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SurgicalDiseasesoftheLiverOutlinesoftoday’scontentsSurgicaldiseasesoftheliver1.Classification2.Surgicalanatomy3.Liverabscessbacterialabscess4.Tumor

oftheliverHCC1.Classification•traumatic•Infectious：BacterialAbscess•Tumorous:HepatocellularCarcinoma•malformed•others：Intrahepaticc

alculousparasitic2.SurgicalAnatomyoftheliverLiverliesintherightupperquadrantofabdomen.Thelargestgland,weighs1500ginadul

t.FalciformligamentCoronaryligamentTriangularligamentGallbladderLigamentumtereshepaticusDiaphragmThreesetsofl

igaments1.Falciformligament2.Anteriorandposteriorrightandleftcoronaryligaments,fusedtoformrightandlefttri

angularligamentsatthebothendings3.GastrohepaticandhepatoduodenalligamentsFourlobes1.Rightlobe2.Leftlobe3.Quadratelob

e4.CaudatelobeFrenchsegmentalsystemCouinaudnomenclaturesystem8segments: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（Commonhepaticbil

educt）第二肝门ThesecondportahepatisrightmiddleleftHepaticVeins第二肝门(TheSecondPortaHepatis)第三肝门Thethirdportahepatis•Shorthepaticveins•Openings

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

lt•Metabolismofcarbohydrate,lipid,proteinandvitamin:glycogen;fat-solublevitaminA,D,E,K•Coagulation:fibrinogen;coagulationfactors;Prothrombin•Metabo

lismofDrugsandToxins:oxidation,reductionandhydrolysis•ImmunologicFunction•Regulationofthesystemiccirc

ulationLiverBloodflow•70%to75%oftotalhepaticbloodflowcomesfromtheportalvein,whiletheremaindercomesfromthehepaticartery.•However,40%~60%oxygen

supplycomesfromhepaticartery3.LiverAbscessLiverabscessmaybebacterial,parasitic,orfungalinorigin.•Bacterialabscessthemos

tcommon•AmebicabscessnexttothemostcommonBacterialliverabscessEtiology:￭Biliarytract￭Hepaticartery￭Portalvein￭Lymphaticsystem￭in

juryBiliaryInfectionsAbdominalinfectionsGeneralizedsepsisempyemaofthegallbladderappendicitispneumonitisprotractedcholan

gitisdiverticulitisendocarditisportalveinLiverAbscessClinicalfeatures￭Chill,hyperthermia:39~40oC￭Hepa

talgia:persistentpain￭Hepatomegaly￭WBC￭B-typeultrasound:>2cm,96%￭CTscan:positiverate>90%￭X-ray:elevatedhemidiaphragm,bluntco

stophrenicangle,intrahepaticair-fluidlevelDiagnosisandTreatmentCorrectdiagnosisofpyogenicversusamebicabscessisveryimportant,becausethetreatmentsarera

dicallydifferent.Differentialdiagnosisbetweenbacterialabscessandamebicabscess￭History:abdominalinfection

s;diarrhea￭Abscess:multiple;single￭Symptom:feverandchill;feverwithoutchill￭Bloodtestandculture:serologictestpositive;negative￭Stooltest￭Pus￭Diag

nostictherapy:antibiotic,amebicideTherapyforbacterialliverabscess￭Supportivetreatment￭Antibiotics￭Percutaneouscat

heterizationanddrainage￭OpendrainageTransabdominaldrainageExtra-peritonealdrainage•Amebicabscess•Non-operative•Exc

ept:ruptureandsecondaryinfectionpercutaneousdrainage4.TumoroftheliverClassification•Benigntumors•MalignanttumorsBenignTumors•CavernousHemangioma

•Adenoma•Focalnodularhyperplasia•Lipoma•Teratoma•LeiomyomaMalignantTumors•Primarylivercancer•Secondary(metastati

c)livercancerPrimaryLivercancer(PLC)•Hepatocellularcarcinoma(HCC,90~95%0fPLC)•Cholangiocarcinoma•Hepatocellular-cholangiocellularcar

cinoma(combinedtype)Cellulartypes:HepatocellularCarcinoma(HCC)PrevalenceofHCCAge-StandardizedLiverCancerIncidenceRatesAmongM

alesJemalA,etal.CACancerJClin2002●fifthmostcommoncancerinmenandeighthinwomen●thirdleadingcauseofcancerdeat

hinmenandthesixthamongwomen●Chinaaccountsforover55%ofthetotal•hepatitisvirusBorC•cirrhosis•aflatoxinEt

iologyHepatitisBVirus•70%~80%ofHCCpatients,HBVcarrierinAsiaandAfrica•21%ofHCCpatients,HBVinfectioninUSAHepatitisC•HCVinfectionpre

sentsin51%ofthepatientswithHCCinJapan.•26%withHBVinfectioninthesamecountryCoexistenceofCirrhosisandHCC•68%～74%UK•70%Japan•80%～86.5%ChinaClinicalfeat

ures1.Hepatalgia:upperabdominalpain,tenderness2.Generalanddigestive:weakness,anorexia,malaise,weightloss3.Hepato

megaly:abdominalmass(14%),4.Jaundice(24%)DiagnosisSpecificmarker:AFP(α-fetalprotein)elevation,>or=400ug/L

•Radioimmunoassay:positivity69~93%•30%negative•Mildelevation:acutehepatitis,chronicliverdisease•Markedlyincrease:teratocarcinoma

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

ypoechoiclesion•MRI(magneticresonanceimaging),sensitivity95%•Radioisotopescanning:99mTcredhepaticsingle-photonemissioncomputedtomography,SPECT

>3cm;85~90%•X-ray•Needlebiopsy:guidedbyultrasound•Laparoscopy:over70%ofliversurfacedirectassessmento

fabdominalspreadTreatmentofHCCtreatmentoptionsforHCC1.Hepaticresectionthemosteffective2.Chemoembolization3.Chemotherapy4.Cryosurgery5

.RadiofrequencyAblation6.RadiationTherapy7.PercutaneousEthanolInjection8.LiverTransplantationHepaticResection•Atpresent,r

esectionistheonlytherapythatsubstantiallyprolongssurvival.•Resectionhasoftenresultedincure,particularlyintheabsenceofcirrhosis.**Selection

ofsuitablepatientswhocouldtolerateahepaticresection.•Thepatientsarerequiredtomeetthefollowingcriteria:•Serumalbumin＞

3.5gm/dl•Prothrombintime＜3seconds•ASTnormal•Serumtotalbilirubinnormal•ICGretention(at15min.)＜15%•Withoutascites•Nontumoro

usliverparenchyma＞50%Case1HepaticresectionTransarterialchemoembolization,TACEEmbolizationistheprocessofinj

ectingaforeignsubstance(iodizedoil)intothetumortostopthebloodflow.Thelackofblooddeprivesthetumorofneededoxygenandnutrientsandeventuallycau

sescellstodie.Case2RegionalchemotherapySystemicchemotherapy•responseratelessthan25%ChemotherapyRegionaldrugdeliverysystem(Asubc

utaneousportisasmallmetalchamberwitharubbertopthatisplacedundertheskinoftheabdomen.)CryoablationDoublefreezetechnique:Thetumoranda

halfinchmarginofnormalliverarefrozento-190°Cfor15minutes,whichislethaltoalltissues.Theareaisthawedfor10minutesandthenre-frozento-190°Cfora

nother15minutes.Afterthetumorhasthawed,theprobeisremoved,bleedingiscontrolled,andtheprocedureiscomplete.5-yearsurvival:11~60%,dependingonc

aseselectionRadiofrequencyablationCoagulativenecrosisfrom1.6to3cmIndications:fewerthanthreelesionseachlessthan3cmindi

ameter,orasinglerecurringlesionlessthan5cmindiameter.