1. What are the learning objectives for studying the liver?
• To understand the anatomy of the liver. • To recognize the signs of acute and chronic liver disease. • To understand the investigation of liver disease. • To know the management of liver trauma and infections. • To know the management of benign and cystic liver lesions, intrahepatic cholangiocarcinoma, hepatocellular carcinoma, and colorectal liver metastases.
1/116
| Term | Definition |
|---|---|
| 1. What are the learning objectives for studying the liver? | • To understand the anatomy of the liver. • To recognize the signs of acute and chronic liver disease. • To understand the investigation of liver disease. • To know the management of liver trauma and infections. • To know the management of benign and cystic liver lesions, intrahepatic cholangiocarcinoma, hepatocellular carcinoma, and colorectal liver metastases. |
| 2. Describe the basic anatomy and physical characteristics of the liver. | • The liver is a highly complex organ found only in vertebrates, responsible for over 500 functions. • Located in the right upper quadrant, protected by ribs, weighing about 1.5 kg. • Wedge-shaped in coronal and axial planes, divided by the middle hepatic vein into two lobes (right lobe ≈ 60%). • Covered by a thin capsule (Glisson’s capsule) and visceral peritoneum except for the posterior “bare area.” • The right and left lobes are functional units separated by the middle hepatic vein (Cantlie’s line). |
| 3. What is the embryological origin of the liver and biliary system? | • Development begins at 3–4 weeks’ gestation from a hepatic foregut diverticulum budding into the ventral wall of the primitive midgut. • This diverticulum forms the liver, extrahepatic biliary ducts, gallbladder, and ventral pancreas. • The basement membrane around the liver bud is lost, and hepatoblasts invade the septum transversum, differentiating into hepatocytes and cholangiocytes. |
| 4. Describe the ligaments and peritoneal reflections of the liver. | • The liver is covered by visceral peritoneum and a connective tissue layer (Glisson’s capsule). • At the porta hepatis, the capsule continues into the liver carrying branches of hepatic artery, portal vein, and bile ducts. • Fixation is by hepatic veins and peritoneal ligaments: – Left and right triangular ligaments attach liver to diaphragm. – Falciform ligament (remnant of umbilical vein) connects liver to anterior abdominal wall. – The lesser omentum connects stomach and liver, enclosing the portal triad. |
| 5. Describe the blood supply of the liver. | • Dual supply: 80% from portal vein and 20% from hepatic artery. • Arterial supply: usually from the coeliac trunk → common hepatic artery → right and left hepatic arteries. • Variants: right hepatic artery from superior mesenteric artery |
| 6. What is the anatomy of the porta hepatis (liver hilum)? | • A transverse fissure on the visceral surface between the fissure for ligamentum teres and the gallbladder fossa. • Contains structures in the hepatoduodenal ligament: – Bile duct (anterior-right), hepatic artery (anterior-left), and portal vein (posterior). • The right and left hepatic ducts join to form the common hepatic duct |
| 7. Describe the venous drainage of the liver. | • The IVC lies in a groove on the posterior surface of the liver. • Three large hepatic veins (right, middle, left) drain directly into the IVC just below the diaphragm. • Short inferior hepatic veins drain the posterior surface. • The right adrenal vein drains adjacent to the retrohepatic IVC. |
| 8. Explain the segmental anatomy of the liver and its surgical importance. | • The liver is divided into right and left functional units by Cantlie’s line. • Couinaud described eight segments, each with its own vascular inflow, outflow, and biliary drainage. • Right lobe: segments V–VIII supplied by right hepatic artery and right portal vein, drained by right hepatic duct. • Left lobe: segments I–IV supplied by left hepatic artery and left portal vein, drained by left hepatic duct. • Enables anatomical resections preserving maximal function. |
| 9. Describe the microscopic anatomy of the liver. | • Consists of ≈ 100,000 hexagonal lobules, each with a central vein and peripheral portal triads. • Sinusoids connect portal vessels to central vein, lined by endothelial and Kupffer cells. • Hepatocytes form plates between sinusoids and perform metabolism, detoxification, storage, and bile secretion. • Bile canaliculi drain bile opposite to blood flow toward portal tracts. |
| 10. List the main functions of the liver. | • Metabolism of carbohydrates, proteins, and lipids. • Synthesis of plasma proteins (albumin, clotting factors). • Bile formation and bilirubin conjugation. • Detoxification (cytochrome P450 system). • Storage of vitamins A, D, E, K, B12 and minerals. • Glucose homeostasis, urea synthesis, and immune functions. • Heat generation and angiotensin synthesis. |
| 11. What are the common clinical signs of liver disease? | • Jaundice, nausea, vomiting, right upper quadrant pain, malaise, confusion, and foetor hepaticus. • Signs: bruising, tremors, peripheral edema, ascites, spider naevi, palmar erythema, and gynecomastia. |
| 12. Define acute liver failure and outline its features. | • Defined as evidence of coagulopathy (INR > 1.5) and encephalopathy in a patient without pre-existing liver disease, with illness duration < 26 weeks. • Features: jaundice, hepatic encephalopathy (asterixis, confusion, coma), coagulopathy. • Mortality 30–40% |
| 13. List common causes of acute liver failure. | • Viral hepatitis (A–E). • Paracetamol overdose. • Drug toxicity (halothane, isoniazid, valproic acid, NSAIDs, antidepressants, statins). • Mushroom poisoning, toxins (carbon tetrachloride). • Shock, autoimmune disease, Budd–Chiari syndrome, fatty liver of pregnancy, malignancy, metabolic disorders (Wilson’s disease), Reye’s syndrome, SARS-CoV-2 infection. |
| 14. Outline the supportive management of acute liver failure. | • Maintain fluid and electrolyte balance. • Correct acid–base status and monitor blood glucose. • Provide nutritional support and renal monitoring (haemofiltration). • Treat infections and monitor for cerebral edema. • Extracorporeal liver support devices may be used as bridge to transplantation. |
| 15. What are the characteristic features of chronic liver disease? | • Symptoms: lethargy, fever, jaundice, weight loss, and ascites. • Signs: spider naevi, palmar erythema, bruising, gynecomastia, and splenomegaly. • Neurological: hepatic encephalopathy with memory impairment, confusion, and flapping tremor. • Circulatory: hyperdynamic circulation, warm peripheries, and low blood pressure. |
| 16. What are the common causes of chronic liver disease and their general features? | • Common causes: Chronic viral hepatitis (B, C), alcohol misuse, non-alcoholic fatty liver disease, autoimmune liver disease, metabolic and genetic disorders (e.g. Wilson’s disease, hemochromatosis). • Features: Lethargy, weakness, jaundice, fever, muscle wasting (sarcopenia), ascites, bruising due to coagulopathy, hyperdynamic circulation (high cardiac output, low blood pressure, flushed extremities), hepatic encephalopathy, spider naevi, palmar erythema, and splenomegaly from portal hypertension. |
| 17. How is the severity of chronic liver disease assessed? | • Child–Turcotte–Pugh (CTP) classification assesses hepatocellular function using bilirubin, albumin, INR, ascites, and encephalopathy. – CTP-A (5–6 points): good function. – CTP-B (7–9): moderate impairment. – CTP-C (10–15): severe impairment. • Model for End-Stage Liver Disease (MELD) score predicts short-term survival based on serum bilirubin, creatinine, and INR. • Used to predict surgical risk and transplantation priority. |
| 18. What are the operative risks in patients with chronic liver disease? | • Operative and anesthetic risks increase with disease severity. • Mortality after surgery: – 10% in CTP-A. – 30% in CTP-B. – 75–80% in CTP-C. • MELD score: operative mortality increases by 1% for each point up to 20 and by 2% for each point thereafter. • Risk is markedly higher for emergency procedures. |
| 19. Describe the commonly used imaging modalities for liver disease and their indications. | • Ultrasound (US): First-line for jaundice or right upper quadrant pain |
| 20. What are the main advantages and limitations of ultrasonography in liver imaging? | • Advantages: Readily available, safe, and non-invasive. • Limitations: Operator-dependent |
| 21. Describe the role of CT and MRI in liver imaging. | • CT: – Detects arterial-phase enhancement of small HCCs. – Defines venous anatomy and tumour relationship to vessels. – Rim enhancement suggests inflammation |
| 22. What is the role of PET scanning in liver disease? | • Demonstrates metabolic activity using 18F-FDG tracer. • Malignant tissue shows high glucose uptake. • False positives from inflammation and false negatives in small or necrotic lesions. • Useful for detecting metastases and lymph node involvement. |
| 23. Outline the principle and use of octreotide scanning. | • Octreotide (somatostatin analogue) labelled with indium-111 binds to somatostatin receptors on tumour cells. • Used for identifying carcinoid and other NETs with 75–100% sensitivity for pancreatic NETs. |
| 24. What is hepatobiliary iminodiacetic acid (HIDA) scanning and its uses? | • Uses technetium-99m (99mTc-HIDA), concentrated by hepatocytes and excreted in bile. • Demonstrates intra- and extrahepatic bile ducts and gallbladder. • Normal: enters duodenum within 30 minutes. • Uses: investigation of biliary atresia, post-transplant jaundice, and bile duct patency. |
| 25. What are the main indications and findings of ERCP? | • Indicated for obstructive jaundice when intervention is required. • Defines Klatskin tumours and intrahepatic duct extent. • Allows stent placement and drainage in sclerosing cholangitis or malignancy. |
| 26. Explain endoscopic cholangioscopy and its modern developments. | • Allows direct visualisation of bile ducts. • SpyGlass™ system enables single-operator visualisation and biopsy. • Diagnostic accuracy 85–95% for indeterminate strictures. |
| 27. Describe the role of endoscopic ultrasonography (EUS). | • Evaluates extrahepatic biliary tree and pancreas. • Can visualise caudate lobe and hilar lymph nodes. • Allows fine-needle biopsy of liver lesions. |
| 28. What are the indications for percutaneous transhepatic cholangiography (PTC)? | • When ERCP fails or is impossible due to anatomy or tumour involvement. • Used for imaging, drainage, and combined percutaneous-endoscopic stenting. |
| 29. What is the role of laparoscopy and laparoscopic ultrasonography in liver disease? | • Used for staging hepatobiliary malignancies and detecting occult peritoneal metastases. • Enables targeted biopsies and assessment of tumour spread. • Routine biopsy of resectable lesions is contraindicated due to risk of tumour seeding. |
| 30. What are the main causes and types of liver trauma? | • Causes: Blunt abdominal trauma (road traffic accidents, crush injury) and penetrating injuries (stab or gunshot). • Types: Contusion, laceration, avulsion. • Blunt injuries more common and carry higher mortality. |
| 31. How is liver trauma diagnosed and graded? | • Diagnosis: FAST ultrasound for free fluid |
| 32. Outline the initial management of liver trauma. | • Follow ABC of trauma (Airway, Breathing, Circulation). • Establish large-bore IV access |
| 33. How are penetrating and blunt liver injuries managed differently? | • Penetrating injuries: Often require laparotomy for haemorrhage control. • Blunt injuries: If haemodynamically stable → non-operative management |
| 34. Describe surgical techniques used in managing liver trauma. | • Resectional debridement. • Hepatotomy with direct suture ligation. • Perihepatic packing to tamponade diffuse bleeding. • Pringle manoeuvre (occlusion of portal triad) for vascular control. • Major vascular injury (hepatic veins or IVC) may require venovenous bypass. |
| 35. What are the major complications of liver trauma? | • Intrahepatic or subcapsular haematoma. • Liver abscess and sepsis. • Bile leak or biliary fistula. • Haemobilia, hepatic artery aneurysm, AV or arteriobiliary fistula. • Ascites and hepatic failure. |
| 36. How are late biliary and vascular complications of liver trauma managed? | • Biliary strictures → endoscopic stenting or Roux-en-Y hepaticojejunostomy. • Arterial aneurysm or fistula → embolisation. • Persistent biliary leak → drainage ± stenting |
| 37. What is portal hypertension and what are its main causes? | • Increased portal venous pressure due to resistance to flow. • Causes: – Pre-sinusoidal: portal vein thrombosis, splenic vein thrombosis, schistosomiasis. – Sinusoidal: cirrhosis. – Post-sinusoidal: Budd–Chiari syndrome, veno-occlusive disease, cardiac failure. |
| 38. What are the main complications of portal hypertension? | • Oesophageal and gastric varices. • Ascites. • Splenomegaly and hypersplenism. • Portosystemic encephalopathy. |
| 39. Describe the management of acute variceal bleeding. | • Resuscitation: airway protection, blood transfusion, correct coagulopathy (vitamin K, FFP, platelets). • Drugs: vasoconstrictors (terlipressin, octreotide), prophylactic antibiotics. • Endoscopic control: sclerotherapy or band ligation. • Refractory bleeding: balloon tamponade (Sengstaken–Blakemore/Minnesota tube), TIPSS, or surgery. |
| 40. Describe balloon tamponade in the management of variceal bleeding. | • Provides temporary haemostasis in uncontrolled bleeding. • Gastric balloon inflated with 300 mL air, oesophageal balloon at 60 mmHg pressure. • Aspiration channels for oesophagus and stomach |
| 41. What is a Transjugular Intrahepatic Portosystemic Stent Shunt (TIPSS) and its role? | • A radiological shunt connecting portal and hepatic veins via a stent placed through the jugular route. • Reduces portal pressure and controls variceal bleeding refractory to endoscopy. • Complications: hepatic encephalopathy (~40%), stent occlusion or stenosis (50% at 1 year), capsule perforation. |
| 42. What surgical shunts are used for portal hypertension and how do they work? | • Divert portal blood into systemic veins to decompress portal system. • Types: – Side-to-side or end-to-side portocaval shunt. – Mesocaval shunt using synthetic graft. – Splenorenal shunt. • Selective shunts decompress varices but preserve hepatic flow. |
| 43. What is the Sugiura procedure and when is it indicated? | • Combines splenectomy with oesophagogastric devascularisation and oesophageal transection. • Indicated for refractory oesophageal variceal bleeding when shunts or TIPSS not possible. • Interrupts portacaval shunting while preserving vagus and collateral channels. |
| 44. Outline the management of ascites in chronic liver disease. | • Diagnosis: imaging for cirrhotic morphology, portal vein patency |
| 45. What are the common chronic liver conditions of surgical relevance? | • Primary sclerosing cholangitis (PSC). • Primary biliary cirrhosis (PBC). • Budd–Chiari syndrome. • Caroli’s disease. • Simple and polycystic liver cysts. |
| 46. What is Primary Sclerosing Cholangitis (PSC)? | • A chronic cholestatic liver disease of unknown cause, characterised by diffuse inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts, leading to multifocal stricturing. • Common in young men, often associated with ulcerative colitis. • Progressive, leading to cholestasis and liver failure. Diagnosis: – “Beaded” appearance of bile ducts on cholangiography (due to multiple strictures and dilatations). – If imaging is equivocal, liver biopsy may be required. Complications: – Secondary biliary cirrhosis. – Predisposition to cholangiocarcinoma and gallbladder carcinoma. Management: – Supportive |
| 47. What is Primary Biliary Cirrhosis (PBC) and how does it present? | • A chronic autoimmune destruction of intrahepatic bile ducts, predominantly in middle-aged women. • Symptoms: Lethargy, malaise, pruritus, jaundice. • Diagnosis: Raised liver enzymes, presence of anti-mitochondrial or anti-smooth muscle antibodies |
| 48. What are Non-Alcoholic Fatty Liver Disease (NAFLD) and Non-Alcoholic Steatohepatitis (NASH)? | • NAFLD: Accumulation of fat in hepatocytes not due to alcohol. • NASH: Inflammatory subtype of NAFLD with risk of fibrosis and cirrhosis. • Prevalence: NAFLD affects ~25% of population |
| 49. What is Chemotherapy-Associated Steatohepatitis (CASH)? | • Hepatotoxic injury induced by antitumour drugs such as methotrexate, irinotecan, 5-fluorouracil, tamoxifen, and L-asparaginase. • Histologically resembles NAFLD/NASH. • Important in surgical planning because it reduces future liver remnant (FLR) function. |
| 50. What is Budd–Chiari Syndrome? | • Obstruction of hepatic venous outflow from small hepatic veins to the junction of IVC and right atrium. • Common in: Young women |
| 51. What is Caroli’s Disease and what are its features? | • A rare congenital dilatation of the intrahepatic bile ducts. • Incidence: <1 in 100,000. • Complications: Stone formation, recurrent cholangitis, and sepsis. • Diagnosis: Ultrasound or CT showing intrahepatic “bile lakes” with stones. • Treatment: Antibiotics for sepsis, drainage of infected ducts, resection if segmental |
| 52. What are the infective conditions of the liver? | 1. Ascending cholangitis 2. Pyogenic liver abscess 3. Hydatid disease (Echinococcus infection) 4. Parasitic infections (flukes, amoebae) Each may present with fever, right upper quadrant pain, jaundice, and systemic sepsis. |
| 53. What is Ascending Cholangitis and what causes it? | • Bacterial infection of the biliary tree usually secondary to obstruction. • Charcot’s triad: Fever with rigors, jaundice, and right upper quadrant tenderness. • Common organisms: E. coli, Klebsiella, Enterobacter. • Predisposing factors: Biliary stones, strictures, tumours, and parasites. • Treatment: Prompt IV fluids, broad-spectrum antibiotics, and urgent biliary drainage (ERCP or PTC). |
| 54. What are the routes of infection causing pyogenic liver abscesses? | • Portal route: Spread from intra-abdominal sepsis (appendicitis, diverticulitis). • Biliary route: Ascending infection from cholangitis. • Arterial route: From systemic septicaemia. • Direct spread: From adjacent structures (subphrenic abscess, cholecystitis). |
| 55. What are the clinical features, investigations, and treatment of liver abscess? | • Features: Fever, rigors, malaise, right upper quadrant pain, hepatomegaly. • Investigations: – Ultrasound/CT showing cystic or multiloculated mass. – Aspiration for culture and microscopy. • Treatment: – Broad-spectrum antibiotics (metronidazole + cephalosporin/aminoglycoside). – Image-guided aspiration or drainage. – Surgical drainage if refractory or multiloculated. – Identify and treat source of infection. |
| 56. What is Hydatid Disease of the liver and how is it managed? | • Caused by Echinococcus granulosus (dog tapeworm). • Produces cysts within the liver which may rupture or become infected. • Diagnosis: Ultrasound/CT shows cysts |
| 57. What are the common benign liver tumours? | • Haemangioma – most common benign lesion. • Focal Nodular Hyperplasia (FNH). • Hepatic Adenoma – usually in women taking oral contraceptives. |
| 58. Describe the key features of hepatic adenoma. | • Benign, vascular tumour seen in women aged 25–50 years. • Linked to oral contraceptive use. • May cause pain due to rupture or bleeding. • Malignant potential (≈10% may develop into HCC). • Treatment: Surgical excision if >5 cm or symptomatic |
| 59. What is Focal Nodular Hyperplasia (FNH) and its management? | • FNH is a benign focal overgrowth of hepatocytes and fibrous tissue, possibly due to vascular malformation. • Occurs mainly in middle-aged women. • Imaging: Solid hypervascular lesion with central scar on CT/MRI. • No malignant potential |
| 60. Describe hepatic haemangioma and its clinical importance. | • Vascular malformation of hepatic blood vessels, often multiple. • Usually asymptomatic |
| 61. What is the significance and risk of liver biopsy? | • Used for diagnosis of diffuse liver disease or indeterminate lesions. • Minor complications: Pain, small haematoma. • Major complications: Bleeding, bile leak, haemobilia, infection, pneumothorax. • Mortality: 0.1–0.3%. • Note: Avoid biopsy of resectable malignant lesions due to risk of tumour seeding. |
| 62. What are simple and polycystic liver cysts and their management? | • Simple cysts: Benign, fluid-filled, often asymptomatic |
| 63. What are hepatic cystadenomas and cystadenocarcinomas? | • Rare cystic neoplasms (<200 cases reported). • Cystadenomas: Multiloculated cysts with septations and ovarian-like stroma |
| 64. What are neuroendocrine (carcinoid) tumours of the liver? | • Most hepatic carcinoid tumours are metastatic, commonly from small bowel or colon. • Incidence: 1.5–1.9 per 100,000. • Features: Carcinoid syndrome (flushing, diarrhoea, bronchospasm). • Management: – Resection if isolated hepatic disease. – Debulking for symptom relief if unresectable. – Octreotide for control of hormonal symptoms. |
| 65. What is Hepatocellular Carcinoma (HCC) and its epidemiology? | • Malignant tumour of hepatocytes, most common primary liver cancer. • Accounts for majority of liver malignancies worldwide. • More frequent in men (3:1 ratio). • Global burden: 1 million new cases and 829,000 deaths in 2016. • High incidence areas: Asia and sub-Saharan Africa. • Main causes: Chronic HBV, HCV, aflatoxin exposure, alcohol, obesity, diabetes. |
| 66. What are the main clinical features and prognosis of HCC? | • Features: Weight loss, right upper quadrant mass, jaundice, and decompensated cirrhosis. • Prognosis: – Median survival 6–20 months. – 2-year survival <50%, 5-year <10%. – Better outcome in early-stage disease detected by screening. |
| 67. Describe the Barcelona Clinic Liver Group (BCLC) staging system for HCC. | • Integrates tumour size, number, vascular invasion, liver function (CTP), and performance status. • Stages: – Stage 0/A: Early |
| 68. How is HCC managed surgically? | • Surgical resection: Preferred if preserved liver function (CTP-A). • Transplantation: Best for tumours within Milan criteria (≤5 cm single, or ≤3 nodules ≤3 cm). • Locoregional therapies: RFA, microwave ablation, TACE for unresectable tumours. • Contraindications: Extrahepatic spread, vascular invasion, multifocal disease, poor liver function. |
| 69. What are the main types and features of Intrahepatic Cholangiocarcinoma (ICC)? | • Malignancy of intrahepatic bile ducts, second most common primary liver tumour. • Incidence: 0.5–2 per 100,000 in the West |
| 70. What are colorectal liver metastases and why are they important? | • Liver is the most common site for metastases from colorectal carcinoma. • 20–45% of patients develop liver metastases during disease course. • Curative resection possible in 20–40% |
| 71. How is resectability of colorectal liver metastases determined? | • Resection criteria: All disease must be removable with clear (R0 or R1) margins while leaving adequate functional liver remnant (FLR). • FLR requirement: – ≥25% of total liver volume in a normal liver. – ≥30% if prior chemotherapy. – ≥40% if cirrhosis present. • Technical considerations: – No involvement of major vascular or biliary structures that precludes reconstruction. – No unresectable extrahepatic disease. • Margin status: – R0 = microscopically negative margin ≥1 mm. – R1 = microscopic tumour at margin (acceptable if systemic therapy given). |
| 72. What are the traditional contraindications to liver resection for colorectal metastases? | • Diffuse bilobar disease not amenable to clearance. • Uncontrolled primary tumour. • Extensive extrahepatic metastases. • Insufficient functional remnant liver volume. • Involvement of major hepatic veins, retrohepatic IVC, or biliary confluence. • Severe coexisting medical illness making major surgery unsafe. |
| 73. What are the modern advances that have expanded criteria for liver resection in colorectal metastases? | • Improved anaesthesia, critical care, and surgical technology. • Advanced chemotherapy regimens enabling tumour “downstaging.” • Two-stage hepatectomy and portal vein embolisation (PVE). • ALPPS procedure (Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy). • Laparoscopic and robotic liver resection. • Acceptance of limited extrahepatic disease if controllable. |
| 74. What is the role of a multidisciplinary team (MDT) in managing colorectal liver metastases? | • Ensures coordination between hepatobiliary surgeons, oncologists, radiologists, and pathologists. • Determines resectability and best sequence of therapies. • Decides between synchronous, staged, or “liver-first” approaches. • Plans follow-up imaging and surveillance. |
| 75. What imaging studies are used for staging colorectal liver metastases? | • Triple-phase CT scan (chest, abdomen, pelvis): Detects liver lesions and thoracic metastases. • MRI (with contrast): Best for small or equivocal lesions. • PET-CT: Detects metabolically active lesions and occult metastases. • Intraoperative ultrasound (IOUS): Identifies additional small lesions missed on preoperative imaging. |
| 76. What is the role of chemotherapy in the management of colorectal liver metastases? | • Neoadjuvant (preoperative): – Downstages initially unresectable disease. – Tests tumour biology (progression during therapy = poor prognosis). • Adjuvant (postoperative): – Reduces recurrence risk after curative resection. • Common regimens: 5-fluorouracil (5-FU) + folinic acid ± oxaliplatin (FOLFOX). • Targeted therapies: Monoclonal antibodies to VEGFR (bevacizumab) and EGFR (cetuximab, panitumumab). |
| 77. What is meant by ‘conversion’ chemotherapy in liver metastases? | • Chemotherapy given to downsize initially unresectable liver metastases until curative resection becomes possible. • Response rates of 50–60% when using FOLFOX or FOLFIRI ± biologics. • Successful conversion can increase resection rates and 5-year survival to 35–50%. |
| 78. Describe the surgical options for synchronous colorectal liver metastases. | • Sequential approach: Resect colon first, then liver after chemotherapy and restaging (most common). • Simultaneous approach: Both resected in one operation if technically straightforward and patient stable. • Liver-first approach: In selected cases where advanced liver disease risks becoming unresectable before bowel resection. |
| 79. What is the ‘liver-first’ or reverse strategy for synchronous colorectal metastases? | • Sequence: Systemic chemotherapy → liver resection → resection of primary tumour. • Indicated when: – Extensive or borderline-resectable liver disease. – Asymptomatic or resectable primary tumour. • Benefit: Prevents loss of resectability due to delay or progression during recovery from bowel surgery. |
| 80. What is the prognosis after hepatic resection for colorectal liver metastases? | • 5-year survival: ~50% after R0 resection. • Recurrence rate: 65%, with 40% confined to the liver. • Predictors of poor prognosis: – Multiple lesions (>3). – Size >5 cm. – Synchronous presentation. – High preoperative CEA. – Node-positive primary tumour. • Repeat resection can provide further survival benefit. |
| 81. How is recurrence after colorectal liver resection managed? | • Surveillance: – Clinical review and CT/MRI every 6–12 months for 5 years. – Tumour markers (CEA) monitored if initially raised. • Recurrent isolated liver lesions: Consider repeat resection or local ablation. • Extrahepatic recurrence: Managed with systemic therapy or targeted interventions depending on site. |
| 82. What is the role of re-do (repeat) liver surgery? | • Considered for isolated hepatic recurrence with adequate remnant function. • Outcomes: Comparable long-term survival to first resection if R0 achieved. • Must account for anatomical changes and hypertrophy post prior surgery. • Requires precise preoperative imaging and surgical planning. |
| 83. What are non-colorectal, non-neuroendocrine metastases and can they be resected? | • Include metastases from renal, breast, gastric, lung, melanoma, and sarcoma primaries. • Rarely confined to the liver because they spread haematogenously. • Liver resection may be palliative or potentially curative in selected cases with isolated metastases and good control of the primary tumour. • Survival benefit possible in well-selected patients, particularly with breast or renal metastases. |
| 84. What are Gastrointestinal Stromal Tumours (GISTs) and their hepatic implications? | • GISTs are non-epithelial tumours originating from interstitial cells of Cajal. • 20–25% of patients develop liver metastases. • Treatment: – Targeted therapy with imatinib mesylate (tyrosine kinase inhibitor). – Surgical resection if feasible and disease is localised. – Debulking is not indicated unless all disease can be completely removed. • Follow-up: Continuous surveillance as secondary resistance may develop. |
| 85. What are the surgical principles of liver resection in oncological disease? | • Aim: Achieve tumour clearance (R0 margin) while preserving adequate functional liver tissue. • Preoperative planning: Assess vascular anatomy and FLR using CT/MRI. • Techniques: – Anatomical or non-anatomical resection. – Parenchymal-sparing when multiple lesions present. – Control inflow and outflow vessels before transection (hilar dissection). • Blood loss minimisation: Low central venous pressure anaesthesia, Pringle manoeuvre, topical haemostatic agents. • Postoperative goal: Prevent hepatic insufficiency by ensuring adequate remnant function. |
| 86. What are the key advantages of laparoscopic and robotic liver resections? | • Laparoscopic: – Less postoperative pain and shorter hospital stay. – Reduced blood loss and faster recovery. – Now standard for local resection and left lateral segmentectomy. • Robotic: – Enhanced precision and 3D visualisation. – Overcomes limitations of laparoscopy but costly and time-consuming. – Ideal for complex resections in experienced centres. |
| 87. What is the ALPPS procedure and when is it indicated? | • ALPPS = Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy. • Purpose: Stimulate rapid hypertrophy of the future liver remnant to enable safe resection. • Stage 1: Ligation of portal vein to tumour-bearing lobe and partial parenchymal transection. • Stage 2 (after 1–2 weeks): Resection of diseased lobe after confirming sufficient hypertrophy. • Indications: Bilobar colorectal metastases or extensive tumours requiring major resection. • Risks: High morbidity initially, improved with modified techniques. |
| 88. What is the role of portal vein embolisation (PVE) in liver surgery? | • Principle: Occlude portal branches to tumour-bearing lobe → induce hypertrophy in contralateral lobe. • Technique: Percutaneous or intraoperative embolisation using coils or glue. • Indications: Anticipated small FLR (<25% normal, <40% in cirrhosis). • Advantage: Improves postoperative liver function and reduces risk of failure. |
| 89. What is radiofrequency ablation (RFA) and when is it used? | • A percutaneous or intraoperative technique that destroys tumours by thermal coagulation using radiofrequency energy. • Indications: Small (<3 cm), unresectable HCC or metastases |
| 90. Compare microwave ablation with radiofrequency ablation. | • Microwave ablation: – Uses electromagnetic waves to produce heat directly within tissue. – Produces higher temperatures, faster ablation, and larger treatment zones. – Less affected by nearby blood vessels. • RFA: – Uses alternating current through electrodes to generate frictional heat. – Slower and limited by tissue impedance. • Both: Used for local tumour control |
| 91. What are the potential postoperative complications of major liver surgery? | • Immediate: Bleeding, bile leak, infection, hepatic failure. • Delayed: Intra-abdominal abscess, biliary stricture, ascites, portal vein thrombosis. • Systemic: Coagulopathy, renal failure, respiratory complications. • Prevention: Careful patient selection, meticulous technique, and early postoperative monitoring. |
| 92. What are the key factors influencing hepatic regeneration after resection? | • Adequate residual hepatocyte mass and intact portal inflow. • Preservation of arterial and venous drainage. • Absence of infection and sepsis. • Nutritional support and avoidance of hepatotoxic drugs. • Regeneration can restore up to 90–100% of previous liver volume. |
| 93. What are the general prognostic indicators following hepatic resection for malignancy? | • Tumour size and number. • Margin status (R0 vs R1). • Presence of vascular invasion. • Underlying liver function (CTP, MELD). • Absence of extrahepatic disease. • Response to preoperative therapy. |
| 94. What is the overall principle of modern liver surgery? | “Maximum preservation of functional parenchyma with oncological adequacy.” • The aim is to remove all disease while leaving enough liver tissue to sustain metabolic, synthetic, and detoxifying functions. • Achieved through anatomical resection, careful vascular planning, and use of adjunctive radiological and ablative techniques. |
| 95. What pre-operative factors must be assessed before undertaking major liver resection? | • General fitness: Cardiopulmonary reserve, renal function, nutritional status. • Liver function: Child–Turcotte–Pugh (CTP) or MELD score, synthetic ability (albumin, INR). • Volume analysis: CT volumetry to determine future liver remnant (FLR) ≥ 25 % (normal), ≥ 40 % (cirrhosis). • Vascular anatomy: Presence of replaced or accessory hepatic arteries |
| 96. How is intra-operative blood loss minimized during hepatic resection? | • Maintain low central venous pressure (≤ 5 cm H₂O). • Intermittent Pringle manoeuvre (clamping of portal triad) to control inflow. • Use of CUSA (cavitating ultrasonic suction aspirator), harmonic scalpel, or bipolar sealing devices for parenchymal transection. • Topical haemostatic agents: fibrin glue, argon-beam coagulation, collagen fleece. • Early ligation of inflow vessels before parenchymal division. • Correction of coagulopathy guided by thromboelastography. |
| 97. What are the anaesthetic considerations specific to hepatic surgery? | • Low CVP anaesthesia to reduce venous bleeding. • Avoid excessive fluid loading before parenchymal transection. • Maintain normothermia and glucose balance. • Continuous monitoring of coagulation and urine output. • Close post-operative observation in a high-dependency or intensive-care setting. |
| 98. Describe the Pringle manoeuvre and its indications. | • Definition: Temporary occlusion of the hepatoduodenal ligament (portal vein, hepatic artery, and bile duct) using a vascular clamp or umbilical tape. • Indications: – Control of bleeding during hepatic transection. – Temporary inflow occlusion in trauma or major resection. • Duration: Intermittent clamping (15 min clamp / 5 min release) to limit ischaemia. • Tolerance: Liver tolerates warm ischaemia for up to 45 minutes. |
| 99. What is perihepatic packing and when is it used? | • Used in severe hepatic trauma or diffuse parenchymal bleeding when direct haemostasis is impossible. • Packs placed around the liver conforming to the diaphragm’s contour compress parenchyma without obstructing IVC flow. • Abdomen temporarily closed |
| 100. What postoperative care is required after major liver resection? | • Intensive monitoring of haemodynamics, urine output, and drainage. • Serial liver function tests and coagulation profile. • Maintain normoglycaemia and correct electrolyte imbalance. • Early enteral nutrition to support regeneration. • Prophylactic antibiotics and deep-vein-thrombosis prophylaxis. • Early mobilisation and respiratory physiotherapy. |
| 101. What are the early postoperative complications following hepatic surgery? | • Haemorrhage: From cut surface or major vessels. • Bile leak: Managed by ERCP stenting or drainage. • Infection or abscess: Managed with antibiotics and image-guided drainage. • Coagulopathy: Due to impaired synthesis |
| 102. What late complications can occur after hepatic resection? | • Biliary strictures at the transection margin. • Intra-abdominal collections or subphrenic abscess. • Portal vein thrombosis or hepatic artery pseudoaneurysm. • Incisional hernia. • Recurrent tumour within remaining parenchyma. |
| 103. What measures promote hepatic regeneration after partial hepatectomy? | • Maintenance of portal inflow and venous drainage. • Adequate oxygenation and nutrition (high-protein diet). • Control of infection and avoidance of hepatotoxic drugs. • Administration of growth factors and insulin support via normal metabolism. • Regeneration completes within 6–8 weeks, restoring 90–100 % of original volume. |
| 104. How is hepatic failure recognized and managed postoperatively? | • Recognition: Rising bilirubin, prolonged INR, encephalopathy, hypoglycaemia, and ascites. • Management: – Supportive intensive therapy (ventilation, fluids, glucose). – Correction of coagulopathy and electrolytes. – Nutritional support. – Exclude sepsis and mechanical obstruction. – Consider transplantation if irreversible failure. |
| 105. What are the key principles of oncologic clearance in liver surgery? | • Achieve complete R0 resection (microscopically negative margins). • Respect segmental and vascular anatomy. • Avoid tumour rupture or spillage. • En-bloc resection of involved structures if feasible. • Lymph-node sampling for staging when indicated. • Avoid needle biopsy of potentially resectable lesions. |
| 106. What are the advantages of anatomical over non-anatomical liver resection? | • Removes tumour and its portal/venous drainage territory, reducing microscopic spread. • Better oncologic clearance with lower recurrence rates. • Facilitates control of inflow and outflow vessels. • Predictable postoperative function because remnant perfusion preserved. • However, non-anatomical (parenchyma-sparing) resection is preferred for multiple small metastases. |
| 107. What is the importance of the Couinaud segmental classification in hepatic surgery? | • Divides the liver into eight functional segments, each with independent vascular inflow, outflow, and biliary drainage. • Enables segment-based anatomical resections (segmentectomy, lobectomy, hemihepatectomy). • Guides interventional radiology procedures and ablations. • Minimizes functional loss by targeting affected segments only. |
| 108. What are the major prognostic factors influencing outcome after hepatic resection for malignancy? | • Tumour size and number. • Presence of vascular or biliary invasion. • Resection margin status (R0 vs R1). • Underlying liver disease (fibrosis, cirrhosis). • Absence of extrahepatic spread. • Response to neoadjuvant therapy. • Postoperative hepatic reserve and complications. |
| 109. What follow-up schedule is recommended after liver tumour resection? | • First two years: Imaging (CT or MRI) and liver function tests every 6 months. • Years 3–5: Annual imaging if no recurrence. • Monitor tumour markers (AFP for HCC, CEA for colorectal metastases). • Lifelong surveillance in high-risk cases or cirrhosis. |
| 110. Summarise the key milestones in the evolution of liver surgery. | • 1952: First formal hepatic resection performed. • 1970s–80s: Development of low-CVP anaesthesia and segmental anatomy understanding. • 1990s: Introduction of laparoscopic and ultrasonic dissection. • 2000s: Virtual-reality and robotic training, enhanced recovery protocols. • Current era: Parenchyma-sparing resections, ALPPS, and living-donor transplantation demonstrating ongoing refinement. |
| 111. What are the general principles for preventing postoperative sepsis in hepatic surgery? | • Strict asepsis and antibiotic prophylaxis covering Gram-negative and anaerobes. • Meticulous haemostasis and bile-duct closure to prevent leaks. • Adequate drainage of potential collections. • Early removal of unnecessary catheters and drains. • Glycaemic control and nutritional optimisation. |
| 112. Outline the indications for referral to a tertiary hepatobiliary centre. | • Major hepatic trauma requiring vascular reconstruction. • Complex liver tumours (hilar cholangiocarcinoma, multiple metastases). • Failure of conservative management after packing or embolisation. • Liver transplantation evaluation. • Advanced interventional or radiologic procedures (TACE, TIPSS, PVE). |
| 113. What is the rationale for combined hepatic and portal-vein resections in tumour surgery? | • En-bloc removal of tumour invading portal structures to achieve R0 margins. • Reconstruct portal continuity using end-to-end anastomosis or interposition graft. • Offers improved long-term survival compared with palliative bypass if complete resection achieved. |
| 114. What are the typical survival outcomes after major hepatic resections for malignancy? | • Colorectal metastases: 5-year survival ≈ 50 %. • Hepatocellular carcinoma: 5-year survival 40–70 % (early stage, R0 resection). • Intrahepatic cholangiocarcinoma: 5-year survival ≈ 25 %. • Overall peri-operative mortality: 1–2 % in modern series. |
| 115. Summarise the golden principles of liver surgery for MBBS finals. | • Respect hepatic anatomy — every resection must be segmentally logical. • Preserve maximum viable parenchyma. • Control inflow and outflow before parenchymal division. • Prevent and promptly manage bleeding and bile leaks. • Employ multimodal therapy: surgery + interventional + oncologic care. • Meticulous postoperative care ensures regeneration and function. |