Extended Right Hepatectomy

Extended right hepatectomy surgery

An extended right hepatectomy (or right trisectionectomy) is a significant liver resection when the right lobe of the liver is resected (or partially resected) along with a portion of the left lobe. This normally comprises segment V, VI, VII, VIII and segment IV of the liver. Its aim is to cure liver disease and still have enough healthy liver to still maintain normal liver functioning.

Indications

Extended right hepatectomy was reserved for those with generalized disease such as:

• Hepatocyte cell carcinoma (large liver tumours) 
• Liver metastases with colorectal cancer.
• Intrabiliary hepatic metastasis in a case of gallbladder carcinoma.
• Large non-viral liver masses 
• Traumatic Liver injury 

Extended right hepatectomy procedure

Extended right hepatectomy (right trisectionectomy) is a complex liver resection that involves the right liver (segments V-VIII) together with right segment IV, but that of the left (segment II and III) is preserved. 

Preparation before Surgery

• Invasive monitors General anaesthesia.
• DVT prophylaxis and antibiotic prophylaxis.
• Ultrasound intraoperative to identify tumor and vascular anatomy.
• Checking the future liver remnant (FLR) sufficiency.

Surgical Access

• Open access through right subcostal incision with midline extension (chevron or Mercedes-Benz incision)
• Only the highly specialized centers use laparoscopic/robotic approach.

Liver Mobilization

• Falciform, coronary and right triangular ligaments division.
• Right liver mobilization off the diaphragm.
• Attentive safeguarding of the inferior vena cava (IVC).

Inflow Control (Hilar Dissection)

Identification and isolation of:

• Right hepatic artery
• Right portal vein
• Segment IV portal pedicle

Ligation and division of:

• Right hepatic artery
• Right portal vein
• Segment IV inflow branches

Pringle maneuver can be applied on a case by case basis in order to minimize blood loss.

Outflow Control

Identification of:

• Right hepatic vein
• Middle hepatic vein (commonly liken in prolonged right hepatectomy)
• Subdivision of the hepatic veins near IVC.

Liver Parenchymal Transection

• Segment II–III Transection plane and segment IV.

Techniques used:

• CUSA (ultrasonic dissector)
• Harmonic scalpel
• Clamp-crush technique
• Minimal bile ducts and vessels are cut or closed.
• Constant management of bleeding and bile discharge.

Specimen Removal

En bloc removal of:

• Right liver (segments V–VIII)
• Segment IV
• Specimen referred to a histopathology laboratory.

Hemostasis and Bile Leak Test

• Close examination of liver cut surface.
• Saline or dyes via bile system test.
• Hemostatic agents on demand.

Drain Placement and Closure

• One or two intraperitoneal drains that are around transection surface.
• Layered abdominal wall closure.

Post-Operative Care 

• Move to ICU under observation.

Serial monitoring of:

• Liver function tests
• Coagulation profile
• Drain output

Duration of Procedure

• 5-8 hours, depending on the complexity of tumors and adhesions.

Extended right hepatectomy recovery

The success rate of recovery following a long right hepatectomy (right trisectionectomy) is slow since it is a significant liver operation. Most patients postoperative care can and do recover well, with a healthy remaining liver.

Postoperative Period (Day 0-2)

• ICU occupancy: 24-48 hours close observation.

Continuous monitoring of:

• Blood pressure, urine output
• Liver function tests  
• Coagulation (INR)
• Epidural or IV analgesia in the management of pain.
• Oxygen therapy and chest physiotherapy.
• Early movements of limbs to avoid clots.

Early Recovery in hospital (Days 3-7) 

• Transfer from ICU to ward

Gradual removal of:

• Oxygen support
• Urinary catheter
• Liquid foodstuff to soft foodstuff to normal foodstuff.
• Output observed (leaking bile or bleeding)
• Ambulation to enhance pulmonary blood flow and oxygenation.

Hospital Stay

• Average stay: 7–14 days
• Drains are customarily withdrawn when output is small and non-bilious.
• Release after normalization of liver and pain.

Liver Regeneration

• The remaining liver (segments II and III) starts regenerating in days.
• Considerable regeneration takes place after 2-4 weeks.
• Functional recovery is typically attained at 6-8 weeks.

Home Recovery (Weeks 2–6)

• Mild fatigue is common
• Slowly progressive rise in activity each day.
• Avoid heavy lifting (>5 kg)
• Infection surveillance and wound management.
• Breathing exercises should be continued.

Diet During Recovery

• Protein-rich diet with the aim of liver regeneration.
• Small, frequent meals
• Adequate hydration

Avoid:

• Alcohol
• Oily and processed foods
• Unprescribed medications

Follow-Up Schedule

• First follow-up: 7 -10 days post discharge.
• Repeat blood tests, repeat imaging as recommended.

If cancer-related:

• Chemotherapy/Additional treatment consultation Oncology.

Return to Normal Activities

• Light activities: 2–3 weeks
• Office work: 4–6 weeks
• Complete physical activity: 8 -12 weeks.
• Driving: typically in 3-4 weeks, pain-free.

Best hospital for extended right hepatectomy India

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

Conclusion

An extended right hepatectomy is a very complicated procedure that is life saving and has been done to patients with extensive liver tumors or further hepatobiliary diseases. Even though it is associated with the loss of a significant part of the liver, the patient should be carefully selected, the surgery should be performed in the most accurate way, and the postoperative care should be detailed, which allows the rest of the liver to recover and resume its functions. There has been an improvement in the outcomes due to the development of imaging, perioperative management, and hepatobiliary surgical expertise. The majority of patients recover well and have a good quality of life, particularly when surgery is done in centers with good experience and facilitated with systematic follow up care. Finally, prolonged right hepatectomy is a curative or disease-controlling procedure in patients who otherwise would result in limited treatment options, indicating it is a key procedure in the current liver surgery.

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FAQ

How does it compare to right hepatectomy?

• Standard right hepatectomy (S4B resection), in addition to removing segments V–VIII, also involves removal of segment IV (S4) to the left of the middle hepatic vein.

Can the liver regrow after such large chunk taken out of it?

• Yes. The liver begins to regenerate within days with major functional recovery by 6 to 8 weeks.

Is this surgery curative for cancer?

• For some, surgery can be curative. It may be curative, especially if a negative margin is obtained.

Do I need chemotherapy after surgery?

• It depends on the diagnosis. Many patients with cancer now receive adjuvant chemotherapy.

Can you do this surgery laparoscopically?

• It can be done laparoscopically or robotically in selected high-volume specialized centers only.