Liver resection, medically known as a hepatectomy, is a surgical procedure that removes a portion of the liver. The decision to perform this operation, especially a repeat procedure, does not depend on a fixed number of surgeries an individual can undergo. Subsequent resections are determined by a delicate balance of biological capacity and complex clinical factors unique to each patient. A surgeon’s focus is not on counting prior operations but on ensuring the remaining liver tissue can sustain all necessary bodily functions after the removal of the diseased section. This evaluation considers the organ’s ability to regrow, the specific nature of the underlying disease, and the patient’s overall health status.
The Limits of Liver Regeneration
The liver is the only visceral organ capable of restoring its mass after a portion is removed, a process called compensatory hypertrophy. This means the remaining healthy tissue enlarges its own cells to compensate for the lost volume, rather than replacing the resected lobe. Regeneration is triggered almost immediately after surgery by various growth factors and chemical signals.
The primary biological constraint for any liver resection is the size and health of the Functional Residual Liver Volume (FRLV)—the liver tissue remaining after the planned surgery. To prevent post-hepatectomy liver failure, a minimum volume of healthy, functional liver must be preserved. In a patient with an otherwise healthy liver, surgeons aim to leave at least 20% to 30% of the total liver volume.
This minimum percentage increases significantly if the liver is compromised by chronic conditions. Patients with underlying diseases like fibrosis, severe steatosis (fatty liver disease), or cirrhosis require a much larger FRLV, often 40% or more, to safely tolerate the procedure. These conditions impair the liver cells’ ability to regenerate, making the remaining tissue less resilient. Measuring the FRLV is a routine pre-operative step, typically done using advanced imaging techniques like computed tomography (CT) or magnetic resonance imaging (MRI) for a three-dimensional volume assessment.
Key Factors Determining Subsequent Operations
Beyond the absolute volume of the remaining liver, a second operation’s feasibility hinges on several dynamic clinical and pathological factors.
Disease Status
The first consideration is the status of the disease that necessitated the initial surgery, such as cancer recurrence. Surgeons evaluate the location, size, and number of new tumors. They must confirm that the disease has not spread outside the liver, which would disqualify a patient for further local resection. The pattern of recurrence dictates whether the remaining healthy liver can be safely dissected again to achieve complete removal of the new lesions.
Liver Health and Regeneration
The second factor is the overall health of the liver tissue and its capacity to regenerate after the first procedure. A liver with significant scarring (fibrosis) or high fat content (steatosis) from prior chemotherapy or lifestyle factors has a reduced ability to recover from a second insult. Specialized liver function tests, such as the indocyanine green (ICG) clearance test, are often used to gauge the metabolic reserve of the liver. This provides a more functional assessment than volume alone. A poor functional reserve significantly elevates the risk of liver failure following any subsequent resection.
Patient Overall Condition
The patient’s overall physical condition and ability to withstand another major operation are also evaluated. Factors assessed include age, the presence of comorbidities like heart disease or diabetes, and nutritional status. The ability to recover from the initial resection indicates tolerance for a second procedure. A second operation is only considered if the patient’s overall fitness suggests a reasonable chance of recovery and long-term benefit.
Techniques for Maximizing Remaining Liver Volume
When pre-operative imaging shows the FRLV will be below the safety threshold, surgeons use specialized techniques to encourage the healthy portion of the liver to grow before resection.
Portal Vein Embolization (PVE)
One widely used intervention is Portal Vein Embolization (PVE), a minimally invasive procedure. PVE blocks blood flow in the portal vein branch supplying the diseased part of the liver intended for removal. Redirecting the portal blood flow forces the healthy side to undergo rapid hypertrophy, or accelerated growth. This process typically takes several weeks, aiming to increase the FRLV to a safe, operable size. PVE is preferred due to its lower risk profile compared to open surgery, increasing the number of candidates for curative resection.
Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS)
For patients needing an accelerated timeline or having a severely small FRLV, a two-stage surgical approach called Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) may be considered. The first stage involves dividing the liver parenchyma along the planned resection line and ligating the portal vein supplying the tumor-bearing section. This dual intervention induces faster and more substantial FRLV growth, often achieving sufficient volume within one to two weeks. The second stage then removes the diseased segment.
Recovery and Long-Term Monitoring
Following a liver resection, patients are closely monitored, often in a high dependency or intensive care setting, for the first one or two days. This intense observation allows the medical team to promptly detect any signs of post-hepatectomy liver failure or other complications. Drainage tubes, intravenous fluids, and pain management are common immediately post-operatively.
The typical hospital stay is usually between one and two weeks, with overall recovery extending for several weeks to months. Regular blood tests track the liver’s function, monitoring levels like bilirubin and the International Normalized Ratio (INR). These levels indicate how well the organ is performing its metabolic and clotting duties.
Long-term surveillance is a key component of care, particularly for patients with liver cancer or metastases. This ongoing monitoring involves regular follow-up appointments, blood work, and advanced imaging scans to check function and look for disease recurrence. Early detection of a new tumor is paramount, as it allows the medical team to assess the feasibility of another local treatment, potentially including a repeat resection. The data gathered during this surveillance ultimately determines if a patient is a safe candidate for future surgical procedures.