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SurgicalDiseasesoftheLiverOutlinesoftoday’scontentsSurgicaldiseasesoftheliver1.Classification2.Surgicalanatomy3.Liverab

scessbacterialabscess4.TumoroftheliverHCC1.Classification•traumatic•Infectious：BacterialAbscess•Tumorous:HepatocellularCarcinoma•malformed•others：In

trahepaticcalculousparasitic2.SurgicalAnatomyoftheliverLiverliesintherightupperquadrantofabdomen.Thelargestglan

d,weighs1500ginadult.FalciformligamentCoronaryligamentTriangularligamentGallbladderLigamentumtereshepaticusDiaphragmThreesetsofligaments1.Fal

ciformligament2.Anteriorandposteriorrightandleftcoronaryligaments,fusedtoformrightandlefttriangularligamen

tsatthebothendings3.GastrohepaticandhepatoduodenalligamentsFourlobes1.Rightlobe2.Leftlobe3.Quadratelobe4.CaudatelobeFr

enchsegmentalsystemCouinaudnomenclaturesystem8segments:hepaticvenousdrainageandportalveinsystemdistribution•4intheright(segments5-8)•3intheleft(

segments2-4)•1caudate(segment1)第一肝门(Thefirstportahepatis)•肝动脉（Hepaticartery）•门静脉（Portalvein）•肝总管（Commonh

epaticbileduct）第二肝门ThesecondportahepatisrightmiddleleftHepaticVeins第二肝门(TheSecondPortaHepatis)第三肝门Thethirdportahepatis•Shorthepaticveins•Openi

ngsofshorthepaticveinsenteringinferiorvenacava第三肝门(thethirdportahepatis)LiverFunctions•Bileformation：600~1000ml/day/a

dult•Metabolismofcarbohydrate,lipid,proteinandvitamin:glycogen;fat-solublevitaminA,D,E,K•Coagulation:fibrinogen;coagulationfact

ors;Prothrombin•MetabolismofDrugsandToxins:oxidation,reductionandhydrolysis•ImmunologicFunction•Regulation

ofthesystemiccirculationLiverBloodflow•70%to75%oftotalhepaticbloodflowcomesfromtheportalvein,whiletheremaindercomesfromthehepaticart

ery.•However,40%~60%oxygensupplycomesfromhepaticartery3.LiverAbscessLiverabscessmaybebacterial,parasit

ic,orfungalinorigin.•Bacterialabscessthemostcommon•AmebicabscessnexttothemostcommonBacterialliverabscessEtiology:￭Biliarytract￭Hepatic

artery￭Portalvein￭Lymphaticsystem￭injuryBiliaryInfectionsAbdominalinfectionsGeneralizedsepsisempyemaofthegallbladderappendicitispneumonitisprotrac

tedcholangitisdiverticulitisendocarditisportalveinLiverAbscessClinicalfeatures￭Chill,hyperthermia:39~40oC￭Hepatalgia:persiste

ntpain￭Hepatomegaly￭WBC￭B-typeultrasound:>2cm,96%￭CTscan:positiverate>90%￭X-ray:elevatedhemidiaphragm,bluntcostophrenicangle,intr

ahepaticair-fluidlevelDiagnosisandTreatmentCorrectdiagnosisofpyogenicversusamebicabscessisveryimportant,becausethetreatmen

tsareradicallydifferent.Differentialdiagnosisbetweenbacterialabscessandamebicabscess￭History:abdominalinfections;diarrhea￭Abscess:multiple;single￭S

ymptom:feverandchill;feverwithoutchill￭Bloodtestandculture:serologictestpositive;negative￭Stooltest￭Pus￭Diagnostictherapy:antibioti

c,amebicideTherapyforbacterialliverabscess￭Supportivetreatment￭Antibiotics￭Percutaneouscatheterizationanddrainag

e￭OpendrainageTransabdominaldrainageExtra-peritonealdrainage•Amebicabscess•Non-operative•Except:ruptu

reandsecondaryinfectionpercutaneousdrainage4.TumoroftheliverClassification•Benigntumors•MalignanttumorsB

enignTumors•CavernousHemangioma•Adenoma•Focalnodularhyperplasia•Lipoma•Teratoma•LeiomyomaMalignantTumor

s•Primarylivercancer•Secondary(metastatic)livercancerPrimaryLivercancer(PLC)•Hepatocellularcarcinoma(HCC,90~95%0fPLC)•Cholangiocarcinoma•Hepato

cellular-cholangiocellularcarcinoma(combinedtype)Cellulartypes:HepatocellularCarcinoma(HCC)PrevalenceofHCCAge-StandardizedLiverCancerIncidenc

eRatesAmongMalesJemalA,etal.CACancerJClin2002●fifthmostcommoncancerinmenandeighthinwomen●thirdleadingcauseofcancerdeathinmenandthesixtham

ongwomen●Chinaaccountsforover55%ofthetotal•hepatitisvirusBorC•cirrhosis•aflatoxinEtiologyHepatitisBVirus•70%~80%ofHCCpatients

,HBVcarrierinAsiaandAfrica•21%ofHCCpatients,HBVinfectioninUSAHepatitisC•HCVinfectionpresentsin51%ofthepatientswithHCCinJapan.•26%withHBVin

fectioninthesamecountryCoexistenceofCirrhosisandHCC•68%～74%UK•70%Japan•80%～86.5%ChinaClinicalfeatures1.Hepatalgia:upperabdominalpain,tenderness2.Ge

neralanddigestive:weakness,anorexia,malaise,weightloss3.Hepatomegaly:abdominalmass(14%),4.Jaundice(24%)DiagnosisSpecificmarker:AFP(α-feta

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

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

Hypoechoiclesion•MRI(magneticresonanceimaging),sensitivity95%•Radioisotopescanning:99mTcredhepaticsingle-photonemissi

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

rfacedirectassessmentofabdominalspreadTreatmentofHCCtreatmentoptionsforHCC1.Hepaticresectionthemosteffective2.Chemoe

mbolization3.Chemotherapy4.Cryosurgery5.RadiofrequencyAblation6.RadiationTherapy7.PercutaneousEthanolIn

jection8.LiverTransplantationHepaticResection•Atpresent,resectionistheonlytherapythatsubstantiallyprolongssurvival.

•Resectionhasoftenresultedincure,particularlyintheabsenceofcirrhosis.**Selectionofsuitablepatientswhocouldtolerateahepaticrese

ction.•Thepatientsarerequiredtomeetthefollowingcriteria:•Serumalbumin＞3.5gm/dl•Prothrombintime＜3seconds•ASTnormal

•Serumtotalbilirubinnormal•ICGretention(at15min.)＜15%•Withoutascites•Nontumorousliverparenchyma＞50%Case1Hepat

icresectionTransarterialchemoembolization,TACEEmbolizationistheprocessofinjectingaforeignsubstance(iodizedoil)int

othetumortostopthebloodflow.Thelackofblooddeprivesthetumorofneededoxygenandnutrientsandeventuallycausescellstodie.Case2Regio

nalchemotherapySystemicchemotherapy•responseratelessthan25%ChemotherapyRegionaldrugdeliverysystem(Asubcutaneousportisasmallmetalch

amberwitharubbertopthatisplacedundertheskinoftheabdomen.)CryoablationDoublefreezetechnique:Thetumorandahalfinchmarginofnormalliverarefro

zento-190°Cfor15minutes,whichislethaltoalltissues.Theareaisthawedfor10minutesandthenre-frozento-190°Cforanother15minutes.Afterthet

umorhasthawed,theprobeisremoved,bleedingiscontrolled,andtheprocedureiscomplete.5-yearsurvival:11~60%,dependingoncaseselectionRadiofrequencyablati

onCoagulativenecrosisfrom1.6to3cmIndications:fewerthanthreelesionseachlessthan3cmindiameter,orasinglerecurringle

sionlessthan5cmindiameter.