ABOUT LIVER

RESECTION
Surgical removal of
part of the liver
A guide for patients
and relatives
This booklet has been written to provide information about the
operation called a liver resection. This is a major operation and involves
removal of a part of the liver. Information about the benefits and risks
will help you make an informed decision about the operation.
It is important to remember that each person is different. This booklet
cannot replace the professional advice and expertise of a doctor who
is familiar with your condition. If you have questions that this booklet
does not cover, please discuss them with your surgeon or cancer nurse
specialist.

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What is the liver?
The liver is a large organ which lies on the right side of the upper
abdomen, under the rib cage. It has many functions related to body
metabolism (chemical processes within the body) and is very important
to health. One of its functions is to produce yellow-green fluid called
bile. Bile flows down a tube called the bile duct to the intestine, where
it mixes with food and helps digestion.
The gall bladder is a small sac attached to the side of the bile duct. The
gall bladder stores excess bile and pushes it down the bile duct in to
the intestine, ready for when it is needed for digestion.
The liver has right and left lobes (sections). An artery (hepatic artery)
and a vein (portal vein) carry blood to the liver. Blood from the liver
flows through the hepatic veins back to the heart.
The liver and its location in the body

Liver

Liver

Gall
bladder
Pancreas

Bile duct

Small Stomach
intestine
(duodenum)

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What is liver resection?
Liver resection is the removal of part of the liver during an operation.
The body can cope with removal of up to two-thirds of the liver.
The liver also has the ability to grow back. Within 3 months of your
operation, the remainder of your liver will have grown back to near
normal size.
The operation is named depending on which portion of liver is being
removed. For example, removal of the right side of the liver is called
right hemi-hepatectomy. Since the gall bladder is located on the right
side of the liver, it is often removed with a right hemi-hepatectomy.
Liver operations can sometimes be carried out using keyhole surgery.
The surgical team at Oxford specialises in these procedures. With
keyhole surgery, instruments are inserted through small cuts in the
abdomen.
The surgeon can see what is happening through a narrow camera,
which is also inserted into the abdomen. This avoids making a large
cut on your abdomen, meaning you should have a quicker recovery
from the operation. If this type of operation is suitable for you, your
surgeon will discuss it in more detail.

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When is liver resection recommended?
The most common reason for carrying out a liver resection is to treat
cancer that has spread to the liver from a primary cancer in another
part of the body.
Your specialists, including your liver surgeon, the radiologist (X-ray
doctor) and oncologist (cancer chemotherapy specialist), have
reviewed the results of your tests and believe that it may be possible to
remove the cancer completely.
The operation is also used to treat cancers which start in the liver, the
bile duct or the gall bladder. It may occasionally be needed for benign
(non-cancerous) liver problems, such as liver cysts.
Occasionally, it is not possible to be absolutely sure about what is
causing the problem with your liver. You may have been advised to
have the operation to remove an abnormality, as this may be the best
way to make a definite diagnosis.

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What alternative treatments are
available?
• Chemotherapy
If you have cancer, chemotherapy can shrink the cancer or delay its
growth, but is not an alternative treatment which offers a cure.
Chemotherapy involves regular injections (into one of your veins)
and/or tablets of one or more drugs over a period of 3-6 months.
Your oncologist (cancer chemotherapy specialist) will answer any
questions you have about this.
• Microwave ablation
Microwave ablation is a procedure which uses heat from microwave
energy to destroy cancer cells. It can be used to treat cancer that
has spread (metastasised) to the liver from other parts of the body,
usually from the colon or rectum. Only tumours of a certain size and
in a certain location are considered suitable for microwave ablation
treatment.
This procedure is carried out by a radiologist and takes 15-45
minutes. It can be carried out under general anaesthetic (where you
are asleep) during open abdominal surgery (where a larger cut is
made on the abdomen), or by using keyhole surgery, or by using a
needle through the skin and into the tumour.
Microwave ablation could potentially destroy all cancer cells,
especially in small metastases (approximately less than 3cm lesions).
However, as there is no sample to look at under a microscope after
the ablation (unlike after open or keyhole liver surgery), there is
a risk of some cancer cells remaining after microwave ablation.
To assess this risk, people who receive microwave ablation are
scanned afterwards much more often. If the cancer is found to have
returned, a further ablation might be possible.
There is a multi-centre clinical trail looking at the outcomes of liver
surgery compared to microwave ablation for colorectal metastases in
the UK. Oxford is one of the centres taking part.

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• Selective internal radiation therapy (SIRT)
Selective internal radiation therapy (SIRT) is used to treat cancers
of the liver. It is generally used with cancers that cannot be treated
surgically. The treatment involves injecting microspheres (tiny beads)
of radioactive material into the arteries which supply the tumour.
These microspheres are carried into the tumour in the bloodstream,
where they can destroy tumour cells by releasing radiation directly
into the tumour.
• Stereotactic body radiotherapy (SBRT)
Stereotactic body radiotherapy (SBRT) is a new procedure for
treating liver cancer. It uses high doses of radiation delivered to a
precise target within the liver. This helps to avoid damaging healthy
tissue nearby.
The treatment is given in either a single treatment session or up
to approximately five treatment sessions (each session is called a
‘fraction’).
• Portal vein embolisation
Portal vein embolisation (PVE) is a procedure which is carried out in
the Radiology department. It assists with the treatment of cancer of
the liver. PVE is carried out when liver cancer is suitable for surgical
removal, but the remaining liver would be too small to work well
afterwards. It can be done 4 to 5 weeks before the operation.
PVE works by blocking the blood flow to the affected part of the
liver from the bowel (portal venous flow). The blood flow from the
bowel to the liver is then redirected to the healthy part of the liver,
which is expected to remain after surgery. The aim of this procedure
is to shrink the part of the liver affected with cancer, whilst allowing
the remaining healthy liver to grow bigger.
• Staged liver surgery
Sometimes after PVE, the healthy part of the liver that is going to
remain after surgery does not grow enough to carry out the liver
surgery safely. If this happens, your surgeon may offer a two-step
operation called an ALPPS procedure (associated liver partitioning
and portal vein ligation for staged liver surgery).

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 In the first stage, your surgeon will tie off a branch of the portal vein
that supplies the section of liver to be removed.
The liver will be divided completely, in preparation for removal of the
area affected by the tumour. However, the surgeon will not remove
this part. Instead, the affected part of the liver will be left in place
and still supplied with blood from the hepatic artery. This means it
will still be able to work.
The blood flow from the portal vein is then increased to the healthy
part of the liver, which enables it to grow.
The second stage of ALPPS is usually carried out 6-10 days after
stage one. This stage involves removing the affected part of the liver.
You will need a general anaesthetic for both stages. You will usually
stay in hospital between both operations, although you may be able
to spend a few days at home.
Your surgeon may recommend an ALPPS procedure instead of trying
PVE first. We will talk with you about this, if it is recommended.

What are the benefits of surgery?

The operation aims to completely remove the cancer and give you the
best chance of a cure. The other non-surgical treatments help to delay
the progress of the cancer, but are unlikely to cure it.

Will surgery improve my chance of

survival?
Without surgery, very few people with cancer involving the liver survive
for more than 5 years. A successful operation can improve your chance
of long-term survival by 25%-45%.
Despite a successful operation, there is a risk of the liver tumour
recurring. This happens in at least two-thirds of people. The chance of
the cancer recurring depends on the type of tumour that you have. If
you wish, your surgeon can discuss the likely outcomes in your case.

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What are the risks and possible
complications?
The operation is a major procedure with associated risks. However,
the operation has become much safer over the years. At specialised
centres such as Oxford, where a large number of these procedures are
carried out by specialist surgeons, 98 out of 100 people will survive
the operation. Your surgeon will discuss the specific risks with you.
Possible complications include:
• those related to general anaesthesia, such as chest infection and
possibly needing support on a breathing machine (ventilator) in the
intensive care unit
• bleeding during or after the operation, which may require blood
transfusions or a further operation
• wound infection
• blood clots forming in the legs
• bile leak
After your operation, bile may leak from the cut surface of your liver.
Your surgeon may leave a drain tube in the area of the operation, to
drain out any fluid that collects inside. If you develop leakage of bile
this is likely to heal on its own, but may need further operations to
stop the leakage.
• jaundice
You may develop yellowing of your eyes and skin after the
operation. This is due to excess bile, which the remaining liver is
unable to cope with.
Another symptom of jaundice is a build-up of excess fluid in the
abdomen and legs. This problem is temporary until the liver grows
and recovers normal function.
The risk of you developing jaundice depends on the amount of your
liver that is left behind and how well it functions.

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What anaesthetic will I have?
Our normal anaesthetic technique for this procedure is a combination
of general and epidural anaesthesia. During general anaesthesia you
are completely asleep and will have a tube put into your windpipe to
help your breathing. Although this is done very gently, you are likely to
have a sore throat after the operation.
You may also have a narrow tube called a catheter for giving you pain
medication infusions placed into your back (epidural) or near your
wound (local anaesthetic infusion). An epidural and a local anaesthetic
infusion are ways of blocking the signal from the nerves in the area of
the operation.
Before you go to sleep with the general anaesthetic, the anaesthetist
will place the catheter in your back, next to your spinal cord nerves, or
into the area around the wound. The anaesthetic will be given through
this catheter during the operation and it will remain in place for 3-5
days after the operation.
Both the epidural and the local anaesthetic infusion will help you to
breathe deeply, which can be difficult if you are in a lot of pain. You
will also be able to sit and walk around more comfortably.
These types of pain relief are very safe. The chance of any permanent
nerve damage from an epidural is very rare; less than 1 in 10,000.
Your anaesthetist is also responsible for replacing fluids and blood
during the operation. About 1 in 6 people will need blood transfusions
during or after this type of operation.
You will meet the anaesthetist and can ask any questions on the day
of the operation.

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What if surgical removal of the cancer
is not possible?
Sometimes, problems are discovered during the operation that could
not be identified before surgery. This includes spread of the cancer
to other areas of the liver or to other parts of the body. Such findings
occur in 1 or 2 in 10 people.
If the cancer has spread but is still just within the liver, it may be
possible to remove all the cancer by removing more of your liver than
was planned. We may use ultrasound or other forms of imaging
during your operation, to try to identify any other small tumours that
we can safely remove.
Surgery will not be helpful if all the cancer cannot be removed. If this
happens your surgeon will not remove any of the cancer.

How do I prepare for surgery?

If you are a smoker, try to stop smoking as soon as you know that
you need an operation. It will also help your recovery if you are able
to increase your activity levels and take part in some gentle exercise
before you come in to hospital for your operation.
You will need to arrange for additional help at home whilst you
recover, particularly if you live alone.
You will be given an appointment at the Pre-operative Assessment
clinic before your operation. This is to check you are fit enough
to safely have the operation. You will have a chest X-ray, an
electrocardiogram (ECG) to check your heart, and blood tests. The
appointment will be approximately 2 hours long.
Please bring a list of your medication with you, including any off the
shelf or herbal remedies you might use. Our team will give you further
instructions and explain what you can expect when you come in for
your operation.
You will be given some written information about our Enhanced
Recovery After Surgery programme (ERAS), which explains how the
team caring for you will help you to recover as quickly as possible.

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Getting you moving and back to your normal diet as soon as possible
after your operation can help reduce the chance of complications and
the length of time you may need to stay in hospital.

What happens after the operation?

After you return from the operating theatre recovery room you will
need to be cared for the Churchill Overnight Recovery Unit (CORU) or
the Churchill Intensive Care Unit (CICU) if you are having a major liver
resection. The operation will only go ahead if there is an available bed
on the unit you need to go to.
When you are well enough, you will return to the specialist ward,
usually the day after surgery. You will be able to start eating within 2-3
days.
It is important that you get out of bed and move about as soon as
possible. Our physiotherapist will help you with breathing exercises.
These are important to help prevent a chest infection.

How long will I be in hospital?

You are likely to be able to go home 3-7 days after the operation, but
it may be earlier than this if you have had keyhole surgery. The ward
nursing staff will give you painkillers to take at home, if needed.
You will have a follow-up appointment in the Surgical Outpatient
clinic, but please telephone your clinical nurse specialist if you have
any concerns after you have left hospital.

When can I return to normal

activities?
For the first few weeks after the operation you will find movement
and activity difficult and you are likely to need help. You may also feel
low in mood, but this will get better. It is important to keep as active
as possible, but also to rest. You are likely to be back to your normal
activities after 2-3 months and there are usually no restrictions on
activities after this time.

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Will I need any other treatment for
my cancer?
Sometimes survival rate can be improved by combining other
treatments with surgery, such as chemotherapy. We will discuss the
option of chemotherapy with you. You may see an oncologist, who
specialises in the medical treatment of cancers with chemotherapy.
Whether you receive chemotherapy or not after your operation, you
will be regularly followed up, either at the Liver Clinic at the Churchill
Hospital, at your local hospital, or both.

What are long-term consequences of

the operation?
There are few long-term consequences of liver resection.
You may have some numbness around the surgical scar. This is from
having to divide small nerves when cutting muscles.
Occasionally, a type of hernia called an incisional hernia may develop
around the scar. This is caused by a weakness in the wall of the
abdominal muscles. It usually doesn’t need any treatment, but if it
causes pain or becomes too large an operation may be needed to treat
it.
There should be no permanent effects on your lifestyle or diet after
this surgery.

Symptoms to look out for

Call your GP or specialist nurse if you develop any of the following
symptoms:
• a high temperature
• a sharp or persistent pain
• being sick or not being able to eat as you would normally
• becoming jaundiced (yellowing of your skin and eyes)
• your wound becomes red and painful or has a smelly discharge.

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Further information
Cancer Research UK
Website: www.cancerresearchuk.org/cancer-help
Macmillan Cancer Support
Website: www.macmillan.org.uk
Tel: 0808 808 00 00
Maggie’s Cancer Centre (Oxford)
Tel: 01865 751 882
Website: www.maggiescentres.org/oxford

Useful contact numbers:

Oxford University Hospitals’ Switchboard 0300 304 7777
Hepatobiliary Team Secretary 01865 235 668
Specialist Cancer Nurses and Specialist Dietitian 01865 235 130
(or call the switchboard and ask for bleep 1386/1891)
Pre-operative Assessment clinic
(John Radcliffe Hospital) 01865 857 635
Pre-operative Assessment clinic
(Churchill Hospital) 01865 226 982/3
Oxford Upper GI Ward (Churchill Hospital) 01865 235 061
Intensive Care Unit (Churchill Hospital) 01865 235 084
Churchill Overnight Recovery Unit 01865 235 127

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If you need an interpreter or would like this information leaflet
in another format, such as Easy Read, large print, Braille,
audio, electronically or another language, please speak to the
department where you are being seen. You will find their contact
details on your appointment letter.

Document revised by Sue Wilner, (HPB Specialist Nurse) and

Consultant Hepatobiliary and Pancreatic Surgeons, Mr. Michael Silva and
Mr. Zahir Soonawalla

July 2019
Review: July 2022
Oxford University Hospitals NHS Trust
www.ouh.nhs.uk/information

OMI 55947P