Surgical Gastroenterologist,Laparoscopy,Hepatobiliary

KRISHNA SURGICAL

GASTROENTEROLOGY & ENDOSCOPY

CENTER

Cell: + 91-9840147487

Plot no 5, Anna street, Amaravathy Nagar, Jelladianpet, Pallikaranai, Chennai.

Introduction

Liver is the largest abdominal organ. Blood draining from the abdominal organs such as the stomach, bowel and pancreas drain into the portal vein. This subsequently enters into the liver and bathes the liver cells. This arrangement allows the liver to extract nutrients, flowing after digestion from the gut. It also unfortunately makes the liver vulnerable to spread of infections and cancers of the abdominal viscera. For example amoebiasis can enter the liver and form abscesses following a primary infection in the large intestine. Similarly abscesses can develop due to seeding of bacteria from bowel sources such as diverticulitis or even appendicitis.

DR. KUMARAKRISHNAN S, Surgical Gastroenterologist, Liver basic information DR. KUMARAKRISHNAN S, Surgical Gastroenterologist, Liver basic information Liver has a very rich dual blood supply. The venous drainage is into the inferior vena cava, via the hepatic veins, only centimetres away from the heart! There are very few external landmarks over the liver. Its soft tissue is very friable and does not easily accept sutures like other tissues like skin or bowel. Hence major advances in liver surgery has happened over the last 30 years. Progress came with better understanding of the segmental anatomy of the liver. It was realised that complications were less once liver was treated as an aggregate of several segments of liver. Each segment has distinct inflow (portal and hepatic) and outflow (hepatic veins). When surgery is done respecting these divisions, it is possible to excise offending lesions along segmental lines. The excision also satisfies oncological standards with minimal morbidity. Liver is unique amongst internal organs due to its capability to regenerate back to original size. This allows us to remove up to 80% of the liver in selected patients. Regeneration depends on the both quantity and quality of the remnant liver.

Liver Cancer

Liver cancer can be primary (ie arising from tissues intrinsic to liver) or metastatic (secondary spread from cancer elsewhere). Metastasis is the culmination of spread of cancer from distant primary sites. While the outlook is still poor, there is a ray of hope for selected patients. Surgery is possible in a minority of patients, depending on the type and location of the cancer metastasis.

Surgery

  • Primary liver cancer: Surgical decision depends upon feasibility of removal with reasonable quantity (and quality) of liver remnant.
  • Secondary (metastatic): The decision to remove metastatic deposit in the liver in depends on the following factors
    • Number of cancer deposits.
    • Extent of the cancer deposits
    • The Original cancer – has it been completely removed?
    • The gap between removal of the first cancer and the appearance of metastasis – longer the interval, better the outlook.
    • Nature of the original cancer – colorectal (large bowel) cancers remain the major cancer, for which experience and evidence exists. Other metastatic cancers can be removed, provided there is no other spread and the lesion is stable.

A PET scan is valuable in excluding occult distant spread before embarking on liver surgery. The decision is individualised. Currently as a general rule, if a lesion is technically amenable for segmental excision, with a reasonable liver remnant and the cancer is a stable slow growing cancer with no evidence of any other spread, then liver resection is a reasonable option. Segmental resection has changed the scene by extending resection options and the ability to conserve more functional parenchyma. The following is an illustration of liver resection applied to a suspected gallbladder cancer which I operated, which illustrates the principles.

A 73 year old lady presented with right hypochondrial pain. Ultrasound showed a suspicious growth in the fundus of the gallbladder in addition to stones. A PET CT showed a hot spot in the same area. The CT images again showed a lesion in the fundus invading into liver. Growth from fundus of gallbladder.Same patient – showing gallstones also

PET CT – shows uptake in same area Gallbladder cancers are very aggressive cancers. Suspicious lesions should be treated by extended removal of gallbladder which involves removal of adjacent liver segments. Biopsy should not be done as this can seed needle tracts. A decision was made to perform extended cholecystectomy with resection of adjacent liver segments (IVb, V and VIII). At surgery a mass was palpable at the fundus involving adjacent liver. To achieve clearance, a minimum of segment IVb, and V is required. On review of the ductal anatomy, it was decided to excise Segment VIII as well as the bifurcation was very close to the growth. Extended cholecystectomy was done along with resection of segments IVb, V and VIII. A nodal dissection of the lesser omentum was done. The common bile duct was preserved. The histology showed xanthogranulomatous cholecystitis. This is a rare condition, which is often indistinguishable from malignancy. The patient made an uneventful recovery. Specimen after fixation - whitish growth,Growth involving liver

I offer liver resection for carefully selected patients with liver metastasis.

Liver Surgery

History of liver surgery: Liver is a difficult organ from a surgical perspective. It has a very rich dual blood supply. The venous drainage is into the inferior vena cava, via the hepatic veins, only centimetres away from the heart! There are very few external landmarks over the liver. Its soft tissue is very friable and does not easily accept sutures like other tissues such as skin or bowel. However progress came with better understanding of the segmental anatomy of the liver. It was realised that complications were less once liver was treated as an aggregate of several segments of liver. Each segment has distinct inflow (portal and hepatic) and outflow (hepatic veins). When surgery is done respecting these divisions, it is possible to excise offending lesions along segmental lines. The excision also satisfies oncological standards with minimal morbidity.

Liver is unique amongst internal organs due to its capability to regenerate back to original size. This allows us to remove up to 80% of the liver in selected patients. Regeneration depends on the both quantity and quality of the remnant liver. Anaesthetic considerations: Bleeding is the major concern during liver resections. There are some useful manoeuvres such as low CVP and aiming for a low urine output such as 25ml/hr. These run counter to most anaestheists’ reflexes. Hence it is important to have an anaesthetist who understands and is experienced with these issues.

For appointments please contact me on 91-9600147810.

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