Assessment of hepatic reserve for the indication of hepatic resection.

The main goal of liver resection in patients with liver tumor is to cure the patients with the lowest operative risk. Based on our experiences, we report herein, indications of liver resection according to the nature of underlying liver parenchyma. In patients with normal underlying liver parenchyma, major resection does not require specific preoperative assessment. Non-tumorous biopsy is indicated in cases of massive steatosis and/or in patients in whom a complex technical procedure is anticipated. Portal vein embolization (PVE) is considered if the future liver remnant (FLR) is < 30%. In patients with chronic liver disease, major hepatectomy is a risky situation, requiring specific preoperative assessment, including non-tumorous biopsy and PVE which could be associated with transarterial chemoembolization. Absence of hypertrophy of the FLR after PVE is a contraindication to a major hepatectomy. Intraoperative procedures in patients "at risk" require specific techniques, including intermittent clamping, anterior approach with hanging maneuver, and fixation on anatomical position of the remnant liver.