Liver Tumors

Liver Tumors

The Liver

The liver is the largest glandular organ of the body. It is located in the upper right part of the abdominal cavity, directly beneath the diaphragm. It weighs about (1.4 kg). It is reddish brown in colour and is divided into four lobes of unequal size and shape. Blood is carried to the liver via two large vessels called the hepatic artery and the portal vein and these subdivide in the liver repeatedly, terminating in very small capillaries. The liver has essential functions including: production of bile protein formation, sugar metabolism and breakdown of waste products and toxins from the blood stream. A healthy, functioning liver is essential for life.

Many liver diseases have no symptoms at all apart from making you feel a bit run down. Jaundice is a yellow pigmentation of the eyes and skin, which occurs when there is a build up of bilirubin (a constituent of bile) in the blood stream. If this is caused by a blockage to the outflow of bile from the liver (obstructive jaundice) then this may be associated with itching of the skin as well as very dark urine and pale faeces. Jaundice may also be caused by inflammation or infection of the liver (hepatitis) as well as by cirrhosis, excessive breakdown of red blood cells (haemolysis) and a large number of other complex metabolic conditions. Some conditions affecting the liver are painful pain from the liver is usually felt in the top right hand side of the abdomen, just beneath the ribs, it may be worse on taking in a deep breath. The pain may also be felt to travel or radiate around to the back or right shoulder. Similar pains can come from the gallbladder, diaphragm, spine and chest which can make liver pain hard for doctors to diagnose. Fluid retention can occur in some liver disease such as cirrhosis. This usually takes the form of swelling of the abdomen (tummy) and ankles. Bruising of the skin can occur if the liver is not making clotting factor proteins properly. Encephalopathy is a term used by doctors to describe the drowsiness and confusion that can occur in patients with liver failure, it is also quite common for a few days after major liver surgery. It is caused by a build up of waste products in the blood stream in particular ammonia.


Hepatitis is inflammation of the liver it may be caused by a number of conditions including infections (such as viral hepatitis A, B or C), chemicals (e.g. alcohol), drugs (e.g. paracetamol overdose) or disorders of the immune system. When there has been longstanding inflammation of the liver, it develops areas of chronic scarring and fibrous tissue around patches of regenerating liver cells. This pattern of scarring (fibrosis) and regeneration is the start of cirrhosis of the liver. Treatment of both hepatitis and cirrhosis is aimed at finding the cause of the inflammation and treating or stopping this first to prevent more permanent damage occurring. Surgery is reserved for managing the complications of cirrhosis. Liver transplants are performed at a small number of centres across the Italy for very specific circumstances in patients with advanced cirrhosis or severe liver failure from a variety of causes. We do not perform transplants in Poliambulanza.

There are many dozens of benign (i.e. not cancerous) conditions that affect the liver, most of them do not require any treatment once we are sure of the diagnosis. Here are a few of the ones that we as liver surgeons are most often asked about by patients: Haemangiomas are benign liver lesions that are virtually always harmless. They are very common and are caused by an overgrowth of blood vessels at one or more sites in the liver. They are often picked up on scans of the liver, but even very large haemangiomas do not usually require any treatment or cause any symptoms. Rarely they can appear similar to more worrying tumours on scans and under these circumstances we occasionally perform surgery to remove one to confirm that this is the correct diagnosis. However usually the appearances on scans are sufficient to confirm the diagnosis Liver cysts are rounded collections of fluid within the liver, they are benign, very common and nearly always harmless. Very large cysts may become uncomfortable if they stretch the liver or press on adjacent organs such as the diaphragm, stomach or bowel. Massive cysts can reach diameters of 20-30 cm (8-12 inches) and contain several litres of fluid, cysts of this size may give a visible swelling in the abdomen (tummy) and be very uncomfortable, often associated with pressure symptoms which may include shortness of breath from pressure on the diaphragm. A few people have rare polycystic conditions affecting the liver where the liver is full of hundreds of small and large cysts. Sometimes these are associated with cysts in other organs such as the kidney. A tiny number of people have an extremely rare variant called angiomyolipomata, where some of the cysts are surrounded by abnormal blood vessels and thick sheets of fibrous scar tissue If there has been haemorrhage (bleeding) or infection or inflammation in the cyst then the fluid inside it may become thickened and form strands of internal scar tissue, these can make the cyst look like a more complex lesion such as cystadenoma. Patients with bad pressure symptoms from large cysts often benefit from keyhole surgery to drain and de-roof the cysts and improve their discomfort, this is usually a very effective treatment, particularly for patients with large solitary cysts. For patients with large numbers of small cysts surgery is less effective and therefore surgery may not be advisable unless we think that we can effectively deal with a particularly dominant cyst or prominent cluster of cysts that appear likely to be contributing to your symptoms. Focal Nodular Hyperplasia (FNH) is an uncommon benign condition that affects the liver mainly in young and middle aged women. It does not usually cause any symptoms. The main difficulty with this condition is that it can look similar to some other more serious liver problems so we often investigate it more extensively and very occasionally biopsy it or remove the area surgically to be sure that it is safe. Rarely very large areas of FNH can compress adjacent organs or structures inside the tummy and cause symptoms such as heart burn or indigestion after eating, under these circumstances keyhole surgery may be offered to remove the tumour. Liver adenoma is a rare benign tumour of liver cells it occurs more often in women and is sometimes associated with oestrogen treatments such as the contraceptive pill or HRT. We frequently operate and remove adenomas as there is a small but significant risk that they can turn cancerous in the long term. Some small adenomas may regress and disappear if oestrogen treatments are stopped, although this phenomenon is well reported in the medical literature it is rarely seen in clinical practice hence we usually end up removing these tumours, often as a keyhole operation. Cystadenoma is a very rare benign tumour often affecting the central portions of the liver, these tumours also have the tendency to turn cancerous in the long term and we usually operate and remove them. It can be difficult to diagnose this condition which can appear similar to other cystic liver diseases such as hydatid disease or simple liver cysts. Hydatid disease is a disease caused by a parasitic infection. It is common in areas where sheep farming is prevalent including some Italian region. The parasite (echinococcus) has a complicated life cycle involving sheep (or goats), dogs and occasionally man. The parasites grow in cysts in the liver and may have no symptoms or they may cause pain, fever, abdominal swelling or jaundice. The parasitic infection is usually treated initially with several months of antiparasitic medication (e.g. albendazole), to eradicate the most active disease, followed by surgical resection of the cysts. The prognosis is excellent if correctly treated. Necrotic nodule is a term used to describe areas of dead liver that have formed hard shrunken areas of scar tissue, sometimes they are thought to represent dead tumours that have outgrown their blood supply and shrivelled up, they may also arise in areas of previous liver injury. The precise reason why they occur is not usually known. They are of no consequence in themselves, however they are very hard to diagnose and often look suspicious on scans hence again they may be removed if we find them whilst investigating the liver.

Liver cancers fall into two broad groups: primary cancers which have arisen in the liver and secondary cancers which have spread to the liver from another organ. Anyone with primary liver cancer should have their condition assessed by a specialist multi disciplinary team (MDT) including at least one hepatologist (liver doctor), oncologist (chemotherapy cancer specialist), hepatobiliary radiologist (liver X-ray / imaging specialist), hepatobiliary pathologist and a liver surgeon, before deciding on treatment. Patients with secondary liver cancers from bowel cancer, neuroendocrine tumours, kidney cancer and GIST cancers should also all be assessed by a liver MDT. Hepatocellular carcinoma (HCC or hepatoma) HCC is a primary liver cancer. It is much more likely to occur in people who have cirrhosis, particularly if it is associated with hepatitis B or C infection or haemachromatosis (a rare metabolic disorder). Small HCC s usually do not give any symptoms, but larger tumours often give upper abdominal discomfort and may be associated with signs of liver failure such as jaundice, drowsiness and fluid retention. They occasionally cause intra abdominal bleeding. Treatment may be with surgical resection, liver transplant, radio-frequency ablation (RFA) or trans arterial chemo embolisation (TACE). The treatment that we use depends on the quality of the background liver (i.e. cirrhotic or healthy) the site and size of the tumour and the relationship of the tumour to the major blood vessels in the liver. Small tumours are usually straightforward to treat. Large tumours can be much more problematic, particularly if they are in the centre of the liver or involve major blood vessels. Patients sometimes present with several small HCC tumours dotted around the liver, in these cases a combination of treatments may be used, using TACE to shrink the bigger tumours, RFA to treat central liver tumours and surgery to remove more accessible, superficial deposits of disease. Although traditional chemotherapy has not been very helpful in HCC in the past there are some new chemo drugs that are becoming available which appear to be much more effective in controlling this type of cancer. We hope that they will prove to be a powerful additional treatment to complement surgical and radiological techniques. For further advice on this you would need to speak to an oncologist (chemo specialist). Cholangiocarcinoma is an uncommon primary malignant tumour (cancer) of the bile ducts, which can arise in the small bile ducts within the liver, the big branches in the centre of the liver (hilum) or in the main bile duct draining out of the liver. It is more common in patients who have had tropical parasitic infestations of the bile ducts (clonorchis), originate from north west asia (Afghanistan / Pakistan / north west India) or have had sclerosing cholangitis (chronic inflammation of the bile ducts). Cholangiocarcinomas are difficult to treat because they often arise in the centre of the liver and involve the main blood vessels and bile ducts entering and exiting the liver at this point. Bile duct tumours in this central part of the liver are called hilar cholangiocarcinomas (or Klatskin tumours). Approximately 20% of patients with cholangiocarcinoma are suitable for surgical resection of the tumour. The operations are often more extensive than routine liver resections and usually involve major liver resection as well as removal of the bile duct and wide clearance of lymph glands around the liver to try and clear the tumour. Sometimes it is necessary to divide and reconstruct the blood vessels entering the liver (portal vein or hepatic artery). This is amongst the most difficult surgery that we perform. Bile duct tumours that arise more peripherally on the edge of the liver are a little easier to treat, although the principles are the same. Gallbladder cancer is another type of cholangiocarcinoma (see above) which develops inside the gallbladder. It often spreads directly into the liver and often blocks off the bile duct and blood vessels in the centre of the liver. Large tumours present the same difficulties as hilar cholangiocarcinoma (see above) and are managed in an identical fashion, however sometimes gallbladder cancer is caught at a very early stage, when the outlook and management strategy is rather different. Small, early gallbladder cancers can be very hard to identify and often have similar symptoms to gallstones with upper abdominal pain related to eating fatty foods. On scans it can be difficult to be sure if the problem is a benign polyp, unusual gallstone, gallbladder scarring / inflammation or a small cancer. In this case where there is diagnostic doubt and a suspicion of a tumour, then we usually recommend a keyhole operation under general anaesthetic, inspecting the gallbladder with a laparoscope to see if it looks cancerous and then removing it intact, often with a small block of liver tissue and the adjacent lymph glands to ensure that it is all taken away. This is sent for analysis, if cancer is confirmed then for early tumours no other treatment is necessary. However sometimes further open surgery may be required if the tumour is invading more deeply into the liver or lymph nodes. Unfortunately the commonest scenario that we encounter is that the tumour has been found by chance in someone who has had their gallbladder removed for painful gallstones, the patient is then referred on to us for a specialist opinion and further treatment. This is not absolutely ideal as it is best to remove early gallbladder tumours with some surrounding tissue to ensure clearance of all the disease, however it is often not possible to identify these tumours beforehand. Under these circumstances we usually try to perform further keyhole surgery to remove tissue from the liver next to where the gallbladder was, the stump of the cystic duct (the connection of the gallbladder to the bile duct) and the lymph glands nearby. We also remove a core of skin and scar tissue from the old port sites where the gallbladder was previously removed. If all of this tissue is clear no further surgical treatment is necessary. If tumour is found to infiltrate widely into the areas that we have removed then more extensive open surgery as for hilar cholangiocarcinoma may be required. Secondary Liver Cancers Until the last twenty years almost all secondary cancers in the liver were considered inoperable. As surgical techniques have improved and our knowledge of the behaviour of different types of cancer has expanded the indications for operating on secondary liver cancers have widened. New chemotherapy drugs that can shrink tumours have also helped to broaden the number of cases that we can offer surgery to. Colo-rectal liver metastasis ( metastasis from colon cancer) The most common secondary cancer that we operate on after it has spread to the liver is bowel cancer (colon and rectum cancers). Approximately 30-40 per cent of all patients with spread of this tumour to the liver are operable. Due to the more favourable nature of this cancer it is even sometimes possible to manage spread to the lung with surgery as well (in conjunction with our colleagues in the chest surgery unit). The risks of liver surgery to the patient are relatively low with approximately a 1 in 100 risk of death whilst in hospital for healthy patients undergoing conventional liver surgery. High risk patients (e.g. very elderly or with severe heart or lung disease such as angina or emphysema) and more extensive resections can have a much higher risk. Out of the patients that we operate on for bowel cancer secondaries (metastases), most will have a significantly prolonged life span and between a third and a half of all the patients that we treat are cured of their cancer. Without surgery the disease is effectively incurable, although chemotherapy may substantially improve the length of survival for many patients. The best results are seen in patients who are able to have a combination of liver surgery and chemo. If you have been on a standard chemo regime we usually suggest waiting for approximately 4 weeks after your last cycle of chemo treatment before having surgery to allow you and your liver to recover before the operation. If you have had a more intensive chemo regime with some of the aggressive new drugs that are available we might suggest waiting for 8 or more weeks to allow you and your liver to recover before facing the surgery. The decision about whether surgery is the right treatment needs to be made by a multidisciplinary team involving a specialist liver surgeon, chemotherapy expert (oncologist), radiologist (X-ray imaging doctor) and other interested professionals. As our expertise in this field has increased we have been able to successfully operate on more complicated patterns of disease. The number of tumours and their size does not make greatly influence our ability to operate. We have removed more than 20 tumours at a single operation and individual tumours over 25cm (10 inches) in diameter. The important question is not so much what needs to be removed, but rather how much healthy liver can we leave behind. If we can remove all the disease and leave enough good liver behind then the operation is possible. Sometimes in patients with several tumours involving both sides of the liver we see a pattern of disease that means there are too many tumours to safely treat in one operation, under these circumstances we may do a two stage operation. This usually involves operating on one side of the liver first (usually the left side, often as a keyhole operation) to clear the cancers from this side and let it grow back before operating on the other side a few weeks later. If we think that the tumours are placed directly on the important blood vessels entering or leaving the liver then surgery may be very high risk or not possible and other treatments may be necessary. There are few absolute rules under these circumstances and each of these difficult or high risk cases must be carefully weighed up by the whole team to offer the patient the best options. Neuro-endocrine tumours (NET or Carcinoid tumours) These are tumours that grow from hormone secreting cells in the digestive tract. They can arise almost anywhere in the intestines and related digestive organs and subsequently spread to the liver. They have a very wide range of clinical behaviour, some tumours are small, slow growing and almost benign in nature, at the other end of the spectrum there are very fast growing aggressive forms of the disease that behave in a similar manner to the more common bowel cancers. Most tumours behave somewhere between these two extremes. Many of these tumours produce hormones that can produce classic symptoms when the hormones are released from the tumour into the blood stream such as serotonin (5-HT), is most commonly released from  mid gut  tumours arising from the small intestine, appendix or right side of colon, tumours secreting this hormone produce the classic carcinoid syndrome of facial and body flushing, palpitations (racing heart beat), dizziness and occasionally diarrhoea and cramping abdominal pains. These symptoms may be triggered by stress, exertion, certain foods and alcohol. insulin, is one of the hormones made by the pancreas to control blood sugar levels. It acts to lower blood sugar in response to the normal fuctuations that follow a meal. In insulinoma (a variety of NET arising from the pancreas) excessive amounts of insulin are produced with a tendency to develop very low blood sugar levels, this may lead to dizzy spells and cravings for sweet foods. glucagon, is another blood sugar regulating hormone that has the opposite action to insulin producing a higher blood sugar. This results in fatigue, weight loss and in some cases a diabetes type picture in patients with hormone secreting glucagonoma tumours. Gastrin is a hormone that regulates acid and digestive juice production in the stomach, tumours making this are called gastrinomasVIPomas, PPPomas and many other types of very rare hormone secreting tumours can occur and produce clinical pictures according to the hormones that they produce. The tumours can be hard to diagnose initially as they grow in parts of the abdomen that are hard to assess clinically and because the symptoms are often slowly progressive over several years they are often misdiagnosed as irritable bowel syndrome, gallstones or crohn s disease before the true diagnosis becomes evident. The classic sites for the primary to occur in are the pancreas, ileum and appendix. Liver secondaries are often manageable by surgery, although it is difficult to cure these tumours it is often possible to extend and improve life by many years through a combination of surgery and other medical and radiological treatments. Gastro Intestinal Stromal Tumours (GIST / Leiomyosarcoma) these are rare cancerous tumours arising from the muscular wall of the intestines. They frequently spread to the liver and very good results can be achieved by a combination of surgery and new chemotherapy agents. The largest series of data from the worlds biggest liver surgery centres have reported successful results from liver surgery for a wide variety of other secondary cancers. Almost all of these cases are highly selected individual patients who have favourable patterns of tumour behaviour and spread that make resection appropriate. Our own combined experience of over 400 liver resections supports this highly selective practice for a few patients with liver secondaries from the following cancers. Occasionally Malignant melanoma (skin cancer) Renal (kidney) cancers Adrenal cancers Rarely Gastric (stomach) cancers Breast cancer Very rarely Testicular teratoma Thyroid cancers Sarcomas Oesophageal (gullet) cancers Lung cancer (Adenocarcinoma variant)

Liver surgery is most commonly performed for people who have malignant (cancerous) tumours in the liver. Our aim as liver surgeons is to try and pick those people who have the best chance of being cured or at least would have a significantly prolonged life span or improved quality of life after liver surgery. Unfortunately many people with liver cancers would be no better off after an operation therefore we do not operate on everyone with liver cancer. The cancers that we can help most with are outlined above in section 5. Whenever we plan to operate we always weigh up the risks of the operation against the potential benefits for the individual. These risks and benefits are different for each patient and can only be decided after reviewing all the evidence and discussing the pros and cons. If we do not think that an operation has a good chance of improving the length or quality of your life we will not offer you surgery, but instead will make other suggestions about how to treat or manage your disease. We rarely operate on benign liver tumours unless any of the following criteria are met: a) The tumour is causing pain or discomfort b) The tumour may turn cancerous in the future c) We cannot be sure from the scans whether this is a benign or malignant tumour


  • Is liver surgery safe?
    Liver surgery has changed faster than any other branch of general surgery in the last twenty years and has now become relatively safe surgery if performed by experts in specialist units such as the Poliambulanza hospital. For the majority of operations that we perform the risk of death whilst in hospital after the operation is around 1 or 2 in 100. If we think that your operation is higher risk than this we will estimate this for you so that you can make an informed decision about surgery.
  • Will I need a blood transfusion after the operation?
    The vast majority of patients do not require blood transfusion after surgery. For routine surgery we expect the blood loss to be around 200-600ml. Even with complicated operations it is uncommon for blood loss to reach much more than 1000ml (approximately 2 pints).
  • How long will I be in hospital after open surgery?
    The average stay for open surgery is around seven to ten days after the operation. Younger, fitter patients often go home a little sooner. If any complications occur we keep you in until they are resolved, how ever long that takes.
  • How long will I stay in hospital after keyhole liver surgery?
    The average stay after keyhole surgery is 2 to 4 days although a few fit young patients may be able to go home the day after operation.
  • Who will do the operation?
    The vast majority of operations are performed by a consultant liver surgeon (Pearce / Abu Hilal). Some straightforward cases are performed by a specialist registrar (a qualified senior surgical trainee) assisted or supervised by a consultant liver surgeon.
  • What complications can occur?
    Any operation has the general risks of the anaesthetic which depend on the over all health of the patient as well as the magnitude of the surgery. There are some risks specific to liver surgery such as a leak of bile from the cut surface of the liver. This occurs in 4 or 5 people in every 100 cases that we operate on, they usually resolve without the requirement for any further surgery. A small number of patients develop collections of infected fluid next to the surface of the liver these are usually managed by drainage of the fluid under local anaesthetic. After major resections it is not unusual to go slightly jaundiced a few days after the operation, this may be accompanied by drowsiness or confusion (see common symptoms above). It usually resolves within a few days.
  • Does the liver grow back?
    The liver can regenerate after surgery. The speed of regeneration depends on the quality of the liver as well as how much has been taken. It is possible to remove up to approximately 85% of an otherwise healthy liver in a fit patient.
  • Would a transplant be better?
    Most transplants are done for cirrhosis and liver failure. Although the idea of  getting rid of it all  is very attractive for cancer surgery the problem is that the strong drugs that you need to take after a transplant to prevent rejection, weaken the immune system and for most types of tumour make the cancer much more likely to come back else where in the body.


  • When will I go back to work?
    Every individual and their response to surgery is different but the majority of patients having uncomplicated routine liver surgery are able to go back to work three months after the operation. Younger, fitter patients may get back sooner as may those who have desk jobs. In general terms it is good advice not to rush back to work as major surgery is often more debilitating than people think and it is unwise to return to a heavy schedule until you are strong enough to face it.
  • When can I drive a car?
    It is usually around six weeks after surgery before you can try driving again. You must be moving freely enough to operate the wheel, gears and instruments without restriction and most importantly be able to perform an emergency stop without discomfort or difficulty.
  • I am still getting some pain after the surgery, is this normal?
    Every week after the operation you should feel the discomfort improving, however when you first get back to strenuous physical activity it is common to get some twinges of pain in the upper part of the abdomen as the scar and the deep layers of sutures in the muscular wall of the abdomen heal and settle down. You may get the odd twinge even a year or more after the operation on certain awkward movements or activities. If you are getting pain or discomfort that is worse than when you were discharged from hospital you should seek advice from a doctor or qualified nurse familiar with your treatment, this could be your GP or practice nurse or a member of the liver surgery team.
  • Will I need chemotherapy as well?
    This is a common question after liver cancer surgery and one that can only be answered for specific individuals it depends on the type of tumour, the type and results of surgery, the time after any previous surgery and whether you have had chemo before. If we think it is necessary we will ask one of our oncology doctor (chemotherapy) colleagues to give an opinion. For some diseases the answer is not clear and therefore we may suggest going into one of the national studies that we are involved in looking at different combinations of treatments to improve outcome.
  • The wound looks a bit red, is it infected?
    Most wounds look quite red and angry a few weeks after the surgery when the clips or sutures have been removed, this is a normal part of the healing process. If the wound has got a wider red patch on it or particularly if it has discharged pus or you feel feverish you need to be seen by a doctor or qualified nurse familiar with your treatment. This could be your own GP or practice nurse or we are happy to arrange review back on the ward or in outpatients if it is more convenient.
  • Can I drink alcohol?
    In the first few weeks after major liver surgery it is wise to be cautious and avoid alcohol, (although for those patients who feel the need it is probably safe enough to have one or two units of alcohol to celebrate release from hospital).
  • I am on a lot of other medications, are they safe after liver surgery?
    Some medicines are broken down in the liver and may become much more potent if the liver is not working effectively in the first weeks after a major operation. It is best to ask the doctor looking after you before you leave hospital if it is all safe, as some medications (particularly warfarin and digoxin) may need the dose changing before you go home.
  • I take herbal medicines, are these safe after liver surgery?
    Many herbal remedies are very potent medicines whose properties may be affected by liver surgery. This web site does not offer any authorative knowledge about alternative medications, however it is probably safest to avoid herbal preparations in the weeks before and after surgery as their effects may be unpredictable. St John s Wort is one particularly strong herbal preparation that affects liver function and should be avoided at this time.
  • Am I going to be followed up?
    Yes, follow-up appointments will be scheduled after surgeries. If the surgery has been performed to treat a malignant tumor, you will be followed for the next 5-10 years.

The first successful major liver resection (right hemi hepatectomy) was performed in 1952 in Paris. In the 1980. Since then, liver surgery has become very safe if performed by properly trained experts, backed up by specialist anaesthetic, nursing and critical care staff in specialist centres, with the full range of equipment available. It should never be done by non specialist surgeons or outside high volume specialist centres as the risk becomes unacceptably high.

Laparoscopic surgery has taken off across the world for all kinds of abdominal surgery. However it has been slow to get established in liver surgery because of the technical difficulty of the procedure and the type of training that most traditional liver surgeons have had. The first case was performed in France in 1993 and the first small series of laparoscopic liver resections were reported in the 1990s. The largest series worldwide are from centres in France, the USA and Australia. By 2006 there were still fewer than 1,000 reported cases of laparoscopic liver resection in total worldwide over the last 13 years.
Poliambulanza is one of a few hospital specialized in laparoscopic liver surgery. In the last years we have published several scientific papers on this topic, and presented our data at national and international conferences.  Approximately 30% of all patients requiring liver surgery are suitable for laparoscopic resection in our current practice. 

The advantages are a much faster recovery time and shorter hospital stay, with fewer respiratory (chest) complications and less abdominal scarring.
The long term results of keyhole surgery for liver cancers appear to be the same as for conventional open surgery, so when ever we can operate this way we do because of the rapid recovery for the patient.
Almost all parts of the liver are accessible by laparoscopic surgery, the easiest areas to reach and operate on are at the left hand side of the liver or at the front of the liver near the gallbladder.

Liver Tumors

The far right hand side of the liver is also relatively easy to approach.

Liver Tumors

Superficial tumours on the surface of the liver can usually be managed laparoscopically unless they are very close to the important blood vessels in the liver.

Liver Tumors

Lesions placed centrally in the right or left sides of the liver usually require removal of all or most of that side of the liver (right or left hemi hepatectomy).

Liver Tumors

Lesions in the centre of the liver close to the main blood vessels are very difficult to operate on and may require very large and relatively high risk resections, usually performed as an open operation.

Liver Tumors

There are many dozens of treatments that have been tried for liver cancers:

  • Radio Frequency Ablation (RFA)
    This is a relatively new technique that uses radiofrequency electrical energy emitted from a probe placed into the tumour. This causes the tumour to heat up and kills the cancer cells. It is very effective for some small tumours such as Hepatocellular Carcinoma (HCC  see above) and is particularly useful for patients who also have cirrhosis. The long term results are less well established than with surgery, for most other types of tumours. We also recommend it for patients who have small tumours but are not fit enough to withstand more major surgery. The procedure still requires a general anaesthetic in most cases.
  • Chemotherapy
    This is the administration of strong drugs to the human body, usually either by injection or tablet, with the intention of killing cancer cells. This is most useful for secondary liver tumours, such as colorectal cancer secondary tumours, it is of little value for primary liver cancers. Chemo may be given a few months before surgery to shrink a tumour to make it easier to operate on or after an operation to reduce the chance of the tumour coming back in the future. We also use chemotherapy in cases where we are unable to operate in order to try and slow down the rate of growth of the tumour and thus improve the life span of the individual.
  • Embolisation
    This is a technique whereby a fine catheter (plastic tube) is inserted into one of the arteries at the top of the leg and manouvered up the arterial system until the tip lies inside the arterial blood vessel supplying the liver. Small pieces of sponge or fine metal coils are then released into the artery supplying the liver tumour, thus partly blocking off it s blood supply and causing it to shrink. It is particularly useful for tumours with a very rich blood supply such as neuroendocrine or Carcinoid tumours. In some cases it can even be effective for very large or widespread liver tumours
    A similar technique injects chemotherapy agents into the liver tumour at the same time, this is known as Transarterial chemo embolisation (T.A.C.E.) it is a very effective treatment for Hepatocellular carcinoma (HCC).
  • SIRS
    This stands for selective intra-hepatic radiotherapy with micro-spheres. It is a very new technique that combines radioactive material with embolisation spheres (see above) that are injected into the arteries inside the liver. At present this is an experimental technique that is only performed in a very few centres worldwide. We only suggest patients consider it as a last resort if they have cancerous disease confined to the liver and are not able to have other more conventional treatments.
  • Micro waves / Cryo-therapy / HIFU / Ethanol injection etc
    Several other methods have been used to kill liver cancer cells by putting probes into the tumour and either injecting alcohol, or heating them up or freezing them. In general they are less effective or less safe than surgery or radiofrequency treatment (RFA) and we do not use them in this centre. 

Liver Disease

Many types of liver disease may not give symptoms in the first stages but the most common symptoms of presentation are:

Is a yellow pigmentation of the eyes and skin, due to a compromised liver's production of bile. Bile can back up into the blood, causing the skin and eyes to turn yellow and the urine to become dark.

Typical pain related to the liver in the right upper abdomen with possible radiation to the back and/or right shoulder. Similar pain can be caused by the gallbladder, duodenum and diaphragm; therefore the diagnosis can be made only by liver specialists after a series of investigations.

Ascites (swollen abdomen) and oedema (swollen legs and ankles)
This is due to fluid retention in the legs and abdomen as a result of impaired production of a protein called albumin.

Of the skin can occur if the liver is not making clotting factor proteins properly.

Hepatitis is inflammation of the liver parenchyma, which can be caused by 1- viral infection (hepatitis A, B or C) 2- Alcohol 3- drugs such as high doses of paracetamol overdose) or disorders of the immune system.

When there has been longstanding inflammation of the liver, it develops areas of chronic scarring and fibrous tissue around patches of regenerating liver cells. This pattern of scarring (fibrosis) and regeneration is the start of cirrhosis of the liver.

Liver Tumors

Many liver lesions are benign and incidentally found during investigations for other reasons. However only specialist liver surgeons will be able to decide whether to ignore, investigate further or treat. Some of the most common liver lesions are discussed below.

Liver cysts
Is a yellow pigmentation of the eyes and skin, due to a compromised liver's production of bile. Bile can back up into the blood, causing the skin and eyes to turn yellow and the urine to become dark.

Are the most common benign liver lesion, filled with fluid and easy to diagnose on ultrasound. Normally they are not symptomatic and would not need any treatment. However they reach large dimensions (30 cm in diameter) giving pain and discomfort and hence surgical treatment may be required. The surgical treatment is normally by resecting as much as possible of the cystic wall to avoid cysts re accumulating. This can be easily done with keyhole surgery. Aspiration of these cysts is not advised as they have a high chance or recurrence and infection.

Focal Nodular Hyperplasia (FNH)
Is less common benign lesions that affect the liver mainly in young and middle aged females. Again their radiological appearance may be similar to other malignant liver conditions and many radiological tests may be required to define their entity. FNHs are completely benign and do not require any treatment unless symptomatic (painful, compressing other intra abdominal organs). In these cases surgical resection maybe required.

Liver adenomas
Are rare benign live tumour. They are more common in women and are frequently due to the use of the contraceptive pill or HRT. They can also be related to other steroid hormone treatments and drugs, including anabolic steroids used in body building.

Are rare benign tumour often affecting the liver. They have a risk for potential malignant transformation, therefore they should be removed surgically if diagnosis is proved or difficult to exclude.

Hydatid disease
Is a parasitic infestation by a tapeworm of the genus Echinococcus.
The parasite (echinococcus) can pass to the man threw a cycle involving; goats (sheep) and dogs. The parasites grow in cysts in the liver and may have no symptoms, but can also give pressure effect leading to obstructive jaundice and abdominal pain. In case of cystic rupture, the classic triad of biliary colic, jaundice, and urticaria is observed. The parasitic infection is usually treated initially with antiparasitic medication (e.g. albendazole), to eradicate the most active disease, followed by surgical resection of the cysts. Malignant liver tumours Primary liver tumours Liver cancers fall into two broad groups: 1.primary cancers which have arisen in the liver 2.secondary cancers which have spread to the liver from another organ.

Hepatocellular carcinoma (HCC or hepatoma)
Hepatocellular carcinoma accounts for most primary liver tumours. It occurs more often in men than women. It is usually seen in people ages 50-60yrs. The disease is more common in Africa and Asia than in the UK and Europe. In most cases, HCC develops in cirrhotic liverscirrhosis and is highly associated with hepatitis B and/or C infection. Symptoms related to hepatomas occur only when they reach a significant size. Small hepatomas as usually diagnosed during investigations for other reasons or during screening scans in patients known to have cirrhosis. Large hepatomas may give pain and other symptoms such as fatigue, jaundice and ascites. Occasionally they may rupture causing severe intra abdominal bleeding. Liver transplant is the treatment of choice as it has shown to give the longest survival. However only patients with small tumours (< 5 cm in diameter) and with less than 3 lesions in the liver are considered eligible. If transplant is not possible; surgery can be considered in patients with normal livers or when cirrhosis is still at an early stage. Abdominal CT scan If surgery or transplant is not possible, other treatments such as Radiofrequency ablation (RFA) and transarterial chemoembolisation (TACE) can be offered. RFA for small lesions or a combination of RFA and TACE can achieve good results in some patients in terms of tumour ablation, control of tumoral growth or in some cases as a bridge toward surgery or transplant. Traditionally chemotherapy and radiation treatments were not considered. However, new drugs such as Sorafenib tosylate have shown to be effective in blocking the tumour growth. Sorafenib is now approved for patients with advanced hepatocellular carcinoma. Having explained the possible treatment options of this complex condition, every patient with HCC should be seen by a liver specialist for investigation and should be discussed in a liver multidisciplinary meeting with all involved clinicians from different specialities to decide the best management plane.

Cholangiocellular carcinoma (CCC)
Cholangiocellular carcinoma (CCC) is the second common primary liver tumour after hepatocellular carcinoma (CCC). It can arise from either the distal or proximal extrahepatic duct including bifurcation or from the intrahepatic ducts. It is more common in patients who have had tropical parasitic infestations of the bile ducts (clonorchis) or have had sclerosing cholangitis (chronic inflammation of the bile ducts). Hilar CCC (Klatskin Tumours) can be treated surgically if they are diagnosed in an early stage .The procedure involves the removal of the bile duct and the most involved part of the liver with all the regional nodes. If they are invading the major adjacent vessels (portal vein and hepatic artery), surgical treatment can be difficult. The presence of distant metastasis is a contraindication to surgery. Intra hepatic duct CCCs can be treated surgically by resecting the interested lobe of the liver Distal duct CCCs are treated with a pancreatic head resection (Whipple s procedure). See pancreas

These are tumours that have spread to the liver from other organs. These are also calledliver metastasis. The treatment of liver metastasis depends on their origin and many other factors including their distribution, number, location, size and the patient s general medical conditions. In recent years and thanks to excellent surgical results, aggressive surgical methods have been considered. Surgery in combination with chemotherapy and other ablative treatments such as radiofrequency ablation have permitted more patients to benefit from radical treatment.

Colo-rectal liver metastasis
Color liver metastases are the most common. They are caused by cancer spreading from the colon and rectum. The possibility of surgical treatment depends on the tumour distribution and relation with major vascular structures. However using today s operative criteria, we have been able to push boundaries and offer surgical resection to almost 50% of patients. Today we can potentially treat patients with disease in both lobes of the liver and even in the presence of a large number of metastasis. However all patients have to be assessed individually and their suitability for an operation should be discussed in multidisciplinary meetings. In addition, thanks to the liver s ability to regenerate, further surgery could still be considered should a patient experience recurrence of a cancer in the future. Thanks to these advances over the years survival in patients with colorectal liver metastases has improved greatly. Post surgical survival depends on factors related to tumour aggressiveness and biology. A combination of surgery and chemotherapy is known to offer the best results. Chemotherapy can be given prior to surgery (neoadjuvant chemotherapy), after surgery (adjuvant chemotherapy) or can be used in a sandwich treatment (before and after). The best course of action would be discussed in a meeting with consultants from different specialities called a Multi-Disciplinary Team Meeting or MDT. In major liver centres, mortality should not exceed 3%. Hence, this surgery should only be considered in specialized centres and by expert liver surgeons. Patients not deemed suitable for liver resection, can benefit from other treatment s such as radiofrequency ablation and palliative chemotherapy.

Other Tumours
Metastasis from other tumours such as neuroendocrine tumours, Gastro Intestinal Stromal Tumours (GIST), renal cancers and melanoma are frequently treated by surgical resection. In rare cases even metastasis from breast cancer can be considered for resection, however, this depends on various factors and every case is treated and considered individually on its own merits.

Background on Liver Surgery

Liver surgery was introduced in the early 50's. This was due to the difficulties faced when dealing with the liver tissue. The liver has a large blood supply, with a rich network of veins and arteries, these can bleed extensively leading to hemorrhages that may be difficult to control. Liver surgery continued to struggle up until the late 80's where mortality rates were around 25%. However, thanks to advances in surgical techniques, improvement of surgical instrumentations and an improved knowledge of the liver tissue and how it behaves, mortality rates have now dropped to less than 3% in recognised centres.

Open liver surgery approach:
This is the most commonly used approach and until recently was the only one available. This is normally performed through a 15-25 cm long incision in the upper abdomen.

Laparoscopic (keyhole) liver surgery:
The laparoscopic approach has been used since the 1990's for gallbladder, colonic, prostate, renal and other types of surgery. However, due to the difficult nature of the liver, laparoscopic liver surgery has only started in the last ten years and is still limited to very few centres. This surgical approach is hugely used at Poliambulanza and we have proved significant benefits and superiority of the laparoscopic approach. We have published a more than 15 papers in peer review journals (see my publications) and last but not least we run regular well-recognised courses to train HPB surgeons all over the world in the field of laparoscopic liver surgery.

The laparoscopic approach offers a few advantages including:

  1. Small incisions
  2. Less pain
  3. Easier and quicker recovery
  4. Shorter hospital stay
  5. Earlier return to work and normal activities
  6. Fewer postoperative scars and internal adhesions

However, this is a delicate and complex type of surgery and should be performed only by expert laparoscopic liver surgeons.

Surgical Risks
Common risks are bleeding, injury to other organs and difficulty in locating the tumours. In these cases conversion to open surgery is mandatory.

Not all liver tumours are amendable to laparoscopic resection. For some tumours such as hilar cholangio carcinoma a laparoscopic approach is not normally undertaken due to the need of extensive lymphoadenectomy (the removal of lymph nodes and lymphatic tissue). In my experience 80% of liver lesions are dealt with by keyhole surgery.

Common Questions On Liver Surgery

  1. What is the risk of mortality?
    Thanks to advances in surgical techniques and anaesthetic support, the mortality rate has dropped from 30% in the early 80's to less than 3% in recognised centres for liver surgery nowadays. My personal mortality rate is 0.5%, having one death in over 200 liver resections. Liver surgery is complex surgery and should only be performed by expert liver surgeons, in major referral centres.
  2. How long does the operation take?
    This depends on the type of liver resection performed. It can range from 1 to 8 hours and the average time for a major liver resection is around 5 hours.
  3. What are the potential surgical complications?
    The most common complications are bleeding, infection, bile leak and liver failure. Meticulous surgery and attention to details are paramount to reduce the risk of bleeding and bile leakage. Good knowledge of the liver physiology, careful patient selection, thorough preoperative assessment and experience in liver surgery are essential to prevent liver failure.
  4. Are patients sent to intensive care (ITU)?
    This depends on the patient's general condition and the extent of the surgical resection performed. The majority of patients do not require intensive care but spend a night or two in a high dependency unit (HDU). Patients undergoing laparoscopic liver surgery have a shorter hospital stay and shorter HDU stay. It is very rare to send patients to ITU after laparoscopic resection.
  5. What is the average hospital stay?
    Again it depends on the type of liver resection performed. For minor resections, which I perform laparoscopically in 100% of the cases the average hospital stay is 2 days and many patients are discharged after 1 day. For a major resection, if the operation is done laparoscopically the average stay is 4 days and 8 days if they are completed as an open procedure rather than laparoscopically.
  6. Is it true that the liver grows back?
    Yes, the liver is a generous organ and it has the ability to regenerate 90% of any tissue removed at resection. This process can take between 6-12 weeks for complete regeneration to take place.
  7. Do I need chemotherapy after surgery?
    This depends on the type of tumour, the patient's general condition and the disease history. However, patients are re-discussed at the MDT after surgery with the result of their histological exam. The decision for further treatment is assessed on an individual basis.
  8. When can I go back to work?
    It is very difficult to give a generic answer as this varies on the type of surgery performed (major/minor resection), the indication (malignant/benign disease), the surgical approach (key hole surgery/open surgery), general health and the patient's occupation. Patients will be seen in an outpatient clinic 2-3 weeks following discharge and return to work will be discussed and a plan agreed.
  9. When can I drive?
    This depends on your recovery and wound size. You need to be pain free and able to perform an emergency stop safely before considering driving again.
  10. Can I drink alcohol?
    Obviously if your disease is alcohol related (for example alcohol related cirrhosis) you should avoid alcohol. Otherwise it would be safe to have a glass of wine every now and then. However, it is advised that you discuss this with your doctor.
  11. Will I have drains after discharge?
    Drains are positioned to remove postoperative secretions out of the abdominal cavity. Occasionally complications occur post operatively such as internal bleeding or a bile leak and this can be quickly seen in the drains and managed accordingly. Occasionally, postoperative secretions such as serous fluids or moderate bile leaks persist for some time and are normally treated conservatively until they settle. If a patient is fit and well they may go home with a drain. This would be reviewed regularly in an outpatient clinic until such time as it was appropriate to be removed.
  12. How often I will be seen in the outpatient clinic after discharge?
    The first visit is normally within 2-4 weeks after discharge. This is to ensure normal recovery and to discuss the histological results and further management. The next check up would be after 3 months, then 6 months and then once a year for the next 5 years. This schedule may differ for some patients if circumstances change.
  13. How I will be sure I have no post operative recurrence?
    With every outpatient appointment a CT scan will be arranged and tumour markers will be regularly checked. This will permit an early identification of disease recurrence and adequate treatment if possible.

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Prof. Mohammad Abu Hilal is the Director of the Department of General Surgery and Head of the Hepatobiliopancreatic, Robotic and Minimally Invasive Surgery Unit at Fondazione Poliambulanza.

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