The Impact of Segmental Anatomy on Hepatic Oncologic Resections

Gross Dissection of Liver for Hepatocellular Carcinoma Using AJCC Cancer Staging Manual 8th Edition: Anatomical and Practical Considerations

“…Thorough review of clinical history will enlighten the dissector as to the surgeon' s intraoperative findings, the lobes, segments, any structures removed, as well has any history of previous liver surgeries, diagnoses, or therapies. Particular attention should be paid to the surgical report, number, location, and size of previously identified tumors, as well as previous therapies such as resection, and oncological or ablative procedures (11). The partial hepatectomy is subdivided into: (i) major hepatectomy, when three segments or more are involved, and (ii) minor hepatectomy, when the resection involves only one or two segments.…”

Perspectives on Hepatic Metastases and the Minimally Invasive Approach to Resection

“…The ability of the surgeon to remove large volumes of liver tissue safely and with expectation of survival depends on a knowledge of the anatomy of the liver 16 and on an appreciation of the extraordinary rapid regenerative capacity following major resection, which have been extensively studied. 17 Following resection as extensive as a right hepatectomy (at which half the liver mass is removed), liver size is regenerated within 3-4 weeks.…”

“…However, segmental liver resection of localised tumours, based on Couinaud's liver segmental classification (Figure 1), would improve vascular control (less blood loss), minimise the risk of recurrence from intrahepatic spread, and reduce the amount of normal liver unnecessarily removed. 16 Clearly, for small, awkwardly located lesions (such as the apex of Segment VIII in the axilla of the right and middle hepatic veins), local resection might be preferable to formal hemihepatectomy, whereby a whole, healthy lobe may need to be sacrificed for a small deposit. For larger metastases or multiple deposits, standard anatomical resections based on Couinaud segments should ensure adequate margins unless this increases the risk of postoperative liver failure.…”

“…1,24,32 Approximately 20% of patients have liver-only recurrence, with more than one-third occurring in the opposite side of the liver 39 and hence amenable for re-resection. 1,24,25,40 16 When disease recurs in the liver, it is more often at some site distant from the original resection line and most likely to have arisen in undetected micrometastases present at the time of original liver resection. 1,24 This would corroborate the importance of perioperative chemotherapy in surgical oncology as it increases progression-free survival.…”

“…Figure 1: Couinaud's segmental anatomy of the liver (with permission: Weledji et al Curr Surg Rep 2016;4:4) 16. …”