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SurgicalDiseasesoftheLiverOutlinesoftoday’scontentsSurgicaldiseasesoftheliver1.Classification2.Surgicalanatomy3.Liverabs

cessbacterialabscess4.TumoroftheliverHCC1.Classification•traumatic•Infectious：BacterialAbscess•Tumorous:Hepatocellul

arCarcinoma•malformed•others：Intrahepaticcalculousparasitic2.SurgicalAnatomyoftheliverLiverliesintherightupperquad

rantofabdomen.Thelargestgland,weighs1500ginadult.FalciformligamentCoronaryligamentTriangularligamentGallbladderLigamentumt

ereshepaticusDiaphragmThreesetsofligaments1.Falciformligament2.Anteriorandposteriorrightandleftcoronaryligaments,fused

toformrightandlefttriangularligamentsatthebothendings3.GastrohepaticandhepatoduodenalligamentsFourlob

es1.Rightlobe2.Leftlobe3.Quadratelobe4.CaudatelobeFrenchsegmentalsystemCouinaudnomenclaturesystem8segments:hepa

ticvenousdrainageandportalveinsystemdistribution•4intheright(segments5-8)•3intheleft(segments2-4)•1caudate(segment1)第一肝门(Thefirstport

ahepatis)•肝动脉（Hepaticartery）•门静脉（Portalvein）•肝总管（Commonhepaticbileduct）第二肝门ThesecondportahepatisrightmiddleleftHepaticVeins第二肝门(T

heSecondPortaHepatis)第三肝门Thethirdportahepatis•Shorthepaticveins•Openingsofshorthepaticveinsenteringinferiorvenacava第三肝门(the

thirdportahepatis)LiverFunctions•Bileformation：600~1000ml/day/adult•Metabolismofcarbohydrate,lipid,pro

teinandvitamin:glycogen;fat-solublevitaminA,D,E,K•Coagulation:fibrinogen;coagulationfactors;Prothrombin•MetabolismofDru

gsandToxins:oxidation,reductionandhydrolysis•ImmunologicFunction•RegulationofthesystemiccirculationLiverBloodfl

ow•70%to75%oftotalhepaticbloodflowcomesfromtheportalvein,whiletheremaindercomesfromthehepaticartery.•However,40%~60%oxygensupplycomesfrom

hepaticartery3.LiverAbscessLiverabscessmaybebacterial,parasitic,orfungalinorigin.•Bacterialabscessthemostcommon•Amebi

cabscessnexttothemostcommonBacterialliverabscessEtiology:￭Biliarytract￭Hepaticartery￭Portalvein￭Lymphatic

system￭injuryBiliaryInfectionsAbdominalinfectionsGeneralizedsepsisempyemaofthegallbladderappendicitispne

umonitisprotractedcholangitisdiverticulitisendocarditisportalveinLiverAbscessClinicalfeatures￭Chill,hyperthermia:

39~40oC￭Hepatalgia:persistentpain￭Hepatomegaly￭WBC￭B-typeultrasound:>2cm,96%￭CTscan:positiverate>90%￭X-ray:elevatedhemidiaphragm

,bluntcostophrenicangle,intrahepaticair-fluidlevelDiagnosisandTreatmentCorrectdiagnosisofpyogenicversusamebicabscessisveryimportant,becausethetrea

tmentsareradicallydifferent.Differentialdiagnosisbetweenbacterialabscessandamebicabscess￭History:abdominalinf

ections;diarrhea￭Abscess:multiple;single￭Symptom:feverandchill;feverwithoutchill￭Bloodtestandculture:serologic

testpositive;negative￭Stooltest￭Pus￭Diagnostictherapy:antibiotic,amebicideTherapyforbacterialliverabscess￭Supportivetreatment￭Antibiotics￭

Percutaneouscatheterizationanddrainage￭OpendrainageTransabdominaldrainageExtra-peritonealdrainage•Amebicabscess•Non-operativ

e•Except:ruptureandsecondaryinfectionpercutaneousdrainage4.TumoroftheliverClassification•Benigntumors•MalignanttumorsBenignTumors•CavernousHemangioma

•Adenoma•Focalnodularhyperplasia•Lipoma•Teratoma•LeiomyomaMalignantTumors•Primarylivercancer•Secondary(metastatic)livercancerPrimaryLivercancer(

PLC)•Hepatocellularcarcinoma(HCC,90~95%0fPLC)•Cholangiocarcinoma•Hepatocellular-cholangiocellularcarcinoma(combinedtype)Ce

llulartypes:HepatocellularCarcinoma(HCC)PrevalenceofHCCAge-StandardizedLiverCancerIncidenceRatesAmongMalesJe

malA,etal.CACancerJClin2002●fifthmostcommoncancerinmenandeighthinwomen●thirdleadingcauseofcancerdeathinmenandthe

sixthamongwomen●Chinaaccountsforover55%ofthetotal•hepatitisvirusBorC•cirrhosis•aflatoxinEtiologyHepatitisBVirus•70%~80%o

fHCCpatients,HBVcarrierinAsiaandAfrica•21%ofHCCpatients,HBVinfectioninUSAHepatitisC•HCVinfectionpresen

tsin51%ofthepatientswithHCCinJapan.•26%withHBVinfectioninthesamecountryCoexistenceofCirrhosisandHCC•68%～74%U

K•70%Japan•80%～86.5%ChinaClinicalfeatures1.Hepatalgia:upperabdominalpain,tenderness2.Generalanddigestive:weakness,ano

rexia,malaise,weightloss3.Hepatomegaly:abdominalmass(14%),4.Jaundice(24%)DiagnosisSpecificmarker:AFP(α-fet

alprotein)elevation,>or=400ug/L•Radioimmunoassay:positivity69~93%•30%negative•Mildelevation:acutehepatitis,chronicliverdisease•Markedlyincrease:ter

atocarcinoma,yolksactumor,rarelymetastastictumorfrompancreasorstomach•B-typeultrasound:>2cm;84%•CTscan(computedtomography):>1cm;90%Hypoechoi

clesion•MRI(magneticresonanceimaging),sensitivity95%•Radioisotopescanning:99mTcredhepaticsingle-photonemissioncompu

tedtomography,SPECT>3cm;85~90%•X-ray•Needlebiopsy:guidedbyultrasound•Laparoscopy:over70%ofliversurfacedirectassessme

ntofabdominalspreadTreatmentofHCCtreatmentoptionsforHCC1.Hepaticresectionthemosteffective2.Chemoemboli

zation3.Chemotherapy4.Cryosurgery5.RadiofrequencyAblation6.RadiationTherapy7.PercutaneousEthanolInjection8.LiverTransplantationHepaticResectio

n•Atpresent,resectionistheonlytherapythatsubstantiallyprolongssurvival.•Resectionhasoftenresultedincure,particularlyintheabsenceofci

rrhosis.**Selectionofsuitablepatientswhocouldtolerateahepaticresection.•Thepatientsarerequiredtomeetthe

followingcriteria:•Serumalbumin＞3.5gm/dl•Prothrombintime＜3seconds•ASTnormal•Serumtotalbilirubinnormal•ICGretention(at15min.

)＜15%•Withoutascites•Nontumorousliverparenchyma＞50%Case1HepaticresectionTransarterialchemoembolization,TACEEmbolizationistheprocessofinjectingafore

ignsubstance(iodizedoil)intothetumortostopthebloodflow.Thelackofblooddeprivesthetumorofneededoxygenan

dnutrientsandeventuallycausescellstodie.Case2RegionalchemotherapySystemicchemotherapy•responseratelessthan25%

ChemotherapyRegionaldrugdeliverysystem(Asubcutaneousportisasmallmetalchamberwitharubbertopthatisplacedundertheskinoftheabdome

n.)CryoablationDoublefreezetechnique:Thetumorandahalfinchmarginofnormalliverarefrozento-190°Cfor15minutes,whichislethaltoallt

issues.Theareaisthawedfor10minutesandthenre-frozento-190°Cforanother15minutes.Afterthetumorhasthawed,theprobeisremoved,bleed

ingiscontrolled,andtheprocedureiscomplete.5-yearsurvival:11~60%,dependingoncaseselectionRadiofrequencyablation

Coagulativenecrosisfrom1.6to3cmIndications:fewerthanthreelesionseachlessthan3cmindiameter,orasinglerecurringle

sionlessthan5cmindiameter.