laparoscopic surgery in the upper abdomen, involving the liver, gall bladder, pancreas, spleen.

1. Dr. Harshal Rajekar MS MRCS DNB
Hepatobiliary, GI and transplant Surgeon,
Pune

2. The myth
• Prometheus enraged the Gods after climbing
the Mount Olympus and stealing the torch in
order to give fire to the humans.
• He was punished by Zeus and chained to a rock
in the Kaukasus Mountains. Every couple of
days, an eagle came and ate part of his liver.
• As the liver regenerated every time, the
eagle returned again and again to
eat the liver and thereby torture
poor Prometheus.

3. Longmire, called it a "hostile" organ because it welcomes
malignant cells and sepsis so warmly, bleeds so copiously, and
is often the 1st organ to be injured in blunt abdominal
trauma.
Yet, the liver is able to regenerate after massive loss of
substance, and is able, in many ways, to forgive insult.
Liver surgery started in the early 1900s. In the
beginning, however, blood loss and mortality
were considerable.
A multicentre analysis in 1977 of more than 600
hepatic resections for various indications showed
an operative mortality of 13%, which rose to 20%
for major resections

4. What is HPB and why is it special?
HPB – separate specialty.
Why?
Complex physiology.
Medical intricacies.
Blood loss, vascularity and portal hemodynamics.
Anatomical complexities.
Difficult to access.

5. So… whats new?
Many advances in the last 2 decades.
Liver surgery.
Liver failure and liver transplantation.
Portal hypertension.
Cholangiocarcinoma.
Liver metastases.
Pancreatitis – acute and chronic.
Biliary tract disorders.

6. Liver Tumours
Incidentally detected mass lesion/ SOL in the liver:
What to do……..?
Clinical history …. h/o liver disease, cirrhosis, previous
malignancy? HBV, HCV?
Other symptoms and medications…. i.e. jaundice, pain,
weight loss, drugs like OCPs.
Tumor markers.
Imaging.
Most of the time biopsy is not required!

7. Algorithm for Solitary SOL of Liver on
USG

8. Solid lesions with malignant potential

9. Liver resection:
J Am Coll Surg. 2010 Oct;211(4):443-9. Epub 2010 Aug 8.
Perioperative management of hepatic resection toward zero mortality
and morbidity: analysis of 793 consecutive cases in a single institution.
Kamiyama T, Nakanishi K, Yokoo H, Kamachi H, Tahara M,
Yamashita K, Taniguchi M, Shimamura T, Matsushita M, Todo S.
Hokkaido University , Sapporo, Japan.
CONCLUSIONS: Shorter operative times and reduced blood loss were
obtained by
 Improved surgical technique and
 New surgical devices and
 Intra-operative management, including anesthesia.

10. Comments
Liver functional reserve and liver remnant volume
Precise delineation of vascular relations using CT
angiography and volumetry
The independent relative risk for morbidity was
influenced - by an operative time >360 minutes,
- blood loss of more than 400 mL, and
- serum albumin levels of less than 3.5 g/dL.
Assessment of liver reserve.
Hepatic resection can be undertaken safely, and
increasing experience as a hepatic surgeon is associated
with greater utilization of parenchymal sparing and
extended resections.

11. Laparoscopic liver surgery:
Feasible.
Easily done procedures – left lateral segmentectomy,
exophytic tumours, pedunculated tumors.
CUSA/ staplers.
Problems: -
Exposure
Bleeding
Retraction and instrumentation.
Retrieval.

12. Pushing the limits
128 patients underwent extended hepatectomy for
malignant diseases (n =15; 11.5%). Thirty-two left and
ninety-five right extended hepatectomies were performed.
Eight patients also underwent caudate lobe resection, and
40 patients underwent a synchronous intraabdominal
procedure. Multivariate analysis showed that a
synchronous intraabdominal procedure was the only
factor associated with an increased risk of morbidity
(hazard ratio [HR], 4.9; P = 0.02). The median survival was
41.9 months. The overall 5-year survival rate was 25.5%.
Annals of Surgery. 239(5):722-732, May 2004.
Vauthey, Jean-Nicolas
University of Texas M.D. Anderson Cancer Center, Houston, TX.
Is Extended Hepatectomy for Hepatobiliary Malignancy Justified?

13. Portal Hypertension:
2 types of portal hypertension:
cirrhotic and
non- cirrhotic.
In NCPF, liver function is well preserved. Other problems
with NCPF include UGIB, hypersplenism,
splenomegaly, ectopic varices .
Rare problems with NCPF : Portopulmonary
hypertension, Hepatopulmonary syndrome and more
often portal biliopathy.

14. Whom to operate and when?
Surgical shunts are indicated in patients
with failure of endotherapy,
ectopic varices, symptomatic hypersplenism or
symptomatic biliopathy.
Persistent growth failure,
impaired quality of life or
massive splenomegaly that interferes with daily activities are other
surgical indications.
Rex-shunt / MLPVB is the recommended shunt for EHPVO.
NCPF, Hepatic schistosomiasis, CHF and NRH have similar
presentation and comparable prognosis.
Khanna R, Sarin SK. Non-cirrhotic portal hypertension - Diagnosis and
management. J Hepatol. 2013 Aug 23.

15. Surgery for portal hypertension:
Zentralbl Chir. 2010 Jun;130(3):238-45.
Surgical treatment of portal hypertension.
Wolff M, Hirner A. Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und
Gefässchirurgie, Rheinische Friedrich-Wilhelms Universität, Bonn.
Surgical shunt procedures continue to be safe, highly effective and durable
procedures to control variceal bleeding in patients with good liver function.
For patients with noncirrhotic portal hypertension, esp. EHPVO, portosystemic
shunt surgery represents the only effective therapy which leads to freedom of
recurrent bleeding and repeated endoscopies for many years, and improves
hypersplenism without deteriorating liver function.

16. Arch Surg. 2007 Jan;136(1):17-20.
Transjugular intrahepatic portasystemic shunt vs surgical shunt in good-
risk cirrhotic patients: a case-control comparison.
Helton WS, et al. Providence Seattle Medical Center, USA.
PLACE OF SHUNT SURGERY IN CLINICAL PRACTICE:
Operative portal decompression is more effective, more
durable, and less costly than TIPS in Child-Pugh class A and B
cirrhotic patients with variceal bleeding.
Good-risk patients with portal hypertensive bleeding should be
referred for surgical shunt.
Shunt surgery is an important treatment for noncompliant
patients or patients living in areas where access to TIPS,
repeated hospitalization and liver transplantation, is limited. It
is safe and effective.

17. Indian J Gastroenterol. 2005 Nov-Dec;24(6):239-42.
Prophylactic surgery in non-cirrhotic portal fibrosis:is it worthwhile?
Pal S, Radhakrishna P, Sahni P, Nundy S, Chattopadhyay TK.
Department of GI Surgery, AIIMS, New Delhi
INDIAN SCENARIO:
In patients with high-risk esophagogastric varices or
symptomatic splenomegaly and hypersplenism,
Patients with high-risk esophagogastric varices or
symptomatic splenomegaly and hypersplenism.
Patients with other complications of portal hypertension.
Patients with poor access to prompt healthcare.

18. Liver failure
2 types of liver failure:
Acute : fulminant liver failure – reversible or
irreversible.
Irreversible FHF qualifies for a transplant
Chronic : i.e. cirrhosis
Decompensated cirrhosis, or cirrhosis with cancer and
in patients with PSC, quality of life indicators

19. ACUTE LIVER FAILURE
Indian J Crit Care Med. 2012 Jan;16(1):1-7.
Structured approach to treat patients with acute liver failure: A hepatic
emergency.
Kumar R, Bhatia V. Department of Hepatology, ILBS Delhi.
Acute liver failure (ALF) is a condition of acute hepatic emergency
where rapid deterioration of hepatocyte function leads to hepatic
encephalopathy, coagulopathy, cerebral edema (CE), infection and
multi-organ dysfunction syndrome resulting in a high mortality rate.
Urgent liver transplantation is the standard of care for most of these
patients.

20. Fulminant liver failure
Kings College criteria
Clichy criteria.
PGIMER (Chandigarh) criteria.

21. Acute Liver Failure (irrespective of etiology)
• Contact transplant team when INR is >2.
End-stage Chronic Liver Disease.
Refer to transplant team when
• Child-Pugh score reaches >6 points.
OR
• At first decompensation with ascites, encephalopathy, variceal
bleeding or jaundice
OR
• At diagnosis of HCC in cirrhosis, provided the Milancriteria are met.
OR
• Impairment of quality of life due to liver disease becomes intolerable
(intractable pruritus, invalidating fatigue and/or performance
status).

22. What's new?
Acute liver failure (ALF) is a disease with a high mortality
 Standard therapy at present is liver transplantation.
Liver transplantation is hampered by the increasing
shortage of organ donors,
 Bioartificial liver therapy for bridging patients with ALF
to liver transplantation or liver regeneration is promising.
Its clinical value awaits further improvement of BAL
devices, replacement of hepatocytes of animal origin by
human hepatocytes, and assessment in controlled clinical
trials.

23. Transplanation for HCC
Milan criteria.
UCSF criteria.
Asan criteria.
Rule of 7.
Japanaese liver tumor study group criteria.
Transplantation superior to surgical excision in
patients with cirrhosis. Surgery is better than RFA,
which is better than TACE.

24. RFA and TACE
Is RFA stand alone treatment for HCC?
Complete response rate only 55% (63% for <3 cm)
> 3 cm in size and > 1 year wait for OLTx
High rate of recurrence in explanted liver
Child’s B group, RFA and surgical resection similar
survival, therefore they should be transplanted
Not an independent therapy for HCC!

25. Surgical Resection Versus Percutaneous
Radiofrequency Ablation in the Treatment
of Hepatocellular Carcinoma on Cirrhotic
Liver.
One- and 3-year survival were 78 and 33%; 1- and
3-year disease-free survival were 60 and 20%.
The advantage of surgery was more evident for
Child-Pugh class A patients and for single tumors
of more than 3 cm in diameter.
(Vivarelli et al, Annals of Surg)

26. Pancreatitis
Acute.
Alcohol.
Gall stone.
Role of surgery –
Necrosectomy;
Complications of acute pancreatitis.
Chronic.

27. Intervention in acute pancreatitis
Infected necrosis, pancreatic abcess, infected peri-
pancreatic collections.
Bleeding.
May be laparoscopically OR retroperitoneoscopic,
endoscopic.
Severity of disease,
Multi-organ failure
Fluid collections.
ARE NOT INDICATIONS FOR SURGERY OR INTERVENTION!!

28. Acute pancreatitis
We studied 70 consecutive patients with SAP (severe acute panc)
with no mortality, 14 were managed medically, 29 managed with
PCD alone, whereas 27 required surgery after initial PCD.
CONCLUSIONS:
PCD reversed sepsis in 62% and avoided surgery in 48% of the
patients. Reversal of sepsis within a week of PCD, APACHE II score
at first intervention (PCD), and organ failure within a week of the
onset of disease could predict the need for surgery in the early
course of disease.
Ann Surg. 2013 Apr;257(4):737-50.
Predictors of surgery in patients with severe acute pancreatitis managed by the
step-up approach.
Babu RY, et al. PGIMER, Chandigarh

29. ERCP should be considered in patients with co-existing
cholangitis or biliary obstruction. However, in patients with
acute gallstone pancreatitis, there is no evidence that early
routine ERCP significantly affects mortality, and local or
systemic complications of pancreatitis, regardless of predicted
severity. (when there is no biliary obstruction or cholangitis)
Cholecystectomy should be delayed in patients who
survive an episode of moderate to severe acute biliary
pancreatitis and demonstrate peripancreatic fluid
collections or pseudocysts until the pseudocysts either
resolve or persist beyond 6 weeks, at which time
pseudocyst drainage can safely be combined with
cholecystectomy.

30. Chronic pancreatitis
Whom to evaluate?
Recurrent pancreatitis.
Unexplained pancreatitis.
Pancreatic calcification/ stones.
Dilated MPD.
Pancreatic pain.

31. Classical triad:
Pain (radiating to back0.
Recurrent attacks of
pancreatitis.
Diabetes.
Weight loss.
Stones.

32. Surgical options in chronic
pancreatitis
Pancreaticojejunostomy (Partington-Rochelle)
Drainage and resection of pancreatic tail (Puestow-Mercadier)
Left resection of the pancreas with retrograde
pancreaticojejunostomy (Duval)
Extended drainage with limited excision of the pancreatic head
(Frey)
Customized cephalic and longitudinal ductal drainage
(Hamburg)
Duodenum-preserving resection of the pancreatic head (Beger)
Pylorus-preserving partial duodenopancreatectomy (Whipple)
Total pancreatectomy

33. J Gastrointest Surg. 2000 Jul-Aug;4(4):355-64.
Quality of life and long-term survival after surgery for chronic pancreatitis.
Sohn TA, et al. The Johns Hopkins Medical Institutions, Baltimore
Patients reported improvements in all aspects of the quality-of-life survey
including enjoyment out of life, satisfaction with life, pain, number of
hospitalizations, feelings of usefulness, and overall health (P < 0.005).
In addition to improved quality of life after surgery, narcotic use was
decreased (41% vs. 21%, P < 0.01) and alcohol use was decreased (59% vs.
33%.
These data suggest that surgery for patients with chronic pancreatitis can be
performed safely with minimal morbidity and excellent long-term survival.

34. Cholangiocarcinoma
Hilar Cholangiocarcinoma – complex disease
Proximity to large vessels.
Difficult to get margins.
Klatskin tumors – even more difficult.
Liver resection is must for adequate clearance.

35. Annals of Surgery. 240(1):95-101, July 2004. Kondo, Satoshi et al; Hokkaido
University Graduate School of Medicine, Japan.
Forty Consecutive Resections of Hilar Cholangiocarcinoma With No
Postoperative Mortality and No Positive Ductal Margins: Results of a
Prospective Study
Results: Hospital or 30-day mortality and morbidity rates were 0% and
48%, respectively. The overall 3-year survival rate and median survival
time were 40% and 27 months. Survival of patients with Bismuth type
III or IV tumors or of patients who underwent right hepatectomy was
significantly better. Survival of patients who underwent concomitant
vascular resection was similar to survival of those who did not.
Univariate analysis indicated the type of hepatectomy, histopathologic
grade, Bismuth classification, concomitant hepatic artery resection,
and International Union Against Cancer stage as significant prognostic
factors.

36. Preoperative biliary decompression
Portal vein embolization
No positive ductal margins

37. Acta Gastroenterol Latinoam. 2012 Dec;42(4):291-300.
Surgical resection with curative intent of hilar
cholangiocarcinoma. Our experience.
Vaccarezza H, Ardiles V, et al. Hospital Italiano de Buenos Aires,
Argentina.
The association of major hepatectomy with caudate lobe
resection and vascular resection when needed, was
associated with 95% tumor-free margin and morbidity and
mortality rate according to the standards of the
international literature.
Associated vascular resection seems to be a feasible and safe
option in the treatment of locally advanced disease.

38. What's Hot ?
Preoperative biliary decompression
Intraarterial chemotherapy for colorectal mets
PVE alone without TACE in HCC
Wait, wait, wait for biliary fistula
Liver transplant for metastatic cancer.
TIPS – covered stents….?