A hepatectomy is a surgical procedure involving the removal of a portion of the liver, or rarely, the entire organ. It describes any liver resection, ranging from removing a small wedge of tissue to excising a whole lobe. This operation removes diseased tissue while preserving enough healthy liver to maintain function.
The liver possesses the capacity for regeneration, meaning the remaining tissue can regrow to restore nearly the organ’s original mass. This allows surgeons to remove a significant portion, sometimes up to 75% of the liver, with the expectation that it will recover its necessary volume. This regenerative ability is a foundational principle that makes hepatectomy a viable treatment for many conditions.
Reasons for Liver Surgery
The primary indications for a hepatectomy involve removing malignant tumors, though certain benign conditions and severe trauma also necessitate the procedure. Liver cancer originating in the organ, known as Hepatocellular Carcinoma (HCC), is a major driver, especially when the cancer is localized. Resection for HCC offers the best chance for long-term survival for many patients.
Metastatic cancer, where the disease has spread to the liver from a primary tumor elsewhere, is another frequent indication. Colorectal liver metastases (CRLM) are the most common secondary tumors treated with hepatectomy. Complete surgical removal remains the only potentially curative option for this aggressive disease, requiring rigorous patient selection and sufficient remaining liver function.
Hepatectomy is also required for non-cancerous conditions, such as large benign tumors like Hepatocellular Adenoma (HCA) or Focal Nodular Hyperplasia (FNH). Adenomas are typically resected due to the risk of malignant transformation or spontaneous bleeding. FNH is usually observed unless it causes persistent symptoms or cannot be distinguished from a cancerous tumor on imaging.
In cases of severe physical injury, a hepatectomy can be a life-saving measure for profound liver trauma. This is reserved for emergencies where non-operative management or less extensive surgical techniques have failed to control massive and life-threatening bleeding. The goal in this emergency setting is immediate hemostasis, even if it requires the removal of a large, damaged section.
Classifying the Extent of Removal
Liver resection is categorized based on the precise amount of tissue removed, utilizing the anatomical segmentation of the liver established by the Couinaud classification. This system divides the liver into eight functionally independent segments. Operating along the boundaries of these segments allows the surgeon to remove diseased tissue while preserving the vascular and biliary integrity of the remaining liver.
The extent of removal is described using specific terminology. A segmentectomy involves the removal of one or two adjacent segments, typically used for smaller lesions. A lobectomy, or formal hepatectomy, is the removal of an entire lobe, which encompasses multiple segments.
The terms major and minor hepatectomy reflect the complexity and risk of the operation. A minor hepatectomy is defined as the removal of less than four liver segments, generally carrying a lower risk of post-operative complications. Conversely, a major hepatectomy involves the removal of four or more segments, associated with a significantly higher risk of complications, including temporary liver insufficiency. The decision on the extent of removal is dictated by the tumor’s size and location, ensuring a margin of healthy tissue is removed while leaving an adequate volume of functional liver remnant.
Surgical Methods and Techniques
A hepatectomy can be performed using one of three primary surgical approaches: open, laparoscopic, or robotic. The traditional approach is the Open Hepatectomy, which requires a single, large incision, often extending under the rib cage, to provide the surgeon with direct visualization and access. This method is typically reserved for the largest, most complex resections, or when the tumor is located deep within the center of the liver.
In contrast, Minimally Invasive Techniques include both laparoscopic and robotic surgery, relying on several small incisions, or ports, through which specialized instruments are inserted. Laparoscopic hepatectomy provides advantages over the open approach, such as reduced blood loss, less post-operative pain, and a shorter hospital stay. It is the preferred method for many smaller lesions located on the liver’s periphery.
Robotic-assisted surgery uses a console-controlled system to manipulate instruments with enhanced precision. The robotic instruments feature a flexible wrist-like joint, offering a greater range of motion and dexterity. Surgeons also benefit from a highly magnified, three-dimensional view of the surgical field. The choice between these methods depends on the lesion’s characteristics, the patient’s overall health, and the surgeon’s expertise.
The Recovery Process
The recovery period following a hepatectomy is highly dependent on the extent of the resection and the surgical technique used. Patients undergoing a major open hepatectomy often require a hospital stay of approximately five to seven days, while those who have a minimally invasive procedure may be discharged in as little as three to four days. Pain is managed through a multimodal approach, often involving patient-controlled analgesia (PCA) or nerve blocks initially, transitioning to oral pain medication before discharge.
Early mobilization, such as walking within the first day after surgery, is a crucial component of the recovery protocol, helping to prevent complications like blood clots and pneumonia. The most significant concern in the immediate post-operative phase is monitoring for complications, particularly bile leakage from the surgical margin or temporary post-hepatectomy liver insufficiency. These issues are often detected through drainage output or blood tests indicating poor liver function.
The liver’s regenerative capacity begins almost immediately, with the remaining tissue working to compensate for the loss of mass. The residual liver volume typically restores 75% to 90% of its original size within two to three months following a major resection. Complete functional recovery, where liver enzyme levels and other measures of function return to normal, usually takes between three and six months. During the first four to eight weeks at home, patients are advised to avoid heavy lifting and strenuous activity to allow the abdominal wall and the regenerating liver to heal fully.