Do they perform liver surgery for cancer? Preparing for surgery

Girls, don’t pass by, we really need your advice, opinions and support.
I recently had a CT scan of the adrenal glands due to high cortisol, everything is fine with the adrenal glands, but they discovered a mass in the liver measuring 9 cm!. It turned out to be focal nodular hyperplasia of the liver, in general benign education, not dangerous. But due to the fact that the size is quite large and it is unknown whether it will grow and at what speed they propose to remove it. Moreover, it seems to depend on hormonal drugs containing female hormones, like OK, which were prescribed to me more than once, perhaps it grew from them. Besides, I’m planning B, and here it’s serious hormonal changes body and medications may be needed, etc. The most important thing is that it is unknown even when it appeared; it is not visible on an ultrasound at all! even now! I previously had an ultrasound of the abdominal cavity, everything was fine. The tests and biochemistry are also fine. This is how you live without suspecting anything and by chance such a find (((
The doctor gave me time to think, when I decide to have the operation, I can watch her for several months, her growth, but what will this change, she won’t get any smaller (((
I'm very afraid of surgery, because... it is very difficult and dangerous, there are often complications and a long postoperative recovery period. Moreover, I can’t stay in hospitals at all, I fall into depression, panic, I can’t sleep there at all, I feel so sick from fatigue and insomnia that even my pace increases. It’s like some kind of phobia, some people have claustrophobia, but I have hospital phobia. I was in bed for 5 days after lapora and almost went crazy, it’s hard for me to spend even 2 days in the hospital, I try to avoid hospitals by all means, but I have to lie here for at least 3 weeks (((
In general, thoughts about the operation are driving me crazy, I’ve lost my appetite, I don’t sleep well, I’m all on my nerves, I even have panic attacks, I have a generally weak psyche and nervous system. I’m on repose, which doesn’t help much.
It’s scary that there is no information on the Internet about this operation, or rather reviews of those who have gone through this, since it is important for me to know what awaits me. When I went to the labora, I dug through a bunch of information, tons of reviews, I knew everything thoroughly and it was easier for me. And here there is complete ignorance, if you come across phrases about this operation, it’s just that it’s VERY HARD.
That’s why I have a big request to you girls, if anyone has had liver surgery or your loved ones or friends, please write how it’s going. Or about other abdominal surgeries (not gynecology). I would like to know what is being prepared, various nuances, etc. Maybe someone knows something about the Vishnevsky Institute of Surgery, I would also be glad to receive information, especially from those who were treated there. And also tell me how you psychologically prepared and set yourself up for those who were facing difficult operations of any nature. In general, I will ask for any information, any opinion, you can write in a personal message

Rehabilitation after liver surgery is extremely important.

Activation.

Early activation after surgery is needed. You will be allowed to get up on the first day after surgery. With the help of a nurse or person caring for you, you will need to short walks by department or ward.

Breathing exercises.

After liver surgery, it can be difficult to take a full breath due to pain. Shallow breathing and a sedentary lifestyle in the first days after surgery can lead to congestion in the lungs with the subsequent development of pneumonia. It is necessary to perform breathing exercises. Your doctor will give you recommendations.

Nutrition.

On the first postoperative day you will be allowed to consume no a large number of water. From the second day after liver surgery, you will be allowed frequent fractional meals ().

Anesthesia.

An important aspect of rehabilitation is adequate pain relief. If you experience pain in the surgical area, tell your doctor so that he can prescribe you painkillers.

After discharge.

Discharge after liver surgery, in the absence of complications, occurs on the 5-7th postoperative day.

You may feel discomfort in the surgical suture area for 2-3 weeks of surgery. Painful sensations They also go away completely 2-3 weeks after surgery.

Shower.

After laparoscopic liver surgery, you can take a hygienic shower 3-4 days after the operation. If you had open liver surgery, you can take a shower 6-7 days after the operation.

Postoperative suture.

If the suture is cosmetic and absorbable suture material was used during suturing, then there is no need to remove such sutures.

If it is necessary to remove stitches, the doctor will inform you about this.

Diet.

You can eat all foods except those that your doctor has forbidden you. As a rule, after liver surgery it is prescribed.

Activity.

After liver surgery, you need to maintain an active lifestyle. You can move, walk a lot. You should not lift more than 3 kg for the first 3 months after surgery.

Ask your doctor when you can return to your normal activities, including your work.

When to call your doctor.

• Your temperature has risen to 38 degrees Celsius or higher;
• Your post-operative wound has become red, hot, and fluid is leaking from it;
• You regularly vomit after eating or drinking water;
• You have jaundice (yellow sclera of the eyes, dark urine);
• You severe pain, which are not relieved by taking analgesics.

If you cannot contact your doctor, immediately go to the clinic or call an ambulance.

Postoperative examination.

Some time after surgery, your doctor will schedule outpatient screening tests to monitor your condition. Don't forget to visit your doctor for outpatient check-ups.

We suggest you read the article on the topic: “What types of liver surgeries are there?” on our website dedicated to liver treatment.

• Types of liver operations
• After the procedure
• What is laparoscopy

Liver surgery is a series of surgical procedures that must be performed in cases such as cancer, cyst, abscess, trauma, and benign tumor. Most often it is based on tumor removal or transplantation.

The liver is a vital organ that is located in the abdominal cavity below the diaphragm and performs a large number of functions. It is divided into lobes, which in turn are divided into secondary lobes, and these into segments or sections. Normally, in an adult, the liver weighs between 1,200-1,800 g, but this characteristic depends on age. A distinctive quality of this internal organ is the ability to regenerate, that is, restore its original size when part of the tissue is removed.

In the case of liver cancer, organ resection may be performed. The essence of resection is removal. There may be removal of a single segment, a section, a lobe, a lobe and a section, or the entire organ. Combined resection will combine the removal of not only a fragment of the liver, but also complete or partial removal another abdominal organ, such as the small intestine.

The peculiarity of resection is that it requires the work of a highly qualified professional. This is necessary to reduce the risk of postoperative bleeding or infection, complications after general anesthesia. In addition, before the operation it is necessary to take into account all possible diseases, even those that are not life-threatening and easily treatable.

Another option is radiofrequency ablation, that is, inserting a needle into the organ and influencing it with radiofrequency radiation. Chemoembolization - application chemical preparation by introducing it into a vessel of a certain part of the liver.

If a cyst forms, puncture sclerotherapy can be used. This operation involves inserting a needle into the cyst, and through it a certain drug. Or laparoscopy - a procedure performed using special punctures in the anterior abdominal wall.

For an abscess, puncture drainage can be used, which is based on inserting a needle into the abscess, then removing the pus, washing the cavity and removing the drainage. As well as laparoscopy or resection.

If the patient has cholelithiasis, laparoscopy can be used. The method of cholecystectomy is resection of the gallbladder itself. Endoscopic removal stone - removal using an endoscope through the oral cavity.

In the case of diseases of the pancreas, pancreaticoduodenal resection is permissible, that is, removal of the pancreas and duodenum when it comes to malignant tumor. Or removal of only the pancreas or part of it.

A separate type of operation is organ transplantation. This option is available in situations with tumors that do not damage nearby blood vessels, and in cases of significant damage that impairs organ function. However, complications such as infection in the rehabilitation period, rejection of a transplanted organ, increased blood pressure and cholesterol, the development of kidney disease and diabetes.

In addition, liver punctures and sutures are performed.

Punctures are performed to biopsy tissue and are most often performed where the organ is hidden under the arch of the ribs. In this case, the action is performed along the anterior or midaxillary line in the region of the 9th or 10th intercostal space.

Sutures are placed when traumatic injuries or after resection. To prevent the suture threads from cutting through the tissue, fibrin buttons are used, which dissolve over time.

Return to contents

After the procedure

After liver surgery, the patient must be monitored in the hospital. This is necessary for proper recovery stable and normal functioning of the body. And also to prevent or treat any complications that arise after surgery.

In addition, a diet is required after surgery. It is based on the fact that food must be taken at least three times a day and a maximum of five, at intervals of four hours. However, the nutrition is not natural, but parenteral. Parenteral nutrition is the administration of necessary substrates using a tube or nutritional enema. Food products must be in a liquid state.

The diet is needed in order to enhance the effect after treatment and increase the effect of the medications used. At the same time, it is necessary to observe the ratios of the amount of proteins consumed (at least 90 g), fats (at least 90 g) and carbohydrates (at least 300 g). The amount of cholesterol consumed should be reduced as much as possible. The amount of fat is the same for each meal, and in no case should you eat exclusively fatty foods. And the transition to natural food consumption should be carried out gradually, over five days.

Return to contents

What is laparoscopy

Laparoscopy is the currently used method for performing surgery on internal organs through holes in the (most often) abdominal wall.

The method owes its name to the main instrument - the laparoscope. It is a pipe containing lenses and a video camera in its structure.

The positive qualities of laparoscopy are that the traumatism of the operation is reduced and the duration of recovery within the hospital is reduced.

In addition, the absence of pain and scars after surgery is significant for the patient. And for the surgeon - simplification of the mechanism of the procedure.

However, there are also negative sides. Laparoscopy has a significant limitation of possible motor manipulations and disrupts the perception of the depth of tissues and organs. In addition, the lack of manual work causes difficulty, because only special tools are used, and it becomes difficult to keep track of the force used.

Laparoscopy may cause complications such as:

• violation of the integrity of blood vessels and intestines;
• electrical burns leading to organ perforations or peritonitis;
• a significant decrease in body temperature;
• increased risk of the event due to the presence of scars from other operations or due to poor blood clotting.

In a situation with an organ such as the liver, laparoscopy is a fairly new diagnostic method. The indications for it include the requirement to determine exact character pathology, as in the case of jaundice. And also in the case of ascites of unknown origin, or with liver enlargement, also of unknown etiology. Including with a cyst or tumor of the liver or with rare diseases.

The liver is the most unique multifunctional organ of our body. Doctors jokingly, but quite rightly, call it a multi-station machine; the number of its functions is close to 500. Firstly, this is the body’s most important “cleansing station”, without which it would inevitably die from toxins. All blood from organs and tissues with toxic metabolic products is collected in the portal vein, passes through the entire organ, purified by hepatocytes, and already purified is sent through the inferior vena cava to the heart. Further, this is participation in digestion - in the digestion of fats and carbohydrates, in hematopoiesis. Protein synthesis also occurs in the liver, various enzymes, immune bodies. Now you can imagine what the consequences of diseases of this organ are when its functions are disrupted. Many of these diseases are treated with surgery.

When is liver resection necessary?

Liver resection of various volumes is performed in the following cases:

• in case of damage with crushing of the liver tissue;
• for benign tumors;
• for cancer (carcinoma);
• with cancer metastases from other organs;
• for various liver developmental anomalies;
• with echinococcal cysts (helminthic infestation);
• for the purpose of transplantation (organ transplantation).

A thorough examination of structure and function is carried out before any intervention is carried out. If necessary, a diagnostic liver puncture is performed using ultrasound (under the control of an ultrasound scanner). Only then are the indications for intervention and its method determined.

Advice: if, after an examination, a specialist suggests surgical treatment, you should not refuse it or hesitate to make a decision. Long period hesitation does not work in favor of the patient, because at this time the disease progresses.

Types of liver surgery

The scope of interventions can vary from removal of a small area to complete removal of the organ (hepatectomy). Partial hepatectomy or liver resection can be economical (marginal, transverse, peripheral), and called atypical. In typical interventions, the anatomical segmental branching of the vessels is taken into account; a segment or the entire lobe can be removed - lobectomy. Their volume depends on the nature of the pathological focus.

For example, in case of cancer metastases, a lobe is completely removed - right or left. For cancer that has grown into the pancreas along with the left lobe, resection of the tail of the pancreas is performed. In cases where there is extensive tumor or cirrhosis, a total hepatectomy is performed ( complete removal) and an orthotopic liver transplant is immediately performed - a transplant from a donor.

Two methods of intervention are used:

• laparotomy or open - through an extensive incision in the abdominal skin;
• laparoscopic or minimally invasive - by introducing a laparoscope with a video camera and special instruments into the abdominal cavity through small skin incisions.

The choice of method is carried out individually. For example, laparoscopic removal can be performed benign tumor the liver is small in size, but if it is affected by cancer and metastases, laparotomy is required.

Is partial liver removal a health risk?

The liver is able to restore its previous volume and function as soon as possible after resection

It is quite understandable for a patient who does not decide to undergo surgery, believing that the removal of part of this organ will entail lifelong health problems. It would seem that such an opinion is logical, but, fortunately, in reality it is wrong.

Liver tissue, like no other tissue in the body, has amazing abilities to restore both its original size and its functions. Even the remaining 30% of liver tissue volume after injury or surgical removal capable of complete recovery within a few weeks. Gradually it grows with lymphatic and blood vessels.

The reasons and mechanisms of such properties have not yet been fully studied, but they make it possible to expand the scope of surgical interventions. Thanks to rapid recovery Partial organ transplantation from a living donor has become widespread practice. On the one hand, the patient does not lose precious time waiting for a cadaveric liver; on the other hand, within a period of 4-6 weeks, both the donor and the patient are completely restored to normal size.

Practice has established that even after removing 90% of the liver, with skillful management of the postoperative period, it completely regenerates.

Advice: It is not at all necessary to stay in the hospital for the entire period of organ recovery. It is also possible to restore the liver at home if you follow doctor’s orders and under his supervision.

Postoperative period

After surgical intervention allocate a stationary period and late period- after discharge. The patient stays in the hospital for 10-14 days after open surgery, and 3-4 days after laparoscopic surgery. During this period, he receives all prescriptions for the prevention of complications, postoperative rehabilitation, diet therapy.

After discharge from the hospital, the main goal is liver recovery. This is a set of measures aimed at creating conditions for the regeneration of liver tissue, which includes:

• dietary nutrition;
• adherence to a physical activity regime;
• general strengthening activities;
• drugs that accelerate liver recovery.

In principle, all these measures are not much different from how to restore the liver after removal of the gallbladder.

Diet food

Don't forget the benefits of proper nutrition

The diet involves frequent meals 5-6 times a day in small quantities to avoid functional overload. It is necessary to completely eliminate alcohol, extractive substances, spices, spicy, fatty foods, confectionery. Food should be rich in proteins, carbohydrates, vitamins, and fiber. This diet should be followed throughout the recovery period, and only after a follow-up examination with a doctor should the issue of expanding the diet be decided.

Maintaining a physical activity regimen

Until the organ is completely restored, heavy physical activity, heavy lifting, running and jumping are excluded. They lead to increased intra-abdominal pressure and impaired blood circulation in the “growing” parenchyma. Measured walking with a gradual increase in load is recommended, breathing exercises, general hygiene exercises.

General strengthening measures

This includes measures to increase the body’s protective properties, enhance immunity, and normalize neurovegetative functions. These are immune stimulants of plant origin, vitamin-mineral complexes with biotin, antioxidants (vitamin E, resveratrol), sedatives and normalizing sleep. All of them are also prescribed by a doctor. Honey is very useful, containing easily digestible carbohydrates, vitamins, minerals and biostimulants necessary for cells.

Drugs that accelerate liver recovery

Accept medicines only by doctor's prescription

In most cases, the measures listed are sufficient for the natural and complete restoration of the organ. However, when the body is weakened in older people, as well as after chemotherapy, radiation therapy regeneration slows down and needs stimulation.

In principle, the same drugs for the liver after removal of the gallbladder can be used after resection. These are the so-called hepatoprotectors, most of them are of natural plant origin: LIV-52, Heptral, Karsil, Essentiale, Galstena, folic acid and others.

Advice: In addition to pharmaceutical hepatoprotectors, various companies today offer supplements, with which the marketing market is oversaturated. These include grifola and Japanese reishi, shiitake and others mushrooms. There is no guarantee of the authenticity of their contents, therefore, in order not to cause harm to health, you should consult a specialist.

Modern interventions, robotic liver surgery

Today, liver surgery is no longer limited to a scalpel and laparoscope. New technologies have been developed and used, such as ultrasound resection, laser, and electrical resection. Operating robotics are widely used.

Thus, FUS (focused ultrasound) technology is used to remove areas affected by a tumor. high frequency). This is a Cavitron device, which destroys and simultaneously aspirates (suctions) the tissue to be removed, while simultaneously “welding” the crossed vessels.

A high-energy green laser is also used, which is most suitable for removing tumors and metastatic nodes by vaporization (evaporation). More recently, the electroresection (IRE) or nanoknife method has been introduced, based on the removal of diseased tissue at the cellular level. The good thing about this method is that you can remove a tumor even near large vessels without fear of damaging them.

Finally, the know-how of modern surgery is robotics. The most common use of the da Vinci surgical robot. This operation is performed minimally invasively, by the “hands” of a robotic surgeon, under the navigation of a tomograph. The doctor monitors the process on the screen in a three-dimensional image, controlling the robot remotely. This ensures maximum accuracy, minimum errors and complications.

The modern level of medicine and surgical technology makes it possible to safely perform operations on such a delicate organ as the liver, up to the removal of large volumes of it, with subsequent restoration.

Video

Attention! The information on the site is presented by specialists, but is for informational purposes only and cannot be used for self-treatment. Be sure to consult your doctor!

Operational access.

To approach all areas of the liver (hemihepatectomy, etc.), a combined approach is used. Thoracophrenia-colaparotomy is relatively more common.

Suturing liver wounds, genatonexia. Before suturing a liver wound, surgical treatment is performed, the extent of which depends on the location and nature of the damage to the organ. In the practice of emergency surgery, the choice of access is midline laparotomy. If the damage is localized in the area of ​​the dome of the right lobe of the liver, it becomes necessary to turn this approach into a thoracolaparotomy. With massive liver damage, sometimes it is necessary to temporarily compress the hepatoduodenal ligament, and sometimes the IVC. To ensure final hemostasis, sutures are placed on the liver (Figure 4). In this case, the operation should be performed quickly, carefully, without unnecessary injury to the liver, maximally preserving the liver tissue and the patency of the IVC. In parallel with the operation, resuscitation measures are carried out, including autohemotransfusion.

Figure 4. Liver sutures: a - Jordon suture; b - Oareus suture; c - Oppel seam; g - Labocchi seam; d - Zamoschina seam; c - Betaneli seam; Varlamov's seam; z - Telkov seam; and - Grishin seam; k - special liver suture with additional nodes

If, after careful treatment of the liver wound (removal of non-viable tissue, reliable hemostasis), it becomes wedge-shaped, then it is recommended to bring its edges closer (compared). U-shaped or mattress seams. And if after treatment the bruised or laceration The edge of the liver cannot be brought closer, then it is isolated from the abdominal cavity, covering the surface of the wound with an omentum or parietal peritoneum (hepatopexy). The bottom of the wound (if it is shaped like a trench) is drained, drainage tubes are brought out through additional incisions abdominal wall. The second drainage will be placed in the subhepatic space. After suturing the bleeding edges of the liver with deep stab wounds, an intrahepatic hematoma can form and hemobilia may occur. To avoid this complication, it is first necessary to find out the possibility of bleeding, its nature and the viability of the liver located near the wound. After the bleeding has stopped, the wound is drained with a thin silicone tube and sutured tightly. The subhepatic space is also drained. In the postoperative period, it is necessary to monitor the nature of the fluid released through the drainage tube.

Liver resection. There are typical (anatomical) and atypical liver resections. During anatomical resection, preliminary hemostasis and excision of the anatomically separated portion of the liver are performed. The main stages of the operation are ligation of vessels in the area of ​​the porta hepatis, ligation of the PV in the area of ​​the porta vena cava, excision of the liver in the direction of the fissure delimiting the resected part, final separation of the part of the liver to be resected, its removal and closure of the wound surface. Certain difficulties are presented by the separation and ligation of Glissonian elements in the area of ​​the porta hepatis, treatment of the hepatic veins and opening of the interlobar fissures. The noted stages of the operation are performed using different methods.

The main ones are:

1) ligation of blood vessels in the area of ​​the porta hepatis;

2) ligation of blood vessels after detection of the interlobar fissure;

3) ligation of blood vessels after gallet amputation of a segment or lobe;

4) separation of the liver with fingers (digitoclasia) and sequential suturing of blood vessels;

5) performing an operation at the moment of compression of the hepatoduodenal ligament;

6) combined use of methods.

Right hemihepatectomy. For this intervention better access Thoracophrenicolaparotomy is considered. To remove the right lobe, the right branch of the PV, PA and the right hepatic duct are ligated. From the IVC system, the right ducts of the middle PV, the right upper PV, as well as the middle and inferior veins. The ligaments of the right lobe are separated and the vessels are ligated at a distance. Then the liver is crossed towards the middle fissure.

On the surface of the liver cut, small vessels are ligated. The liver stump is covered with omentum, which is sutured to the edges of the incision. After isolating the wound surface of the liver, the peritoneal sheets and ligaments are sutured. Wounds of the diaphragm, abdomen and difficult cell are sutured in the usual way.

Left-sided hemohepatectomy. This procedure is technically easier to perform than right hemitepatectomy. The left lobe of the liver is relatively easier to separate; the ratio of vessels here compares favorably with the vessels of the right lobe. In this operation, the use of a median laparotomy is considered more convenient. Separation and ligation of vessels are carried out according to the same principles as for right-sided hemihepatectomy. The liver is divided in the direction of the main fissure. The edges of her wound are sutured or covered with omentum.

Lobectomy, segmentectomy and subsegmentectomy. They are carried out in different ways and in combination. The vascular secretory pedicle is ligated in the area of ​​the porta hepatis or through its dissected tissue. Removing liver lobes is considered more difficult than segmentectomy. To determine the boundaries of the lobes, special diagnostic methods must be used.

Portocaval anastomoses (Figure 5). It is carried out by laparophrenicotomy incision with right side through the 10th intercostal space. On the anterior wall of the abdomen, the subhepatic space is exposed in an oblique or transverse direction. The edge of the liver is raised and the peritoneum covering the hepatoduodenal ligament and IVC is incised. The CBD is moved upward, and the PV is bluntly separated at a distance of 5-6 cm. The IVC is exposed from the liver to the confluence with the right PV. When releasing the IVC and IV, a fenestrated clamp is applied to the first (closer to the liver), and a Satinsky clamp is applied to the IV. Both veins, bringing them closer to each other, are fixed with interrupted sutures within the boundaries of the intended anastomosis. Then, semi-oval holes 10-15 mm long are opened on the walls of the PV and IVC. On back wall At the anastomosis, a continuous suture is applied, the ends of the sutures are tied with the ends of the knots of the previous stay sutures. Such a suture is also placed on the anterior wall of the anastomosis.

Figure 5. Scheme of operations for portal hypertension:
1 - portocaval anastomosis: 2 - silenorenal anastomosis; 3 - ligation of the splenic, hepatic and left gastric arteries; 4.5 - suturing the omentum to the abdominal wall (according to Heller)

The clamps are removed sequentially, first from the explosive, and then from the IVC. When performing an end-to-side anastomosis, the wall of the vein is dissected in the area as close as possible to the liver. The proximal end is ligated, and the distal end is brought to the IVC. The operation is completed by suturing the wound tightly.

Splenorenal venous anastomosis. This anastomosis is punctured end-to-side. For this operation, a laparophrenicotomy incision is used. After removing the spleen, its vein is isolated at a distance of at least 4-6 cm. Then the renal vein is also isolated at a distance of at least 5-6 cm from the gate. A Satinsky clamp is applied to the isolated vein. An oval opening is opened on the wall of the vein corresponding to the diameter of the splenic vein. The end of the splenic vein is brought to the PV and the clamp placed on the distal end of this vein is removed, the edges of the vein are refreshed, and the lumen is washed with heparin. The vessels brought to each other are sewn end to side. The clamps are removed sequentially, first from the renal vein, and then from the splenic vein. If there is bleeding from the anastomotic area, additional interrupted sutures are placed on the edges of the vessels. When it is necessary to preserve the spleen, a splenorenal side-to-side anastomosis is performed or the distal end of the splenic vein is sutured to the side of the renal vein (splenorenal selective anastomosis).

Mesenteric-caval anastomosis. A wide laparatomy is performed. In the area of ​​the mesentery of the TC, in the direction of the pancreas, the peritoneum is dissected and the superior mesenteric vein is found. Using a blunt or sharp method, it is isolated at a distance of at least 4-5 cm. Then the IVC is exposed, and clamps are applied directly under the horizontal part of the duodenum on the isolated veins in the longitudinal direction. On the walls free from clamps, holes with a diameter of 1.5-2 cm are opened and an anastomosis is applied like the letter “H”, i.e. The veins are connected to each other with a vascular prosthesis or an autovenous graft. In mesentericocaval anastomosis, the proximal end of the transected vein is sutured to the lateral part of the superior mesenteric vein above the bifurcation of the IVC.

Ligation of the veins of the stomach and esophagus (Figure 6). These veins are ligated submucosally. The abdominal cavity is opened with a superior midline incision. A wide gastrotomy is performed, starting from the fundus of the stomach to the lesser curvature in an oblique direction. The stomach is freed from its contents and the dilated veins are ligated through the mucous membrane covering this area. First, the veins of the cardia are ligated by stitching, and then the veins of the esophagus. The operation is completed by suturing the stomach wall with double-row sutures. The abdominal wall wound is sutured tightly.

Figure 6. Gastrotomy, suturing and ligation of dilated veins

Go to the list of conditional abbreviations

R.A. Grigoryan

Sometimes drug treatment is ineffective in treating liver diseases. In such cases, surgery may be used.

Liver surgeries are very diverse in technique and scope.

The extent of intervention depends mainly on the disease for which surgery is required. Comorbidities, risk of complications, and other factors also play a role.

Preparing for surgery

Before any abdominal surgery The patient is carefully prepared. The plan for this preparation is developed individually for each patient, depending on the nature of the underlying disease, concomitant conditions and the risk of complications.

All necessary laboratory and instrumental studies are carried out. For example, in the case of a malignant tumor, shortly before surgery, chemotherapy may be prescribed to reduce its size.

Be sure to inform your doctor about the medications you are taking. Especially those that are taken constantly (for example, antiarrhythmics, antihypertensives, etc.).

7 days before surgery, stop taking:

• non-steroidal anti-inflammatory drugs;
• blood thinning drugs;
• antiplatelet drugs.

When performing liver surgery, a morphological study of the removed tissue is always carried out in order to accurately diagnose the nature of the pathological process and assess the correctness of the choice of the volume of surgical intervention.

Types of liver surgery

As already mentioned, there are currently many different methods of surgical treatment of liver diseases. Let's look at the most common of them.

Liver resection

There are typical (anatomical) and atypical (marginal, wedge-shaped, transverse). Atypical resection is done if there is a need to excise the marginal areas of the liver.

The volume of liver tissue removed varies:

• segmentectomy (removal of one segment);
• sectionectomy (removal of a section of the liver);
• mesohepatectomy (central resection);
• hemihepatectomy (removal of a lobe of the liver);
• extended hemihepatectomy (removal of a lobe and section of the liver at the same time).

A separate type is combined resection - a combination of any type of liver resection with removal of part or all of the abdominal organ (stomach, small or large intestine, pancreas, ovary, uterus, etc.). Typically, such operations are performed for metastatic cancer with removal of the primary tumor.

Laparoscopic operations

They are performed through small (2–3 centimeters) incisions in the skin. Typically, these methods are used to perform operations to remove cavity formations (for example, cysts - fenestration) and treat liver abscesses (opening and drainage).

Surgeries on the gallbladder (cholecystectomy and choledocholithotomy) using laparoscopic access have also become widespread.

Puncture drainage

It is carried out for abscesses and sclerosis (for example, for cysts). The operation is performed under ultrasound guidance. A needle is inserted into the formation. In the first case, pus is removed and drained, in the second, the contents of the cyst are aspirated and a sclerosant drug is administered: sulfacrylate, 96% ethyl alcohol, 1% ethoxysclerol solution, etc.

Other operations

For cancerous lesions of an organ, some specific surgical interventions are sometimes used: radiofrequency ablation (removal of a tumor using radiofrequency radiation), chemoablation (injection of a chemical into a vessel supplying the affected area), alcoholization (injection of ethyl alcohol into a tumor).

For diseases of the common bile duct, the following is carried out: resection of cysts with anastomosis between the liver and small intestine; plastic surgery for scar narrowing; stent placement, extended resections for malignant lesions.

In case of cholelithiasis, in addition to the above-mentioned operations of cholecystectomy and choledocholithotomy using laparoscopic access, a similar volume of intervention is performed using traditional (laparotomy) access. Sometimes papillosphincterotomy and choledocholithoestration using an endoscope are indicated.

Liver transplantation

Is the most effective and sometimes the only method treatment of patients with end-stage chronic liver diseases, cancerous tumors, fulminant hepatitis, acute liver failure and some other diseases.

Every year the number of successful operations is increasing all over the world.

Organ donors can be persons who have suffered a brain injury incompatible with life, subject to the consent of their relatives.

In children, it is possible to use part of the liver from an adult donor due to difficulties in obtaining appropriate small sizes donor organs. However, the survival rate for such operations is lower.

Finally, sometimes a portion of an organ from a living donor is used. Such transplants are most often performed on children. The donor can be a blood relative (with the same blood type) of the patient if he informed consent. The left lateral segment of the donor organ is used. As a rule, this type of transplantation gives the least number of postoperative complications.

For some diseases, when there is Great chance regeneration of one's own organ, heterotopic transplantation of an accessory liver is used. In this case, healthy donor liver tissue is transplanted, but the recipient’s own organ is not removed.

Indications for liver transplantation and predicted results (according to S. D. Podymova):

After liver transplantation, patients are prescribed immunosuppressive therapy for a long time to prevent rejection.

Nutrition in the postoperative period

In the first days of the postoperative period, nutrition is exclusively parenteral. Depending on the volume and complexity of the surgical intervention, this type of nutrition lasts approximately 3–5 days. The volume and composition of such nutrition are determined individually for each patient. Nutrition must be fully balanced in proteins, fats, carbohydrates and have sufficient energy value.

Then a combination of parenteral-enteral (tube) nutrition occurs, which should continue for at least another 4-6 days. The need for a smooth transition from parenteral to enteral nutrition is dictated by the fact that surgical trauma to the liver disrupts the normal functioning of the small intestine, the rehabilitation of which takes an average of 7–10 days. Enteral nutrition is introduced gradually increasing the volume of food. This allows for the development of organ adaptation gastrointestinal tract to food loads. If this is neglected, then as a result of intestinal dysfunction, the patient will quickly develop a protein-energy imbalance, deficiency of vitamins and minerals.

7–10 days after surgery, they switch to diet No. 0a, combining it with parenteral nutrition. In the absence of complications, enteral nutrition is gradually expanded in the form of diet No. 1a, and then No. 1. However, some adjustments are made to these diets: for example, they exclude meat broths and egg yolks, replacing them with slimy soups and steamed protein omelettes.

After 17–20 days, it is possible to switch to diet No. 5a. If the patient does not tolerate it well and complains of flatulence, diarrhea, and abdominal discomfort, then a more gentle option can be used - diet No. 5.

Diet No. 5 is prescribed approximately a month after surgery and, as a rule, after the patient is discharged from the hospital.

The indicated periods can be reduced by 3–5 days for small volumes of surgical intervention.

Postoperative period and recovery

The course of the postoperative period depends on many factors: the nature of the underlying disease, the presence or absence of concomitant pathology, the extent of surgical intervention, as well as the presence of complications during or after surgery.

According to L.M. Paramonova (1997) the postoperative period is divided into three conventional parts:

1. early postoperative period - from the moment of surgery to three days;
2. the early postoperative period was delayed - from four to ten days;
3. late postoperative period - from the eleventh day until the end of hospital treatment (discharge of the patient).

During the early postoperative period, the patient is in the intensive care unit and intensive care. In this department, on the first day, active therapy and round-the-clock monitoring are carried out, which ensure the maintenance of vital body functions.

Adequate pain relief and cardiovascular support must be provided.

During the first 2–3 days, hemodilution with forced diuresis is carried out in order to detoxify the body. This also allows for active monitoring of kidney function, since one of the early signs of the possible development of acute liver failure is a decrease in daily diuresis (oliguria) and a change in biochemical parameters blood. The volume of transfused liquids (Ringer's solution, ionic mixtures, etc.) usually reaches two to three liters per day in combination with diuretics (Lasix, mannitol).

Peripheral blood parameters are also monitored for the purpose of timely diagnosis of uncompensated blood loss or the development of postoperative bleeding. A complication in the form of postoperative bleeding can also be diagnosed by monitoring the fluid released through the drains. Hemorrhagic contents are separated, which should not exceed 200–300 ml per day, followed by a decrease in the amount and without signs of “fresh” blood.

Drains usually function for up to 6 days. In the case of liver transplant operations or the presence of bile in the discharged fluid, they are left for up to 10–12 days or more.

If unrecovered blood loss is detected, a transfusion of single-group blood or its components (erythrocyte mass) is performed, based on the levels of “red” blood indicators.

To prevent infectious complications, broad-spectrum antibiotics are prescribed. Hepatoprotectors (Essentiale, Heptral) and multivitamins are also prescribed.

The blood coagulation system is also monitored for the purpose of timely diagnosis of disseminated intravascular coagulation syndrome (DIC syndrome). There is a particularly high risk of developing this syndrome with large intraoperative blood loss and massive blood transfusion. Drugs are prescribed to improve the rheological properties of blood (dextrans).

Due to increased protein catabolism on the first day after surgery, correction of its content in the body is necessary in the form of infusion of protein preparations (plasma, albumin).

Possible complications

It is necessary to remember the risk of respiratory disorders and promptly prevent their occurrence. One of effective methods This prevention is early activation of the patient, breathing exercises.

According to scientific research, after extensive right hemihepatectomies, reactive pleurisy sometimes develops. The causes of this complication are: impaired lymphatic drainage from the liver as a result of surgery, accumulation and stagnation of fluid in the subdiaphragmatic space, and insufficient drainage.

It is very important to promptly identify emerging postoperative complications and carry out their correction and therapy. The frequency of their occurrence according to data different authors is 30–35%.

The main complications are:

• Bleeding.
• Attachment of infection and development of inflammation, up to septic conditions.
• Liver failure.
• Thrombosis.

In the event of postoperative complications associated with prolonged hypotension and hypoxia - an allergic reaction, bleeding, cardiovascular failure - it is fraught with the development of liver failure of the liver stump, especially if there are initial lesions of the organ tissue (for example, fatty hepatosis).

To prevent purulent-septic complications, antibacterial treatment is continued until ten days after surgery. Also during this period, infusion therapy continues. Nutrition should be rational with a high protein content.

From the eleventh day, in the absence of postoperative complications, the volume of therapy is reduced as much as possible and the rehabilitation process begins, which continues after the patient is discharged from the hospital.

The duration of the recovery period depends, first of all, on the volume of surgical intervention performed and the nature of the underlying and possible concomitant diseases. The course of the postoperative period is also important.

During the recovery period, diet No. 5 is prescribed for a long time, and in some cases, for life.

The set of necessary therapy and measures during the rehabilitation period is selected and established by the attending physician individually for each patient.

Complications after surgical interventions on the liver are mainly due to tactical and technical errors made in the process of preoperative preparation of patients, the surgical intervention itself and postoperative management.

There are intraoperative and postoperative complications. Intraoperative complications are caused mainly by careless actions of surgeons, unjustified risks in pursuit of dubious radicality of the operation, as well as severe pathological changes hepatic parenchyma and location of the process [O.B. Milonov et al, 1990]. Intraoperative complications include bleeding, hemobilia, air embolism, etc.

Postoperative complications may be associated with the severe initial condition of the patient, concomitant diseases, incorrect assessment of the patient's condition, expansion of indications for surgical treatment and improper management of the postoperative period. Postoperative complications include bleeding into the abdominal cavity or biliary tract (hemobilia), necrosis of the liver parenchyma, leakage of bile into the abdominal cavity with the development of bile peritonitis, etc. Bleeding and leakage of bile into the abdominal cavity are often the causes of the formation of perihepatic hematomas, ulcers or abscesses of other localizations in the abdominal cavity. The determining factor in the development of postoperative complications is mainly a violation of the technique of performing operations and intraoperative complications.

Bleeding after surgery can be observed from the liver parenchyma and be of varying degrees of intensity. Massive bleeding due to injury to large liver vessels is observed in 16.8% of cases [B.S. Gudimov, 1965]. Profuse intraoperative bleeding with blood loss of 1 liter or more, especially occurring in a short period of time, is the cause of death in an average of 3-10% of patients, which is about 63.5% of the total mortality during liver resection [B.V. Petrovsky et al., 1972; I. Fagarasanu et al, 1977].

Severe bleeding develops when the IVC is damaged in the area of ​​the mouth. The fight against such bleeding is very difficult. It lies in the fact that, despite intense aspiration from the wound, the surgical field is immediately filled with blood. In such a situation, attempting to apply the clamp blindly will result in even more damage.

Profuse bleeding also occurs when the left PV is damaged, and relatively rarely the right and middle PV.

Prevention of damage to the PV and IVC involves maximum caution when isolating these vessels and temporarily isolating them from the circulation using various cannulas and catheters that shunt the subphrenic section of the IVC [VA. Zhuravlev, 1968; B.C. Shapkin, Zh.L. Grivenko, 1977]. Prevention of damage to the PV and IVC is based on a clear understanding of their location and development options, as well as extremely careful isolation of them from surrounding tissues and the correct selection of indications for performing manipulations in the area of ​​the caval gate. The use of a cavacaval shunt helps prevent blood loss even if these vessels are damaged [E.I. Galperin, 1982; Yu.M. Dederer, 1987].

To prevent complications, the correct choice and competent execution of surgical access, which allows free manipulation in the surgical area, are of great importance. When the pathological focus is located in the II-III segments of the liver, the optimal access is considered to be upper midline laparotomy. The need to manipulate right lobe liver necessitates the use of thoracofrenolaparotomy access. In this case, the optimal incision for performing intervention on the right lobe of the liver is in the 7th or 6th intercostal space [O.B. Mnlonov et al., 1990]. A number of authors [E.I. Galperin, 1982; Yu.M. Dederer, 1987 and others] propose to bypass the navel on the right, as a result of which the surgical wound expands even more.

IN Lately To carry out interventions on both lobes of the liver, bipochondrial access began to be used more often.

In the event of bleeding due to damage to the elements of the canal gates of the liver, the actions of the surgical team depend on its intensity. If the rate of blood flow into the wound is moderate and it does not flood the surgical field, then the defect in the vessel wall is recommended to be sutured with atraumatic suture material, using synthetic mononits intended for vascular sutures. If severe bleeding occurs, when the surgical field is flooded with blood, you should not try to apply a clamp blindly in a pool of blood, as this leads to vascular injury and increased bleeding. In such a situation, the simplest technique is considered to be finger pressure on the source of bleeding. After the blood supply stops, the remaining blood is sucked out or dried with a swab without lifting the finger. Then, carefully displacing the latter, the source of bleeding is determined and, under visual control, it is sutured or a clamp is applied.

Bleeding from the vessels of the liver parenchyma can be of a mixed nature and of varying intensity. The latter depends on the size, location and direction of the incision. Minor bleeding can be quickly stopped using hemostatic techniques (electrocoagulation, stitching). With more heavy bleeding The fastest and most reliable effect is obtained by temporary clamping of the hepatoduodenal ligament, the duration of which can be increased to 20 minutes. This time is quite enough to inspect the “dry” wound and suturing the damaged vessel or ligating it. The edges of the liver parenchyma are compared with each other by applying one of the types of sutures.

The most dangerous from the point of view of the development of massive bleeding is liver resection. Temporary clamping of the hepatoduodenal ligament and the use of gentle methods for separating the parenchyma are also considered reliable measures to prevent bleeding. These methods include digitoclasia, etc. separation of the parenchyma with fingers without damaging the vessels and ducts, blunt dissection with an instrument (scalpel handle). The use of special electrosurgical instruments, in particular a rotary bioactive electrocautery for liver resection, is promising [O. B. Milonov et al, 1990].

Bleeding can also occur during palliative resections and other liver operations performed for widespread alveococcosis. The peculiarity of intraoperative bleeding is that it occurs against the background of an existing NP due to damage to large areas of parenchyma, the porta hepatis and obstructive jaundice. Profuse bleeding that occurs in these patients during surgery is often the trigger for the development of NP in the postoperative period, which usually leads to death [S.M. Shikhman, 1986].

The vessels penetrating the parenchymal tissue are fixed in it, and when they intersect, their lumen gapes. Stopping bleeding from these vessels can only be done by suturing the vessel through the alveococcosis tissue. When cutting through the ligature, tamponade can be performed with a free omentum or on the “pedicle”. Small vessels coagulate.

Profuse bleeding that occurs during liver surgery is dangerous not only at the time of its immediate occurrence. Such bleeding and associated blood transfusions of canned blood and various disorders lead to hemorrhagic syndrome, increased recalcification time, decreased plasma tolerance to heparin, increased fibrinolytic activity, deficiency of coagulation factors V, VII, VIII and platelets.

Bleeding that occurs in the postoperative period in the presence of these disorders is often accompanied by the development of acute anemia, hypovolemic hypotension, shock, cerebral hypoxia and NP against the background of metabolic acidosis.

Treatment of this condition consists of taking measures aimed at eliminating anemia, correcting water and electrolyte balance and hemostatic therapy (administration of ε-aminocaproic acid, protease inhibitors). Direct transfusion of same-group donor blood and administration of cryoprecipitate, a drug containing coagulation factor VIII, of native plasma, have a good effect.

Bleeding in the postoperative period can also be caused by impaired hemostasis due to the cutting of ligatures or rejection of a necrotic area of ​​the liver due to its sequestration. Great importance In this regard, attention is paid to the installation of control drains in the abdominal cavity and their diameters. Drains should be installed in the most sloping places so that they are directed from top to bottom or horizontally, but not from bottom to top.

After liver surgery, bleeding can be observed first in the lumen of the biliary tract (hemobilia), and then in the gastrointestinal tract. Hemobilia often develops with various mechanical damage to the liver and intrahepatic bile ducts, abscesses, neoplasms and abnormalities in the development of liver vessels [B.V. Petrovsky et al., 1972]. This can be facilitated by prolonged acholia, aneurysm of the hepatic and cystic arteries. Hemobilia after liver resection is observed in 0.5% of patients [B.I. Alperovich, 1983]. It is also specific for operations performed for advanced alveococcosis or unresectable liver tumors. In most cases, bleeding from the biliary tract is short-lived and stops on its own [O.B. Milonov et al., 1990].

Diagnosis of hemobilia is difficult. Diagnostic errors lead to the wrong choice of treatment tactics, which, in turn, negatively affects the results of treatment.

It should be noted that clinical manifestations hemobilia that occurs in the first days after surgery on the biliary tract is not always given the correct interpretation or is not given due attention.

Hemobilia manifests itself clinically gastrointestinal bleeding and hepatic colic. Classic clinical signs Traumatic hemobilia are: pain in the right hypochondrium and jaundice after operations on the biliary tract. However, in the first 2-3 days after surgery, pain in the right hypochondrium due to hemobilia can be regarded as a consequence of the operation. Distinctive features are intensification or paroxysmal pain. In patients with preoperative jaundice, this sign of hemobilia does not have a decisive diagnostic value. When the biliary tract is drained by a wide anastomosis, jaundice due to bleeding into the biliary tract may be absent. Melena and bloody vomiting are signs of bleeding of various origins from upper sections Gastrointestinal tract.

However, they can only be recognized as manifestations of hemobilia when combined with pain in the right hypochondrium. Symptoms of internal bleeding are an important help in making a diagnosis. The release of blood through the drainage is an absolute sign of hemobilia. Of the additional research methods, fibroduodenoscopic and angiographic studies, in particular superselective angiography, provide valuable information. This method can become not only diagnostic, but also medical procedure. Endovascular embolization is one of the most effective ways elimination of hemobilia.

Therapeutic tactics for hemobilin depend on the pathogenetic mechanism and development. Conservative therapy with the use of hemostatic agents is indicated for hemobilia due to disorders of the blood coagulation system or the formation of a vascular-biliary fistula, when there is no tamponade with blood clots of the bile ducts. In all other types of hemobilia, as well as when the biliary tract is blocked by blood clots, repeated surgical intervention is indicated, aimed at eliminating the cause of bleeding and restoring the patency of the biliary tract.

Regardless of the cause of hemobilia, supplementation of the operation with external drainage of the bile ducts is mandatory. External drainage makes it possible not only to control the patency of the hepaticocholedochus and the dynamics of the process, but also to locally carry out hemostatic therapy.

In the prevention of postoperative hemobilia important have atraumatic operation and correction of blood coagulation disorders. In patients with prolonged obstructive jaundice, it is recommended to carry out dosed decompression of the biliary tract before surgery. This allows you to warn sharp drop pressure between the IV system and the bile ducts. For these purposes, external controlled drainage is used [VA. Shidlovsky, 1986].

After liver surgery, bile leakage and the development of postoperative biliary peritonitis may occur. Most often, this complication develops after palliative resections for alveococcosis due to leakage of bile from the crossed bile ducts located in the alveococcal node in close proximity to the functioning liver parenchyma [S.M. Khakhalin, 1983]. This type of peritonitis usually progresses smoothly. Symptoms of peritoneal irritation and general changes At the same time, they are weakly expressed, which makes diagnosis difficult.

Particularly important in such patients is the identification of the symptom of “moving dullness,” which indicates the presence of free fluid in the abdominal cavity. To confirm the presence of fluid and determine its nature, a diagnostic puncture of the abdominal cavity with a thin needle can be performed. Peritonitis occurs much less frequently after surgical interventions performed using continuous continuous transhepatic drainage. Therefore, this type of BDA is currently preferred. Effective drainage of the abdominal cavity is important for the prevention of biliary peritonitis.

Treatment of postoperative peritonitis with liver alveococcosis has its own characteristics. The decisive point is early relaparotomy. However, when eliminating the source of peritonitis, the surgeon encounters significant difficulties. Indeed, in order to find and bandage the bile ducts from which bile is leaking, it is necessary to remove all sutures from the hepatized surface of the liver wound and the omentum sutured to it. But even under these conditions, exposing damaged passages, especially if they are small in diameter, is very difficult. Regeneration of the liver parenchyma occurs very quickly, and by the time of RL, the growing liver tissue closes the bile ducts and makes it extremely difficult to find them.

Eliminating the source of postoperative peritonitis in patients with alveococcosis usually comes down to carefully separating the sutured liver wound from the abdominal cavity with gauze pads and draining it. Usually two drains are inserted: between the liver and the diaphragm and under the liver so that the end of the drain is in the foramen of Winslow. Thorough sanitation of the abdominal cavity and postoperative intensive care are very important.

After surgical interventions on the liver, suppuration of the residual cavity, leakage of bile into it, development of cholangiogenic liver abscesses, subphrenic and subhepatic abscesses, etc. may be observed [Yu.S. Gilevich et al., 1988; 1990].

Often purulent complications are the starting point in the development of severe NP, which often leads to death. Recently, there has been a tendency towards an increase in the number of purulent complications due to an increase in the volume of surgical interventions on the liver. Of significant importance in the development of purulent complications is the occurrence and subsequent infection of the residual cavity in the subphrenic space. The main reason for the formation and suppuration of the residual cavity is inadequate drainage of the abdominal cavity after liver surgery, especially with extremely large resection. In these situations, blood, bile, and exudate accumulate in the large residual cavity after surgery, since minor bleeding and bile leakage are observed with any methods of liver resection currently used.

After this complex and difficult operation, the patient is forced to spend several days lying on his back, while the fluid accumulating in the residual cavity, due to its hydrostatic properties, occupies the posterior sections of the subdiaphragmatic space, where the drainage and the “cigarette” tampon placed on the anterior abdominal wall are demarcated. Timely and complete emptying of this cavity is not always ensured. Frequent suppuration of the contents of the residual cavity is also facilitated by the weakened condition of the patient, blood loss during surgery, and a decrease in immunological protective mechanisms in case of focal liver lesions [B.I. Alperovich, A.T. Reznikov, 1986]. All this often leads to the development of a subphrenic abscess, which significantly aggravates the course of the postoperative period.

A suppurative process in the liver can also develop as a result of necrosis and sequestration of the liver parenchyma.

The reason for this complication is the ischemia of part of the parenchyma after manipulations on the vessels of this area, as well as due to the development of purulent processes in the liver and biliary system (purulent cholangitis). In most cases, these reasons act simultaneously and aggravate each other [G.I. Veronsky, 1983; T. Tung, 1972]. Based on the etiological factor, two types of necrosis are distinguished: aseptic necrosis and necrosis due to purulent cholangitis. Aseptic necrosis usually develops in connection with a violation of the blood supply to a section of the hepatic parenchyma as a result of erroneous ligation of the vascular-secretory pedicles supplying the remaining segments of the liver during anatomical resections or suturing of large liver vessels during resections. Aseptic necrosis manifests itself as a sluggish abscess. Sometimes serous cavities like cysts form [B.I. Alperovich, 1986].

Necrosis of the liver parenchyma against the background of angiocholitis is much more dangerous from the point of view of the development of abscess formation and sequestration of the liver [B.V. Petrovsky et al., 1972]. The main points of preventing the leakage of bile in the postoperative period are the timely elimination of intrahepatic biliary hypertension during liver surgery and careful treatment of the stump of the resected liver [BA. Alperovich et al., 1986].

With normal passage of bile into the intestine through the hepaticocholedochus, the flow of bile through the drainage, as a rule, quickly stops, which is an indication for its removal. Prolonged secretion of bile, leading to electrolyte and metabolic disturbances, is an indication for repeated surgery aimed at eliminating the cause of biliary hypertension.

The flow of bile into the abdominal cavity with inadequate drainage function leads to the formation of perihepatic ulcers or the development of biliary peritonitis, which requires emergency LC.

Adequate drainage of the abdominal cavity after liver surgery is a measure to prevent postoperative complications. The main condition necessary to prevent complications is the correct technical performance of surgical procedures, as well as high level express diagnostics of intraoperative changes in homeostasis and timely correction of identified changes.

Liver resection for cancer

If a person develops in any part of the body, all therapeutic measures, from the initial examination to postoperative observation, are carried out by an oncologist-surgeon. A doctor of this specialization chooses the tactics and scope of surgical intervention. Surgical treatment of liver cancer is the most difficult, which is associated with the severity of the disease and irreversible damage to the liver parenchyma. Regardless of the stage at which the cancer was diagnosed and how quickly specialists were able to perform surgery, most vital functions of the body are significantly reduced.

After the patient’s final diagnosis has been confirmed and made, the choice of tactics and scope of surgical intervention will depend on the size to which the tumor structure has grown and where in the liver parenchyma it is localized.

If it is diagnosed as operable, the operation can be performed in one of the following ways:

• typical or atypical resection, the difference between which is that with the first, the removal of the anatomical part of the secretory organ is complete and is carried out along interlobar or intersegmental fissures, and with the second, only part of the lobe or segment of the secretory organ is resected;
• Laparoscopic liver surgery is the most safe method surgical intervention in which partial removal of liver tissue is performed. This minimally invasive surgical intervention has many advantages, but it is only possible for small-sized malignant neoplasms.

Worth knowing! Before removing a liver tumor, the specialist must make sure that the volume of intact liver tissue is at least 20%. Thanks to the high regenerative abilities, self-healing of the secretory organ is possible even if after the operation only ¼ of it remains. With extensive lesions, the tumor is considered inoperable. In this case, transplantation is necessary. This surgical intervention involves first completely removing the secretory organ, and then simultaneously replacing it with a donor one.

Indications and contraindications for surgery for liver cancer

The emergence of new diagnostic techniques And innovative methods Carrying out extensive excisions of the hepatic parenchyma makes the removal of liver cancer more and more acceptable in modern oncology. Currently, extensive experience has been accumulated in performing such operations, which proves the success of surgical intervention for RP and expands the indications for it.

Surgery for liver cancer in men and women is performed in almost all cases where such intervention is possible. In order to determine the admissibility of surgical treatment, experts use the Child-Pugh classification, which determines the severity of cirrhosis. With its help they evaluate functionality liver parenchyma after it was damaged by liver cancer. This classification takes into account 5 parameters - two blood parameters (bilirubin and albumin levels), prothrombin time, which evaluates the external pathway of blood coagulation, the severity of ascites and the presence of hepatic encephalopathy of the brain.

Based on these classification parameters, the functional activity of the secretory organ is divided into 3 classes:

• A - all indicators are normal and any surgical intervention is acceptable;
• B - moderate deviations are noted, and surgery carried out with some restrictions;
• C – serious violations have been identified and surgery is unacceptable.

In addition to concomitant cirrhosis, which provokes serious disorders in the liver parenchyma and worsens the patient’s chances of recovery, surgical treatment for liver cancer is impossible in the following cases:

• heavy general state the patient, leaving him no chance to undergo a complex and lengthy operation;
• extensive process of metastasis - multiple metastases have penetrated not only nearby, but also distant internal organs, as well as bone structures;
• the malignant neoplasm has grown into the portal vein or is located in close proximity to it, since in this case the operation almost always ends in extensive internal bleeding.

Surgery for liver cancer is also impossible in cases where liver tissue damage exceeds 80%. In such a situation, an obstacle to surgical treatment will be the irreversibility of disorders developing in the secretory organ and the impossibility of restoring its normal functioning despite the high ability to regenerate.

Preparation for surgery

Before a liver tumor is removed, a surgical oncologist performs a preoperative evaluation.

It allows you to find out the following points that have a direct impact on the choice of the extent of surgical intervention:

• how realistic is it to remove a liver tumor surgically;
• whether the secretory organ will be able to function normally after the operation and whether the cancer patient will develop liver failure;
• whether the patient’s general health will allow him to endure complex extensive surgery and a long postoperative recovery period.

The data from the preoperative assessment most often coincide with the results obtained from the initial one performed for the purpose of making a diagnosis. Research before determining the possibility and extent of surgical intervention includes such measures as general and biochemical tests blood, x-ray chest, ECG, MRI or CT and functional tests of liver tissue.

Worth knowing! Oncological surgeons, when offering patients with oncological lesions of the liver parenchyma the type and volume of surgical intervention, base their decision on the degree of cirrhosis, the number of malignant foci and the size of oncological tumors. These data are determined according to the Barcelona or Child-Pugh classifications.

Progress of the operation

Surgical treatment of liver cancer, as well as diagnosis of the tumor structure to confirm its malignancy, is carried out using laparoscopic surgery.

This is the most optimal method for identifying and removing cancer, taking approximately 1.5 hours and consisting of the following procedures:

• preoperative preparation (cleansing enema, and, if necessary, shaving of the surgical field) and administration of anesthesia;
• selection in the abdominal wall, around the border of the secretory organ, places for 4-5 punctures, having minimal amount vessels and not touching the tumor that can be palpated during palpation;
• filling the abdominal cavity with oxygen or carbon dioxide through a special “sleeve” inserted into one of the holes, the diameter of which does not exceed 12 mm;
• insertion of a rigid medical endoscope through a puncture, allowing one to examine the abdominal organs and conduct ultrasound testing directly on the liver tissues. Thanks to this test, an oncological tumor and possible additional damage are detected in the parenchyma of the secretory organ.

Next, the surgical oncologist measures the size of the damaged liver tissue and determines the boundaries of resection. After removing an oncological tumor, the doctor must make sure that there is no leakage of bile fluid from the edge of the resection, and there is no internal bleeding and through the “sleeve” removes gas from the peritoneum. The advantages of laparoscopic excision of a tumor are minimal trauma and no risk of damage to surrounding organs due to visual control.

If minimally invasive surgery for liver cancer is not possible, abdominal surgery is performed. In this case, access to the secretory organ is carried out through a longitudinal or T-shaped incision. After the skin and muscles of the abdominal wall are cut, the specialist conducts an inspection of the liver parenchyma using ultrasound examination. During the procedure, the oncologist-surgeon finally determines the scope of the surgical intervention. The segments or lobes of the secretory organ damaged by the malignant process are cut off using a scalpel, and the bile ducts and blood vessels are ligated. After pumping out the remaining blood and aseptic substance from the abdominal cavity, the surgical wound is sutured, leaving a small hole for the drainage tube.

Worth knowing! In cases where the parenchyma of the secretory organ is completely affected by liver cancer, the operation is performed using. This is the most serious and most effective intervention in the human body, which has significant differences from the transplantation of any other internal organ. But, unfortunately, transplantation is limited in its use for a number of reasons.

Complementary treatment

Removal of liver cancer is the main method of therapy for this transient pathology. But surgery alone is not enough. In order to achieve, if not complete recovery, then the longest possible rehabilitation, complementary therapy is necessary.

after the operation and before it is to use the following therapeutic techniques:

1. . This drug treatment is used both before and after surgery. Its main goal is to inhibit the development of blood vessels feeding the liver tumor, which leads to the natural death of abnormal cells. Currently, new highly effective drugs have been developed to carry it out, helping to reduce the risk of relapse.
2. The systemic one has very low effectiveness and a large number of side effects that can provoke early death, so specialists use transarterial administration of drugs. In this disease, and are used as cytostatics, which are delivered to the tumor directly through the hepatic artery. This technique significantly increases the effectiveness of cytostatics and reduces side effects.
3. began to be used only recently, thanks to the emergence of innovative irradiation techniques that do not cause significant harm to the tissues of the secretory organ. Thanks to the latest techniques radiotherapy, used in conjunction with surgical treatment and chemistry, the growth rate of oncological tumors in the liver parenchyma is significantly reduced.

Important! Carrying out these activities separately from each other is ineffective and does not have a significant impact on the recovery process.

Postoperative period

After a cancer patient has had a liver tumor removed, he is prescribed supportive care. drug therapy. First of all, for all patients without exception, it consists of the use of painkillers, narcotic analgesics, and then, depending on the postoperative indications, patients are individually given the following prescriptions:

• taking anticoagulants to prevent the development of thrombosis in the vessels penetrating the hepatic parenchyma;
• in case of massive blood loss, an urgent infusion of plasma with albumin, as well as erythrocyte and platelet masses is carried out;
• to normalize metabolic processes and replenish blood volume, patients are prescribed drips with glucose, Rheosorbilact or Ringer;
• prevention of possible inflammation is carried out with broad-spectrum antibacterial drugs administered drip-wise, intravenously or intramuscularly.

Caring for a patient after surgery for liver cancer includes several nuances:

• Firstly, the operated person will complain of severe pain, but this is just “ residual effects surgical intervention” and has nothing to do with a person’s feelings. Therefore, in no case should you administer an additional dose of painkillers to a cancer patient who has undergone surgery - after 5-6 hours, such pain will stop on its own.
• Secondly, a patient with a history of liver cancer after surgery needs increased attention from nearby relatives to his breathing and changes in skin color. Any deviation from the norm should alert you, since often in operated patients, excessive tilting of the head may occur during sleep, as a result of which the tongue closes the lumen breathing tube, which provokes suffocation.
• Thirdly, if a person has had liver cancer removed, complete sterility is necessary - bed linen should be changed at least once every 3 days or even more often, as contamination appears. Bandages only change qualified specialists, and showering is contraindicated until the postoperative wound has completely healed.

Particular attention is paid to diet. After the liver has been removed, the patient's nutrition for the first 3-5 days is exclusively parenteral (intravenous). Its composition and volume are determined individually for each cancer patient. For the next 3 days, liquid food is administered through a tube, and only after a week the person is gradually transferred to natural feeding. All nutritional recommendations given by the attending physician must be followed strictly, since if they are not followed after liver surgery, this will quickly lead to disruption of the functioning of the intestines, and, as a consequence, the development of protein-energy imbalance with a deficiency of minerals and vitamins.

It’s worth saying about . You can take herbal infusions and decoctions to relieve discomfort only after prior consultation with the oncologist-surgeon who performed the operation.

Surgical treatment of metastatic liver cancer at stages 3 and 4 of the oncological process

Secondary liver cancer has always been considered an incurable disease with a near fatal outcome. Resection of the secretory organ, due to the peculiarities of its structure and increased blood supply, was carried out very rarely until recently - such an operation for liver cancer was always accompanied by a high operational risk. The emergence of innovative techniques and the improvement of surgical methods for removing oncological tumors from the liver parenchyma has made it possible to change the approach to the treatment of a dangerous disease. If a person is diagnosed with cancer, surgery to remove it is considered possible in most cases, but the approach to treating secondary malignant lesions is determined by the degree of their spread.

Due to the fact that metastases that have grown from other organs are characterized by slow growth, in approximately 5-12% of clinical cases, resection of the affected area is permissible. But surgical treatment is possible only for a small (1-4) number of metastases. Surgical intervention is performed by lobectomy (resection of the right or left lobe of a secretory organ) or segmentectomy (removal of a segment affected by metastases). Based on statistical data, surgery to remove a liver tumor with metastases from another internal organ leads to early relapse in 42-44% of cases.

The likelihood of recurrence increases in cases where metastatic malignant foci affect both lobes of the secretory organ and when performing resection, the oncologist-surgeon does not have the opportunity to retreat from the oncological tumor to a sufficient distance. Surgical treatment of liver cancer with such localization of metastases involves resection of several single lesions, but such tactics are not generally accepted. The best option When a metastatic oncological tumor is detected in the liver parenchyma, complete removal of the liver or palliative treatment are considered.

Consequences and complications of surgical treatment

Surgical intervention in the affected oncological process hepatic parenchyma may be fraught with the development of negative side effects. The dangerous consequences of surgery for liver cancer are associated with the location of the organ - its resection or transplantation can provoke extensive internal bleeding. If abnormal cells are not completely removed in the early postoperative period, a relapse of the pathological condition occurs. Drug treatment, prescribed after surgery, suppresses immune system, as a result of which a person may develop various infections.

Oncologists also note the following complications of surgical treatment:

• the appearance of biliary fistulas;
• postoperative wound suppuration and sepsis;
• development liver failure, portal hypertension or pneumonia.

How long do patients live after surgery for liver cancer?

The prognosis of patients who have undergone surgery on the hepatic parenchyma is more favorable than those with inoperable oncology. Five-year survival rate is directly dependent on the stage at which the liver tumor was detected and operated on. In the first, it makes up 75% of all clinical cases, in the second - 68%, in the third, 52% of patients reach the critical five years, and in the fourth, only 11% of cancer patients have a chance of surviving until this period.

Significant deterioration is associated with early relapse of the disease. The occurrence of relapses after surgical treatment of liver cancer is observed in 50% - 90% of clinical cases. It is the postoperative exacerbation of the pathological process that becomes, for the most part, the cause of death. In order to prevent early death, the patient after surgery on the hepatic parenchyma must accurately follow all the recommendations of the attending physician.