Central Hepatectomy

Central hepatectomy surgery

Mesohepatectomy or central hepatectomy is a liver-sparing surgery where the main parts of the liver (segments IV, V and VIII) are excised with the right and left peripheral parts of liver spared. It is often done in case of tumors that are situated in the center of the liver, near major blood vessels and bile ducts.

Central Hepatectomy Indications

Central hepatectomy can be implemented under the following circumstances:

• The site of liver tumor was confined to IV, V, and VIII. 
• Hepatocellular carcinoma 
• Cholangiocarcinoma
• Metastatic tumor of the liver
• Neoplastic lesions with symptoms.

Because of the need to preserve liver tissue, especially in patients with cirrhosis or poor hepatic reserve, tailoring the extent of resection to the minimum amount necessary is crucial. 

Benefits of Central Hepatectomy

• Maintains a maximum functional liver.
• Reduced chances of liver insufficiency during the postoperative period.
• Appropriate in the case of chronic liver disease.
• Similar oncological results as those of major hepatectomy.

Central hepatectomy surgery procedure

Mesohepatectomy, or central hepatectomy is where the central liver segments (IV, V, and VIII) are removed yet the peripheral liver tissue (right and left) are maintained. The surgical procedure has been described in a definite and well-organized way below.

Preoperative Preparation

• Liver CT/MRI mapping of location of tumors and vascular anatomy.
• Liver from examination (Child-Pugh score, ICG clearance when necessary)
• Computation of the future liver remnant (FLR) volume.
• Blood typing and cross match.
• Starvation and preventative antibiotics in the patient.

Anaesthesia and Patient Positioning

• Oral endotracheal intubation and general anaesthesia. 
• Patient in an upright position.
• Low central venous pressure to prevent bleeding.

Surgical Approach

Can be performed via:

• Open surgery (Right subcostal or Mercedes incision).
• Laparoscopic (selected cases) approach.
• Robot-based (advanced centers) approach.
• Abdomen palpated to determine the absence of metastasis.

Liver Mobilization

• Splenic separation Falciform, coronary, and triangular ligaments.
• Liver central exposure.
• Ultrasound intraoperative margin assurance.

Vascular Control

Identification and control of:

• Middle hepatic vein
• Segment IV portal pedicle
• Branches of portal vein to V, to VIII.
• In order to minimize the blood loss, Pringle maneuver (temporary clamping of portal triad) can be applied.

Parenchymal Transection

• Tissues of the liver were cut parallel to the transecting lines.

Sectioned with the following using:

• Ultrasonic dissector
• Bipolar cautery
• Cavitron Ultrasonic Surgical Aspirator (CUSA).
• IV, V, VIII positions carefully dissected on the right and left liver.

Central Liver Segment Resection

• Ablation of all the tumor-bearing central segments.

Preservation of:

• Right hepatic vein
• Left hepatic vein
• Sufficient flow in and out of the rest of liver.

Hemostasis and Biliary Control

• Strict management of bleeding points.
• Bile ducts identification and closure.
• Fibrin sealants may be used when necessary.

Drain Placement and Closure

• Drains in transection area.
• Layers of the abdominal wall are closed.
• Patient transferred to recovery or ICU.

Postoperative Monitoring

Continuous monitoring of:

• Liver function tests
• Drain output (bile leak detection)
• Hemodynamic stability
• Premature mobilization and breathing exercises.

Duration

• It is usually 4-8 hours, as the level of complexity and approach requires it.

Central hepatectomy recovery

Central hepatectomy recovery (mesohepatectomy) is aimed at liver regeneration, analgesia, complications prevention, and progressive recovery to normal activity. Due to the fact that this operation uses less liver tissue, it is often a safe and quicker operation to perform than the long liver resection in the case of well-selected patients.

Postoperative Period (Day 0-2)

• Close monitoring in the ICU or high-dependency care.

Continuous monitoring of:

• Blood pressure, oxygen, levels.
• Liver function tests 
• Urine output
• IV analgesics or epidural pain management.
• IV fluids and antibiotics
• Pulmonary exercises to avoid pulmonary complications.
• Surgical drains followed-up on blood loss or bile.

Early Hospital Recovery (Day 3–7)

• Slow change of liquids to soft/normal diet.
• Replacement of IV with oral analgesic drugs.
• Promoting early mobilization and ambulation.
• Urinary catheters removal (typically day 2-3)
• Eradication of drains when the output is lower and is not bilious.
• Liver recovery is monitored by conducting daily blood tests.

Typical hospital stay: 7–12 days

• Dismissal and Home Recovery (Week 2–6)
• Light fatigue and stomachache are typical.
• Wound care education given.
• Do not lift heavy or work hard.
• Go on with breathing exercises and light walking.
• Protein-rich, balanced food in order to provide liver regeneration.
• Several visits with bloodwork and imaging as needed. 

Long Term Recovery (6 Weeks - 6 Months) 

• Slow resumption of regular work and physical exercise.
• The process of liver regeneration starts in the course of months and lasts several weeks.
• Complete functional recovery typically by 3 - 6 months.
• Indicated cancer patients can start adjuvant therapy.

Central hepatectomy complications

Mesohepatectomy (also referred to as central hepatectomy) is a hepatectomy surgery that is liver-preserving and carried out close to great blood vessels and bile ducts. Even though the results in experienced centers are generally good, certain complications may still arise, particularly because repositioning is centrally placed.

Early (Immediate) Complications

• Bleeding
• Bile Leak
• Liver Dysfunction or Liver Failure
• Infection
• Pleural Effusion

Intermediate Complications (First Few Weeks)

• Biliary Stricture
• Ascites
• Delayed Hemorrhage

Late Complications

• Incisional Hernia
• Tumor Recurrence

Best hospital for central hepatectomy India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Conclusion

Central hepatectomy is a highly specialized form of liver-sparing surgery, indicated for tumors located in the central segments of the liver. Although it is technically demanding due to the proximity of major vascular and biliary structures, it offers the greatest volume of healthy liver and reduces the risk of post hepatectomy liver failure. Central hepatectomy is safe, allows an oncologically adequate liver resection with a good functional remnant, and can be performed safely in high-volume hepatobiliary centers with appropriate patient selection and meticulous surgical technique. Almost all patients return successfully to their previous level of function and begin routine work relatively few months after appropriate postoperative management and monitoring. 

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FAQ

Why central hepatectomy preferred rather than major hepatectomy?

• More normal liver parenchyma is preserved which reduces the risk of post hepatectomy liver failure – this is of particular importance in cirrhotic patients or those with limited liver reserve.

Is central hepatectomy a high-risk operation?

• While technically demanding, it is safe in the hands of experienced hepatobiliary surgeons. The general risk is reasonable, and in most cases is lower than that associated with extended liver resections.

Can the liver regenerate after central hepatectomy?

• Yes. The liver is highly regenerative; regrowth occurs within weeks and functional recovery within the recovery takes 3-6 months.

Is central hepatectomy done laparoscopically or robotically?

• Yes, in selected cases in specialized centers with expertise.

Will you need any further treatment after the surgery?

• Some, especially with cancer, may require chemotherapy or other treatments based on the pathology findings.