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03 / Hepatobiliary Surgery · open

Liver resection (segmentectomy)

Removal of anatomical liver segments along Couinaud's planes: cancer surgery built on the fact that the liver is eight independent territories, each with its own inflow, outflow and duct.

Indication: Colorectal liver metastases, hepatocellular carcinoma in a non-cirrhotic or well-compensated liver, and symptomatic benign lesions.

Part of Hepatobiliary Surgery →4 stages3 complications to knowopen

On the tray for this operation

Test yourself on the tray

Stage

1 / 4

Assessment and ultrasound

The abdomen is staged for disease beyond the plan, the liver mobilised on its ligaments, and intraoperative ultrasound maps the lesion, the hepatic veins and the portal pedicles.

🔧 Richardson retractor🔧 DeBakey forcepsExplore anatomy: The biliary tree & its variants

Watch for: Unrecognised additional lesions · Injury during mobilisation of the bare area

Why are we operating?

Liver resection removes tumours along the liver's vascular geography: because each Couinaud segment has its own inflow and drainage, territory can be taken with its vessels controlled while the remainder keeps working. It cures a real fraction of colorectal liver metastases and treats primary tumours in livers that can afford it, and the whole plan is arithmetic about the remnant.

Pulls toward surgery

Resectable colorectal liver metastasesHepatocellular carcinoma in a compensated liverAdequate future liver remnant with intact plumbingSelected benign lesions with symptoms or diagnostic doubt

Gives the team pause

Cirrhosis and portal hypertension rewriting the marginsA remnant too small (grow it or stage it, do not gamble it)Extrahepatic disease reframing intent

Shared foundations

The liver's segmental anatomy

Couinaud's segments turn the liver from an organ into an operable map: eight territories, each with its own portal inflow, arterial supply and biliary drainage. Resection planning, tumour reporting and the operation itself all speak this language.

Understand it once, in the specialty hub

What the surgeon is thinking

  • Assessment and ultrasound

    Why does the operation begin with an ultrasound probe on the liver?

    Intraoperative ultrasound is the final staging test and the final planning meeting: it finds lesions the preoperative imaging missed and maps each tumour against the hepatic veins and pedicles in real time. The transection lines are drawn on its answers, not on the CT's memory.

  • Inflow control

    What is inflow control actually controlling?

    The hepatoduodenal ligament carries the entire portal and arterial inflow: encircling it allows the Pringle manoeuvre, intermittent clamping that turns transection bleeding down at its source. Clamp cycles are timed because inflow occlusion is borrowed ischaemia, tolerated in intervals, resented in continuity.

  • Parenchymal transection

    Why does the anaesthetist's CVP matter as much as the surgeon's technique?

    Transection bleeding is mostly hepatic-vein bleeding, and vein bleeding is pressure-dependent: a low central venous pressure keeps the veins soft and the field readable. The quietest liver resections are duets, with the anaesthetist running one half of the haemostasis.

  • The cut surface and drains

    What is the cut surface's job after the specimen leaves?

    To neither bleed nor leak bile: the raw surface is inspected, sealed and tested because its two late complications, haematoma and bile leak, are exactly the ones that convert a good resection into a long admission. A drain near the surface is a monitor as much as a treatment.

Decision points

  • Anatomic segmentectomy or non-anatomic wedge for a 3 cm metastasis?

    • Anatomic resection

      Takes the segment on its vascular boundaries: cleaner planes, and the oncologic default for HCC, which spreads along portal territories.

    • Non-anatomic (parenchyma-sparing) resection

      For metastases, margins matter more than boundaries: sparing parenchyma keeps future options, since these patients may need the liver again.

    The tumour's biology chooses the geometry: HCC respects portal territories, metastases respect margins. Parenchyma-sparing surgery treats the liver as a resource across a whole disease course, not a single operation.

  • Bleeding accelerates mid-transection. What is the sequence?

    • Pringle on, pressure, and lower the CVP

      The rehearsed triad: inflow clamped in cycles, direct pressure on the surface, anaesthesia dropping the venous pressure further.

    • Chase individual vessels in a red field

      The instinct to resist: blind clamping in the liver tears veins and biliary structures that patience would have controlled.

    Liver bleeding is managed by physiology first and instruments second: control inflow, control pressure, and let the field declare its vessels. The manoeuvres were named before the operation started, which is what makes them available under stress.

Leaving the OR

The handoff

Procedure
Resection of segments VI/VII for colorectal metastases
Remnant
Volumetry adequate; inflow and outflow intact; IOUS found no new lesions
Operative course
Pringle 3 cycles, total 28 min; low-CVP anaesthesia; minimal transfusion
Watch for
Drain colour (bile), glucose and lactate as remnant function, coagulation drift day 1-2

A fictional educational patient, handed over the way real ones are.

The postoperative course

  1. POD 0-1The remnant's function is monitored in the chemistry: lactate, glucose, INR and bilirubin say whether the remaining liver is coping.
  2. POD 2-4Transient transaminase rise settles; mobilisation and feeding proceed; bile in the drain rewrites the plan toward drainage and ERCP.
  3. POD 5-7The collection window for the cut surface: fever plus a fluid collection near the raw area is drained, not watched.
  4. WeeksHistology and margins to MDT; the liver regenerates over weeks, and surveillance imaging inherits the long game.

Watch it done

Find Liver resection (segmentectomy) videos on YouTube

What can go wrong

Postoperative bleedingBile leakIntra-abdominal abscess
OR Prep this operationReview the instruments