Ruminations of an ordinary hepatic surgeon: a journey through the pitfalls of major liver resections.

Historically, major hepatic resections have been fraught with voluminous blood losses and, at times, high mortality rates. Improvements in patient selection and operative technique over the past 20 years have resulted in marked reduction in death and complications and have given the impression that liver surgery can be relatively effortless. Contrary to this belief, the present review illustrates some of the pitfalls and dangers of major hepatectomy and may serve to alert ordinary surgeons to approach this operation with a degree of trepidation and careful planning. Over a 22-year period, 147 liver resections were performed by one surgeon for solid liver tumors (range 0 to 21/yr). Of these, 101 were major hepatectomies comprising at least three anatomic segments (63 right, 24 left, 11 extended right, and 3 extended left) and form the basis for this report. The major resections were performed for benign disease in 16 patients and malignant tumors in 85 (24 primary and 61 metastatic lesions). All but one patient were noncirrhotic. Seventeen patients were more than 70 years and 84 were less than 70 years of age. There were five postoperative deaths among these 101 patients: two intraoperative (coagulopathy after venovenous bypass in 1 and air embolus in 1), two from postoperative liver failure, and one resulting from a myocardial infarction. Three deaths were in patients older than 70 (18%), and two were in patients younger than 70 (2%) (P = 0.03). Complications developed in 20 of 96 survivors, three patients required reoperation for postoperative bleeding, and nine patients had some duration of bile leakage. In contrast, among those undergoing "minor" hepatectomies (n = 46), there were no deaths and six (13%) patients had complications. In patients undergoing major hepatectomies, estimated blood loss was 3836 +/- 3346 ml. Estimated blood loss was unaffected by experience (first 50 patients vs. second 51 patients) or use of the ultrasonic surgical aspirator, but has been reduced by the use of the Harmonic scalpel (2650 +/- 2706.1 ml vs. 3997 +/- 3405.8 ml, P = 0.026). The use of rapid-infusion systems aided in preventing intraoperative hypotension and hypothermia. Estimated blood loss was significantly greater than with minor anterior or lateral segmentectomies (n = 24) (3836 +/- 3346 ml vs. 975 +/- 518.8 ml, P < 0.0001). Hospital length of stay has been shortened, primarily by the use of closed suction drainage compared to open drainage (7.5 2 +/-.4 days vs. 18.8 +/- 8.4 days, P < 0.0001). Major hepatectomies continue to be formidable operations with the potential for copious blood loss and intraoperative instability. Proper patient selection, anesthesia support and availability of rapid-infusion technology, and familiarity with liver anatomy are important in keeping operative mortality and postoperative morbidity at an acceptable level.