- Similar to standard Liver resection
- See: Operating on a patient with cirrhosis
- Important aspects
- Preoperative assessment
- Liver function assessment: Child-Pugh Score and MELD Score scores to stratify surgical risk
- Indocyanine green (ICG) clearance or other dynamic liver function tests for precise reserve estimation
- Imaging: multiphase CT or MRI to define tumour and remnant liver volume
- Future liver remnant (FLR) assessment: must be ≥40% in cirrhotic liver
- Portal hypertension: signs such as splenomegaly, varices, or thrombocytopenia increase surgical risk
- Optimisation before surgery
- Treat ascites, encephalopathy, and coagulopathy preoperatively
- Consider varicele bleeding risk
- Consider portal vein embolisation if FLR is inadequate
- Nutritional support and abstinence from alcohol
- Surgical approach
- Prefer minor resection (non-anatomical wedge or segmentectomy) when possible
- If major resection is necessary, ensure adequate FLR and absence of significant portal hypertension
- Use intraoperative ultrasound to delineate tumour and guide transection plane
- Low central venous pressure (CVP) anaesthesia to reduce bleeding
- Careful mobilisation to avoid capsular tears in fragile liver
- Parenchymal transection as per Liver resection
- Avoid excessive use of Pringle manoeuvre in cirrhotics due to limited ischemic tolerance
- Postoperative care
- Close monitoring in HDU or ICU setting
- Monitor liver function, coagulation, and early signs of liver failure
- Early mobilisation and prevention of infections
- Avoid hepatotoxic drugs, maintain normovolaemia
- Manage ascites and encephalopathy supportively if they occur
- Complications
- Liver failure, ascites, infection, bile leak, coagulopathy
- Risk increases with Child-Pugh B or C, high MELD, and low FLR