Surgery of Liver Tumours

The only therapeutic option which offers the potential of cure in primary or secondary hepatic neoplasms is surgical resection. This is usually achieved by partial resection although total resection and transplantation has been undertaken. Unfortunately, the results of transplantation have been disappointing. Other surgical measures are rarely employed. These include hepatic artery ligation, which has been largely replaced by radiological embolisation with specific indications, and catheter insertion into the hepatic artery or portal vein for the administration of cytotoxic drugs. This too has given disappointing results. Surgical resection of liver can be performed with low morbidity and mortality today. Success is dependent on the expertise of the surgeon and the hepatologist. Major liver resections should not be undertaken by the occasional hepatic resectionist. Full diagnostic workup, including non-invasive and invasive investigations, is required to provide both a diagnosis and a detailed anatomical route map before surgery. Finally, success is dependent upon the selection of a suitable patient with a favourable pathology. The patient’s general condition must be good to withstand major hepatic surgery. Even limited hepatic resections of single localised lesions in cirrhotic patients are only worthwhile if they have good liver functional reserve. The Chiba group advocate that surgical resection be restricted to Child’s A grade cirrhotic patients1. Tumour encapsulation in small lesions in cirrhotic patients 23 confers a significantly better prognosis ’. The fibrolamellar variant of hepatocellular carcinoma should be sought out as a resection is associated with good prognosis. There is debate whether pre-operative tru-cut needle biopsy should be performed. Most internists believe it to be safe. This is true for deep seated lesions but the author believes that superficial lesions abutting on the surface of the liver should not be biopsied pre-operatively because the biopsy site leaves a weak spot in Glisson’s capsule which may exude tumour during manipulation at the time of hepatic resection. Needle tract recurrences have not been a problem other than in some patients after hepatic transplantation.