should be considered.

78. 78 Refractory ascites Most common postoperative complications (5% to 56%) and can lead to liver failure when large amounts of plasma are continuously lost in ascitic fluid. To prevent refractory ascites, the perioperative use of diuretic agents is recommended. Spironolactone, is regarded as the first choic . Surgical site infection Is a common complication after abdominal surgery. Its incidence after liver resection, which is classified as a semiclean surgery is about 5% to 15%. However, sepsis as a result of infection can cause liver failure, even in cirrhotic cases associated with potential immune insufficiency. The use of antibiotics is an essential component of perioperative management to prevent infection.

79. 79 Peptic Ulcer - To prevent postoperative peptic ulcers, the routine administration of proton pump inhibitors or histamine-2 receptor blockers is recommended, since liver cirrhosis itself is associated with a high risk of peptic ulcers, and this risk could be increased by perioperative mental and physical stress. If a peptic ulcer is observed before surgery, the liver resection should be postponed until a healing stage of the peptic ulcer can be confirmed by endoscopy.

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81. Blumgart LH, Belghiti J. Surgery of the liver, biliary tract, and pancreas. 4th ed. Philadelphia, PA: Saunders Elsevier, 2007. Couinaud C. Liver anatomy: portal (and suprahepatic ) or biliary segmentation.  Dig Surg . 1999;16:459-467 Gold JS, Are C, Kornprat P, et al. Increased use of parenchymal-sparing surgery for bilateral liver metastases from colorectal cancer is associated with improved mortality without change in oncologic outcome: trends in treatment over time in 440 patients.  Ann Surg . 2008;247:109-117 [ Sarpel U, Bonavia AS, Grucela A, Roayaie S, Schwartz ME, Labow DM. Does anatomic versus nonanatomic resection affect recurrence and survival in patients undergoing surgery for colorectal liver metastasis?  Ann Surg Oncol . 2009;16:379-384 Man K, Fan ST, Ng IO, Lo CM, Liu CL, Wong J. Prospective evaluation of Pringle maneuver in hepatectomy for liver tumors by a randomized study.  Ann Surg . 1997;226:704-711, discussion 711-713 Fan ST, Lai EC, Lo CM, Chu KM, Liu CL, Wong J. Hepatectomy with an ultrasonic dissector for hepatocellular carcinoma.  Br J Surg . 1996;83:117-120   Schemmer P, Bruns H, Weitz J, Schmidt J, Büchler MW. Liver transection using vascular stapler: a review.  HPB (Oxford) . 2008;10:249-252  81

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