Liver surgery AnatomyHepatectomy Liver tumors BenignMalignant

Liver surgeryLiver surgery Anatomy Anatomy

Hepatectomy Hepatectomy Liver tumors Liver tumors

Benign Benign MalignantMalignant

Liver anatomyLiver anatomy

Liver anatomyLiver anatomy

Liver anatomyLiver anatomy

Partial hepatectomy (30-70%) Partial hepatectomy (30-70%) Liver RegenarationLiver Regenaration

Hypertrophy & Hyperplasia Hypertrophy & Hyperplasia (IGF2, HGF)(IGF2, HGF)

NormaL VS. Cirrhotic liverNormaL VS. Cirrhotic liver

Partial hepatectomy (70%) Partial hepatectomy (70%) Liver RegenarationLiver Regenaration

Hypertrophy & Hyperplasia (IGF2, HGF)Hypertrophy & Hyperplasia (IGF2, HGF)NormaL VS. Cirrhotic liverNormaL VS. Cirrhotic liver

Anatomical considerations:

Adequate Inflow - Portal + Arterial

Adequate outflow – Hepatic Vein

Adequate drainage - Bile duct

Liver anatomyLiver anatomy

Anatomical-nonanatomical resection

Liver anatomyLiver anatomyPartial hepatectomyPartial hepatectomy

Liver anatomyLiver anatomyPartial hepatectomyPartial hepatectomy

Extended Rt. Hep .

Extended Lt. Hep.

LIVER TUMORSLIVER TUMORS

Benign Malignant

Cystic

Solid

Primary“ " Infectious

Parasitic

Amaebic

Echinococus

Bacterial

Prinary Metastatic

Cirrhosis

Benign solid liver tumorsBenign solid liver tumors

Hemangioma Hemangioma

Adenoma Adenoma

FNH FNH

Liver hemangiomaLiver hemangioma

AsymptomaticAsymptomatic

Incidental Incidental

Giant HaemangiomaGiant Haemangioma

Should we operate?Should we operate?

Only when symptomatic Only when symptomatic

Giant hemangioma (I)Giant hemangioma (I)

Giant Haemangioma (II)Giant Haemangioma (II)OperationOperation

LIVER TUMORSLIVER TUMORS

Benign Malignant

Cystic

Solid

Primary“ " Infectious

Parasitic

Amaebic

Echinococus

Bacterial

Prinary Metastatic

Cirrhosis

Liver cystLiver cyst

Amebic liver cystAmebic liver cyst

LIVER TUMORSLIVER TUMORS

Benign Malignant

Cystic

Solid

Primary“ " Infectious

Parasitic

Amaebic

Echinococus

Bacterial

Prinary Metastatic

Cirrhosis

Primary liver tumorsPrimary liver tumors

Cellular componentCellular component HepatocellularHepatocellular

Bile duct Bile duct

Mesenchymal Mesenchymal

Fibrolammellar hepatomaFibrolammellar hepatoma

Extended Lt. Hep .

Primary liver tumorsPrimary liver tumors

Cellular componentCellular component HepatocellularHepatocellular

Bile duct Bile duct

Mesenchymal Mesenchymal

Intrahepatic Bile duct cancerIntrahepatic Bile duct cancer

Intrahepatic cholangiocarcinoma

Adenocarcinoma

Intrahepatic Bile duct cancerIntrahepatic Bile duct cancer

Gallbladder cancer

Primary liver tumorsPrimary liver tumors

Cellular componentCellular component HepatocellularHepatocellular

Bile ductBile duct

Mesenchymal Mesenchymal

Mesenchymal liver tumorsMesenchymal liver tumors

Hemangiosarcoma

Mesenchymal liver tumors Mesenchymal liver tumors HepatoblastomaHepatoblastoma

PM , 4y male child

Mesenchymal liver tumor Mesenchymal liver tumor

Primary lymphoma Primary lymphoma

LIVER TUMORSLIVER TUMORS

Benign Malignant

Cystic

Solid

Primary“ " Infectious

Parasitic

Amaebic

Echinococus

Bacterial

Prinary Metastatic

Cirrhosis

Primary HCC in Cirrhosis Primary HCC in Cirrhosis No regenerationNo regeneration

Major resection – not possibleMajor resection – not possibleLaparoscopic RF/ CryoLaparoscopic RF/ Cryo

Wedge resection- Possible Wedge resection- Possible Liver transplantation Liver transplantation Palliative treatment Palliative treatment

primary & Metastatic liver tumorsprimary & Metastatic liver tumors

LAPAROSCOPIC US

NONRESECTABLE RESECTABLE

Extrahepatic involvement Confined

to liver resection

Laparoscopic

RF / Cryo ablation

Liver MetastasesLiver MetastasesOptimal treatment – resectionOptimal treatment – resection

primary & Metastatic liver primary & Metastatic liver tumorstumors

LAPAROSCOPIC US

NONRESECTABLE RESECTABLE

Extrahepatic involvement Confined

to liver resection

Laparoscopic

RF / Cryo ablation

Liver MetastasesLiver MetastasesSolitary ResectionSolitary Resection

primary & Metastatic liver primary & Metastatic liver tumorstumors

LAPAROSCOPIC US

NONRESECTABLE RESECTABLE

Extrahepatic involvement Confined

to liver resection

Laparoscopic

RF / Cryo ablation

LAPAROSCOPICLAPAROSCOPIC R Radio adio FFrequencyrequency

ABLATIONABLATIONPRIMARY & METASTATIC LIVER TUMORSPRIMARY & METASTATIC LIVER TUMORS

Principles of applicationPrinciples of application

Heating to high Heating to high temperaturestemperatures

80-10080-100 O O

CC

Single cycle of 12 min. Single cycle of 12 min.

Tumors up to 4cm.Tumors up to 4cm.

Radiofrequency Interstitial Ablation

Clinical Application (II)

PercutaneousPercutaneous

Open LaparotomyOpen Laparotomy

Laparoscopic Laparoscopic

Liver tumors – RFA Indications & contraindications

•Liver only disease.

•Identified focal tumors.

•Ideal diameter< 3cm.

•HCC- Cirrhosis.

•Compatible performance status.

•Complete staging protocol.

•Measurable disease (PET,CT,MRI).

LAPAROSCOPIC ABLATIONLAPAROSCOPIC ABLATIONPrinciples of treatmentPrinciples of treatment

Accurate targeting of lesionAccurate targeting of lesionInsertion of needle\probeInsertion of needle\probe

Application ablative Application ablative techniquetechnique

EfficientEfficient

HomogenousHomogenous

Laparoscopic ablation Laparoscopic ablation

guidance systemguidance system 10mm. Sectoral ultrasound probe10mm. Sectoral ultrasound probe

Laparoscopic US-guided Laparoscopic US-guided biopsybiopsy

LAPAROSCOPIC ABLATION TUMORS OF LIVERLAPAROSCOPIC ABLATION TUMORS OF LIVER

Laparoscopic RF ablation systemLaparoscopic RF ablation system

Radio frequency ablation at Radio frequency ablation at laparotomylaparotomy

Local effectLocal effect

Laparoscopic RF ablationLaparoscopic RF ablationStages of the ProcedureStages of the Procedure

US Targeting

Application RF generator

End of procedure

CT appearance of Pre+Post LRFA

Laparoscopic liver resectionLaparoscopic liver resection