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Overview of hepatic resection

Steven A Curley, MD, FACS
Evan S Glazer, MD, PhD, MPH
Section Editor
Stanley W Ashley, MD
Deputy Editor
Wenliang Chen, MD, PhD


Hepatic (liver) resection is needed to manage many types of pathology, malignant and benign. Planning hepatic resection needs to take into account the nature of the lesion and its location within the liver, the patient's anatomy, and the quality and volume of the liver tissue that will remain after resection. Perioperative outcomes for hepatic resection have improved due to better surgical techniques that take advantage of the segmental anatomy of the liver, improved techniques for control of bleeding, and improved intensive care. Hepatic resection that is performed in high-volume centers by specially trained hepatobiliary surgeons is associated with better outcomes [1-3].

Surgical resection of the liver and complications of liver resection will be reviewed here. Specific management of pathologies that indicate a need for liver resection and disease-specific outcomes related to liver resection are discussed in separate topic reviews. (See "Surgical management of potentially resectable hepatocellular carcinoma" and "Surgical management of gallbladder cancer" and "Surgical techniques for managing hepatic injury" and "Treatment of localized cholangiocarcinoma: Adjuvant and neoadjuvant therapy and prognosis".)


The liver is divided into two lobar segments (right and left), and further subdivided into eight (Couinaud) segments based upon vascular supply and bile duct distribution (figure 1). The segmental anatomy of the liver is the basis for the various types of anatomic hepatic resections (figure 2). The surgical anatomy of the liver and types of hepatic resection are discussed in detail elsewhere. (See "Hepatic resection techniques", section on 'Surgical anatomy'.)

Liver function and regeneration after resection — The hepatocytes perform a variety of metabolic functions, including:

Removing metabolic waste products, hormones, drugs, and toxins

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Literature review current through: Nov 2017. | This topic last updated: Oct 26, 2017.
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  1. Farges O, Goutte N, Bendersky N, et al. Incidence and risks of liver resection: an all-inclusive French nationwide study. Ann Surg 2012; 256:697.
  2. Fong Y, Gonen M, Rubin D, et al. Long-term survival is superior after resection for cancer in high-volume centers. Ann Surg 2005; 242:540.
  3. Nathan H, Cameron JL, Choti MA, et al. The volume-outcomes effect in hepato-pancreato-biliary surgery: hospital versus surgeon contributions and specificity of the relationship. J Am Coll Surg 2009; 208:528.
  4. Mortensen KE, Revhaug A. Liver regeneration in surgical animal models - a historical perspective and clinical implications. Eur Surg Res 2011; 46:1.
  5. Uda Y, Hirano T, Son G, et al. Angiogenesis is crucial for liver regeneration after partial hepatectomy. Surgery 2013; 153:70.
  6. Schmelzle M, Duhme C, Junger W, et al. CD39 modulates hematopoietic stem cell recruitment and promotes liver regeneration in mice and humans after partial hepatectomy. Ann Surg 2013; 257:693.
  7. Kele PG, de Boer M, van der Jagt EJ, et al. Early hepatic regeneration index and completeness of regeneration at 6 months after partial hepatectomy. Br J Surg 2012; 99:1113.
  8. Truant S, Bouras AF, Petrovai G, et al. Volumetric gain of the liver after major hepatectomy in obese patients: a case-matched study in 84 patients. Ann Surg 2013; 258:696.
  9. Bruix J, Sherman M, Practice Guidelines Committee, American Association for the Study of Liver Diseases. Management of hepatocellular carcinoma. Hepatology 2005; 42:1208.
  10. Colli JL, Colli A. International comparisons of prostate cancer mortality rates with dietary practices and sunlight levels. Urol Oncol 2006; 24:184.
  11. Kobayashi M, Ikeda K, Hosaka T, et al. Dysplastic nodules frequently develop into hepatocellular carcinoma in patients with chronic viral hepatitis and cirrhosis. Cancer 2006; 106:636.
  12. Clavien PA, Petrowsky H, DeOliveira ML, Graf R. Strategies for safer liver surgery and partial liver transplantation. N Engl J Med 2007; 356:1545.
  13. Schwartz M, Roayaie S, Konstadoulakis M. Strategies for the management of hepatocellular carcinoma. Nat Clin Pract Oncol 2007; 4:424.
  14. Balzan S, Belghiti J, Farges O, et al. The "50-50 criteria" on postoperative day 5: an accurate predictor of liver failure and death after hepatectomy. Ann Surg 2005; 242:824.
  15. Adam R, Chiche L, Aloia T, et al. Hepatic resection for noncolorectal nonendocrine liver metastases: analysis of 1,452 patients and development of a prognostic model. Ann Surg 2006; 244:524.
  16. Reddy SK, Barbas AS, Marroquin CE, et al. Resection of noncolorectal nonneuroendocrine liver metastases: a comparative analysis. J Am Coll Surg 2007; 204:372.
  17. Simons JP, Ng SC, Hill JS, et al. In-hospital mortality for liver resection for metastases: a simple risk score. J Surg Res 2009; 156:21.
  18. Simmonds PC, Primrose JN, Colquitt JL, et al. Surgical resection of hepatic metastases from colorectal cancer: a systematic review of published studies. Br J Cancer 2006; 94:982.
  19. Frankel TL, D'Angelica MI. Hepatic resection for colorectal metastases. J Surg Oncol 2014; 109:2.
  20. Liu DM, Kennedy A, Turner D, et al. Minimally invasive techniques in management of hepatic neuroendocrine metastatic disease. Am J Clin Oncol 2009; 32:200.
  21. Tan MC, Jarnagin WR. Surgical management of non-colorectal hepatic metastasis. J Surg Oncol 2014; 109:8.
  22. Groeschl RT, Nachmany I, Steel JL, et al. Hepatectomy for noncolorectal non-neuroendocrine metastatic cancer: a multi-institutional analysis. J Am Coll Surg 2012; 214:769.
  23. Andreou A, Brouquet A, Bharathy KG, et al. Liver resection for liver metastases from nondigestive endocrine cancer: extrahepatic disease burden defines outcome. Surgery 2012; 151:851.
  24. Ryu SW, Saw R, Scolyer RA, et al. Liver resection for metastatic melanoma: equivalent survival for cutaneous and ocular primaries. J Surg Oncol 2013; 108:129.
  25. Charny CK, Jarnagin WR, Schwartz LH, et al. Management of 155 patients with benign liver tumours. Br J Surg 2001; 88:808.
  26. Bonney GK, Gomez D, Al-Mukhtar A, et al. Indication for treatment and long-term outcome of focal nodular hyperplasia. HPB (Oxford) 2007; 9:368.
  27. Cho SW, Marsh JW, Steel J, et al. Surgical management of hepatocellular adenoma: take it or leave it? Ann Surg Oncol 2008; 15:2795.
  28. Terkivatan T, de Wilt JH, de Man RA, et al. Indications and long-term outcome of treatment for benign hepatic tumors: a critical appraisal. Arch Surg 2001; 136:1033.
  29. Pulitanò C, Aldrighetti L. The current role of laparoscopic liver resection for the treatment of liver tumors. Nat Clin Pract Gastroenterol Hepatol 2008; 5:648.
  30. Chen SC, Tsai SJ, Chen CH, et al. Predictors of mortality in patients with pyogenic liver abscess. Neth J Med 2008; 66:196.
  31. Johannsen EC, Sifri CD, Madoff LC. Pyogenic liver abscesses. Infect Dis Clin North Am 2000; 14:547.
  32. Hsieh HF, Chen TW, Yu CY, et al. Aggressive hepatic resection for patients with pyogenic liver abscess and APACHE II score > or =15. Am J Surg 2008; 196:346.
  33. Stanley SL Jr. Amoebiasis. Lancet 2003; 361:1025.
  34. Li SQ, Liang LJ, Peng BG, et al. Outcomes of liver resection for intrahepatic stones: a comparative study of unilateral versus bilateral disease. Ann Surg 2012; 255:946.
  35. Fang CH, Liu J, Fan YF, et al. Outcomes of hepatectomy for hepatolithiasis based on 3-dimensional reconstruction technique. J Am Coll Surg 2013; 217:280.
  36. Xu Q, Gu L, Wu ZY. Operative treatment for patients with cholelithiasis and liver cirrhosis. Hepatobiliary Pancreat Dis Int 2007; 6:479.
  37. Hayashida N, Shoujima T, Teshima H, et al. Clinical outcome after cardiac operations in patients with cirrhosis. Ann Thorac Surg 2004; 77:500.
  38. Ferrero A, Viganò L, Polastri R, et al. Postoperative liver dysfunction and future remnant liver: where is the limit? Results of a prospective study. World J Surg 2007; 31:1643.
  39. Kishi Y, Abdalla EK, Chun YS, et al. Three hundred and one consecutive extended right hepatectomies: evaluation of outcome based on systematic liver volumetry. Ann Surg 2009; 250:540.
  40. van den Esschert JW, de Graaf W, van Lienden KP, et al. Volumetric and functional recovery of the remnant liver after major liver resection with prior portal vein embolization : recovery after PVE and liver resection. J Gastrointest Surg 2009; 13:1464.
  41. Ribero D, Abdalla EK, Madoff DC, et al. Portal vein embolization before major hepatectomy and its effects on regeneration, resectability and outcome. Br J Surg 2007; 94:1386.
  42. Adams RB, Aloia TA, Loyer E, et al. Selection for hepatic resection of colorectal liver metastases: expert consensus statement. HPB (Oxford) 2013; 15:91.
  43. Shindoh J, Tzeng CW, Aloia TA, et al. Optimal future liver remnant in patients treated with extensive preoperative chemotherapy for colorectal liver metastases. Ann Surg Oncol 2013; 20:2493.
  44. Vauthey JN, Klimstra D, Franceschi D, et al. Factors affecting long-term outcome after hepatic resection for hepatocellular carcinoma. Am J Surg 1995; 169:28.
  45. Brunt EM, Janney CG, Di Bisceglie AM, et al. Nonalcoholic steatohepatitis: a proposal for grading and staging the histological lesions. Am J Gastroenterol 1999; 94:2467.
  46. Vuppalanchi R, Chalasani N. Nonalcoholic fatty liver disease and nonalcoholic steatohepatitis: Selected practical issues in their evaluation and management. Hepatology 2009; 49:306.
  47. Jarnagin W, Chapman WC, Curley S, et al. Surgical treatment of hepatocellular carcinoma: expert consensus statement. HPB (Oxford) 2010; 12:302.
  48. Vauthey JN, Dixon E, Abdalla EK, et al. Pretreatment assessment of hepatocellular carcinoma: expert consensus statement. HPB (Oxford) 2010; 12:289.
  49. Garden OJ, Rees M, Poston GJ, et al. Guidelines for resection of colorectal cancer liver metastases. Gut 2006; 55 Suppl 3:iii1.
  50. Yoo PS, Enestvedt CK, Kulkarni S. Anatomic considerations in the surgical resection of hepatocellular carcinoma. J Clin Gastroenterol 2013; 47 Suppl:S11.
  51. Eiber M, Fingerle AA, Brügel M, et al. Detection and classification of focal liver lesions in patients with colorectal cancer: retrospective comparison of diffusion-weighted MR imaging and multi-slice CT. Eur J Radiol 2012; 81:683.
  52. Ganeshan DM, Szklaruk J. Portal vein embolization: cross-sectional imaging of normal features and complications. AJR Am J Roentgenol 2012; 199:1275.
  53. Ribero D, Amisano M, Bertuzzo F, et al. Measured versus estimated total liver volume to preoperatively assess the adequacy of the future liver remnant: which method should we use? Ann Surg 2013; 258:801.
  54. Miller WJ, Baron RL, Dodd GD 3rd, Federle MP. Malignancies in patients with cirrhosis: CT sensitivity and specificity in 200 consecutive transplant patients. Radiology 1994; 193:645.
  55. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195.
  56. Wu CC, Yeh DC, Lin MC, et al. Prospective randomized trial of systemic antibiotics in patients undergoing liver resection. Br J Surg 1998; 85:489.
  57. Togo S, Tanaka K, Matsuo K, et al. Duration of antimicrobial prophylaxis in patients undergoing hepatectomy: a prospective randomized controlled trial using flomoxef. J Antimicrob Chemother 2007; 59:964.
  58. Bezeaud A, Denninger MH, Dondero F, et al. Hypercoagulability after partial liver resection. Thromb Haemost 2007; 98:1252.
  59. Scheele J, Stang R, Altendorf-Hofmann A, Paul M. Resection of colorectal liver metastases. World J Surg 1995; 19:59.
  60. DeMatteo RP, Palese C, Jarnagin WR, et al. Anatomic segmental hepatic resection is superior to wedge resection as an oncologic operation for colorectal liver metastases. J Gastrointest Surg 2000; 4:178.
  61. Hasegawa K, Kokudo N, Imamura H, et al. Prognostic impact of anatomic resection for hepatocellular carcinoma. Ann Surg 2005; 242:252.
  62. Ochiai T, Sonoyama T, Kikuchi S, et al. Anatomic wide hepatectomy for treatment of hepatocellular carcinoma. J Cancer Res Clin Oncol 2007; 133:563.
  63. Gayowski TJ, Iwatsuki S, Madariaga JR, et al. Experience in hepatic resection for metastatic colorectal cancer: analysis of clinical and pathologic risk factors. Surgery 1994; 116:703.
  64. Fusai G, Davidson BR. Strategies to increase the resectability of liver metastases from colorectal cancer. Dig Surg 2003; 20:481.
  65. Bowers KA, O'Reilly D, Bond-Smith GE, Hutchins RR. Feasibility study of two-stage hepatectomy for bilobar liver metastases. Am J Surg 2012; 203:691.
  66. Jaeck D, Oussoultzoglou E, Rosso E, et al. A two-stage hepatectomy procedure combined with portal vein embolization to achieve curative resection for initially unresectable multiple and bilobar colorectal liver metastases. Ann Surg 2004; 240:1037.
  67. Lordan JT, Riga A, Worthington TR, Karanjia ND. Early and long-term outcomes of patients undergoing liver resection and diaphragm excision for advanced colorectal liver metastases. Ann R Coll Surg Engl 2009; 91:483.
  68. Lin MC, Wu CC, Chen JT, et al. Surgical results of hepatic resection for hepatocellular carcinoma with gross diaphragmatic invasion. Hepatogastroenterology 2005; 52:1497.
  69. Lau WY, Leung KL, Leung TW, et al. Resection of hepatocellular carcinoma with diaphragmatic invasion. Br J Surg 1995; 82:264.
  70. Arnold D, Rummeny EJ, Kirchner T, et al. [Diagnosis and treatment of liver metastases from primary colorectal tumour]. Onkologie 2009; 32 Suppl 2:7.
  71. Nordlinger B, Guiguet M, Vaillant JC, et al. Surgical resection of colorectal carcinoma metastases to the liver. A prognostic scoring system to improve case selection, based on 1568 patients. Association Française de Chirurgie. Cancer 1996; 77:1254.
  72. Cucchetti A, Ercolani G, Cescon M, et al. Impact of subcentimeter margin on outcome after hepatic resection for colorectal metastases: a meta-regression approach. Surgery 2012; 151:691.
  73. Hamady ZZ, Lodge JP, Welsh FK, et al. One-millimeter cancer-free margin is curative for colorectal liver metastases: a propensity score case-match approach. Ann Surg 2014; 259:543.
  74. Gigot JF, Glineur D, Santiago Azagra J, et al. Laparoscopic liver resection for malignant liver tumors: preliminary results of a multicenter European study. Ann Surg 2002; 236:90.
  75. Hanazaki K, Kajikawa S, Shimozawa N, et al. Survival and recurrence after hepatic resection of 386 consecutive patients with hepatocellular carcinoma. J Am Coll Surg 2000; 191:381.
  76. Tralhão JG, Kayal S, Dagher I, et al. Resection of hepatocellular carcinoma: the effect of surgical margin and blood transfusion on long-term survival. Analysis of 209 consecutive patients. Hepatogastroenterology 2007; 54:1200.
  77. Kosuge T, Makuuchi M, Takayama T, et al. Long-term results after resection of hepatocellular carcinoma: experience of 480 cases. Hepatogastroenterology 1993; 40:328.
  78. Poon RT, Fan ST, Ng IO, Wong J. Significance of resection margin in hepatectomy for hepatocellular carcinoma: A critical reappraisal. Ann Surg 2000; 231:544.
  79. Wrighton LJ, O'Bosky KR, Namm JP, Senthil M. Postoperative management after hepatic resection. J Gastrointest Oncol 2012; 3:41.
  80. Okabayashi T, Hnazaki K, Nishimori I, et al. Continuous post-operative blood glucose monitoring and control using a closed-loop system in patients undergoing hepatic resection. Dig Dis Sci 2008; 53:1405.
  81. Cammu G, Vermeiren K, Lecomte P, et al. Perioperative blood glucose management in patients undergoing tumor hepatectomy. J Clin Anesth 2009; 21:329.
  82. Okabayashi T, Nishimori I, Yamashita K, et al. Risk factors and predictors for surgical site infection after hepatic resection. J Hosp Infect 2009; 73:47.
  83. Mullen JT, Ribero D, Reddy SK, et al. Hepatic insufficiency and mortality in 1,059 noncirrhotic patients undergoing major hepatectomy. J Am Coll Surg 2007; 204:854.
  84. Shimada M, Matsumata T, Akazawa K, et al. Estimation of risk of major complications after hepatic resection. Am J Surg 1994; 167:399.
  85. Meijer C, Wiezer MJ, Hack CE, et al. Coagulopathy following major liver resection: the effect of rBPI21 and the role of decreased synthesis of regulating proteins by the liver. Shock 2001; 15:261.
  86. Tanabe G, Sakamoto M, Akazawa K, et al. Intraoperative risk factors associated with hepatic resection. Br J Surg 1995; 82:1262.
  87. Shao YF, Yang JM, Chau GY, et al. Safety and hemostatic effect of recombinant activated factor VII in cirrhotic patients undergoing partial hepatectomy: a multicenter, randomized, double-blind, placebo-controlled trial. Am J Surg 2006; 191:245.
  88. Barbas AS, Turley RS, Mallipeddi MK, et al. Examining reoperation and readmission after hepatic surgery. J Am Coll Surg 2013; 216:915.
  89. Schroeder RA, Marroquin CE, Bute BP, et al. Predictive indices of morbidity and mortality after liver resection. Ann Surg 2006; 243:373.
  90. Sano T, Shimada K, Sakamoto Y, et al. One hundred two consecutive hepatobiliary resections for perihilar cholangiocarcinoma with zero mortality. Ann Surg 2006; 244:240.
  91. Kneuertz PJ, Pitt HA, Bilimoria KY, et al. Risk of morbidity and mortality following hepato-pancreato-biliary surgery. J Gastrointest Surg 2012; 16:1727.
  92. Schemmer P, Friess H, Hinz U, et al. Stapler hepatectomy is a safe dissection technique: analysis of 300 patients. World J Surg 2006; 30:419.
  93. Bhayani NH, Hyder O, Frederick W, et al. Effect of metabolic syndrome on perioperative outcomes after liver surgery: A National Surgical Quality Improvement Program (NSQIP) analysis. Surgery 2012; 152:218.
  94. Cauchy F, Zalinski S, Dokmak S, et al. Surgical treatment of hepatocellular carcinoma associated with the metabolic syndrome. Br J Surg 2013; 100:113.
  95. Koch M, Garden OJ, Padbury R, et al. Bile leakage after hepatobiliary and pancreatic surgery: a definition and grading of severity by the International Study Group of Liver Surgery. Surgery 2011; 149:680.
  96. Sadamori H, Yagi T, Shinoura S, et al. Risk factors for major morbidity after liver resection for hepatocellular carcinoma. Br J Surg 2013; 100:122.
  97. Erdogan D, Busch OR, van Delden OM, et al. Incidence and management of bile leakage after partial liver resection. Dig Surg 2008; 25:60.
  98. Nobili C, Marzano E, Oussoultzoglou E, et al. Multivariate analysis of risk factors for pulmonary complications after hepatic resection. Ann Surg 2012; 255:540.
  99. Chan KM, Lee CF, Wu TJ, et al. Adverse outcomes in patients with postoperative ascites after liver resection for hepatocellular carcinoma. World J Surg 2012; 36:392.
  100. Thomas RM, Ahmad SA. Management of acute post-operative portal venous thrombosis. J Gastrointest Surg 2010; 14:570.
  101. Yoshiya S, Shirabe K, Nakagawara H, et al. Portal vein thrombosis after hepatectomy. World J Surg 2014; 38:1491.
  102. Rahbari NN, Garden OJ, Padbury R, et al. Posthepatectomy liver failure: a definition and grading by the International Study Group of Liver Surgery (ISGLS). Surgery 2011; 149:713.
  103. Hyder O, Pulitano C, Firoozmand A, et al. A risk model to predict 90-day mortality among patients undergoing hepatic resection. J Am Coll Surg 2013; 216:1049.
  104. Paugam-Burtz C, Janny S, Delefosse D, et al. Prospective validation of the "fifty-fifty" criteria as an early and accurate predictor of death after liver resection in intensive care unit patients. Ann Surg 2009; 249:124.
  105. Paugam-Burtz C, Wendon J, Belghiti J, Mantz J. Case scenario: postoperative liver failure after liver resection in a cirrhotic patient. Anesthesiology 2012; 116:705.
  106. Wibmer A, Prusa AM, Nolz R, et al. Liver failure after major liver resection: risk assessment by using preoperative Gadoxetic acid-enhanced 3-T MR imaging. Radiology 2013; 269:777.
  107. Hirashita T, Ohta M, Iwashita Y, et al. Risk factors of liver failure after right-sided hepatectomy. Am J Surg 2013; 206:374.
  108. Boleslawski E, Petrovai G, Truant S, et al. Hepatic venous pressure gradient in the assessment of portal hypertension before liver resection in patients with cirrhosis. Br J Surg 2012; 99:855.
  109. Chen X, Zhai J, Cai X, et al. Severity of portal hypertension and prediction of postoperative liver failure after liver resection in patients with Child-Pugh grade A cirrhosis. Br J Surg 2012; 99:1701.
  110. Chang CM, Yin WY, Su YC, et al. Preoperative risk score predicting 90-day mortality after liver resection in a population-based study. Medicine (Baltimore) 2014; 93:e59.
  111. Wei AC, Greig PD, Grant D, et al. Survival after hepatic resection for colorectal metastases: a 10-year experience. Ann Surg Oncol 2006; 13:668.
  112. Ribero D, Abdalla EK, Thomas MB, Vauthey JN. Liver resection in the treatment of hepatocellular carcinoma. Expert Rev Anticancer Ther 2006; 6:567.