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Experts in Liver Surgery

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Expert Opinion: Liver Surgery

The liver plays a central role in metabolism, deprives the blood of dangerous substances and produces bile for digestion.

The liver is the largest of our internal organs. The liver is involved in the metabolism of fats, carbohydrates and proteins. Toxic substances can excrete the organism via the liver. The organ produces many important blood proteins, such as the coagulation factors. It also provides bile acids for fat loss. Excess glucose stores the liver and provides it to the body when needed. Vitamins and trace elements such as iron, copper, zinc and manganese also store our organism in the liver.

As the only organ except the heart, the liver is involved in two bloodstreams. About 2,000 liters of blood flow through them every day. Their many tasks make the liver vital - too much alcohol and fat hurt her. It is typical that diseases of the pain-insensitive organ often go unnoticed at first.

Liver diseases can have different causes. A common trigger is chronic alcohol abuse - it accounts for about half of all liver disease. In addition, however, chronic viral infections, metabolic diseases or drugs as a cause in question.

Liver disease is often recognized late because it causes significant discomfort at an advanced stage. For a long time, however, only weak and unspecific symptoms occur. These include tiredness and fatigue, loss of appetite, nausea and vomiting, difficulty concentrating and a feeling of pressure in the right upper abdomen.

If you continue to experience such symptoms over a long period of time, you should always think about liver disease and consult a doctor as a precautionary measure. The yellowing of the skin and mucous membranes typical of many liver diseases only occurs at an advanced stage. At the latest, if you notice this symptom, a doctor's visit is urgently needed.

Fatty liver

In a fatty liver - as the name implies - more fat stored in the liver. Cause is usually an unhealthy lifestyle with a high-calorie diet, little exercise and a high alcohol intake. In addition, however, diseases such as diabetes or a lipid metabolism disorder as well as the intake of certain medications can lead to fatty liver.

A fatty liver only causes discomfort when the organ has already increased greatly. Then it can lead to nonspecific symptoms such as tiredness, fatigue, loss of appetite, bloating and flatulence. Likewise, a feeling of pressure may occur in the right upper abdomen.

If a fatty liver is diagnosed, a reduction in body weight and a renunciation of alcohol are of crucial importance. If this is consistently followed, liver fatty degeneration can often be reversed. If there is no change in lifestyle, the liver can become infected - this increases the risk of complications such as liver cirrhosis or liver cancer.

Liver inflammation (hepatitis)

In liver inflammation, a distinction is made between four known types, all of which are triggered by viruses. In addition, hepatitis can also arise as a result of fatty liver disease or by diseases such as diabetes mellitus and other metabolic diseases.

  • Hepatitis A: The hepatitis A virus is transmitted by smear infection and contaminated food - especially drinking water. The infection usually heals by itself and is therefore considered relatively harmless. In old people or the chronically ill, however, it can lead to complications.
  • Hepatitis B: Hepatitis B is one of the most common infectious diseases. The hepatitis B virus is transmitted through bodily fluids such as blood, semen or saliva. Most often, the infection heals by itself. In rare cases, however, it can take a chronic course. It is then important to initiate therapy early enough to avoid possible long-term consequences such as liver cirrhosis.
  • Hepatitis C: Infection with the hepatitis C virus occurs primarily on the bloodstream. If the infection is not detected in time, it takes in more than 50 percent of cases, a chronic course. If this is the case, the risk of liver cirrhosis and liver cancer increases.
  • Hepatitis E: Hepatitis E infection is predominantly transmitted through contaminated water or contaminated food. Usually, the infection heals by itself again, especially during pregnancy, but it can also lead to complications.

There are vaccinations against hepatitis A and hepatitis B. These are especially recommended for people at risk such as medical personnel or travelers traveling in risk areas.

Cirrhosis

Cirrhosis of the liver develops as a result of permanent stress or damage to the liver. Common causes include excessive alcohol consumption and infection with hepatitis viruses. First of all, the burden on the liver leads to a still reversible increase of connective tissue in the liver. Later, liver cells are replaced by connective tissue. This process is irreversible and causes the liver to lose its functions properly.

If cirrhosis of the liver is not treated in time, serious consequences may occur, including ascites, hepatic encephalopathy, impaired variceal bleeding and hepatocellular carcinoma. However, these serious consequences can be prevented or at least postponed by early therapy. However, liver cirrhosis is not curable.

Liver cancer

Liver cancer (hepatocellular carcinoma) is often diagnosed late, because the cancer causes no symptoms for a long time. The first signs include nausea and weight loss, as well as upper abdominal pain and jaundice. As with many other cancers, the sooner the liver cancer is detected, the better the chance of recovery.

The most common causes of liver cancer include infections with the hepatitis B or hepatitis C virus. They account for about half of all liver cancers. Another 40 percent are triggered by alcohol or overweight. Especially in this area, you can do a lot to prevent liver cancer.

In a liver biopsy, the doctor takes a tissue sample from the liver through the abdominal skin using a hollow needle. The method is used in particular for the diagnosis and follow-up of chronic liver diseases such as hepatitis or liver damage caused by alcohol and cancer. Read how the liver biopsy works and what you should consider afterwards.

How does the liver biopsy work?

Before the liver biopsy, the doctor gives the patient, if desired, a light tranquilizer. The doctor carefully disinfects the abdominal skin and injects a local anesthetic because the liver biopsy can be painful. The puncture site (puncture site) is determined by means of ultrasound. The patient now exhales and then stops the air, pushing the liver down from the diaphragm.

Between two costal arches, the doctor inserts a thin, approximately one to two millimeter thick hollow needle into the liver and removes a small tissue cylinder from the liver. The hollow needle is immediately withdrawn from the liver. The puncture thus lasts at most one second.

In some cases a tissue sample of the liver is also taken laparoscopically - via a laparoscopy.

What are the risks of liver biopsy?

Liver biopsy is a relatively safe procedure. Bleeding during or after surgery is the most common complication of biopsy, because liver tissue is well supplied with blood. After the procedure, major bruising may occur in the liver, which may need to be surgically removed. Patients who have a severe coagulation disorder should not be biopsied!

Rarely, inflammation of the peritoneum (peritonitis), infection or injury to adjacent organs such as the lungs or gall bladder. When the lungs are pierced, air or blood may accumulate in the thoracic cavity, which is called pneumothorax or hematothorax and must be treated quickly. The lungs sink together and affect the function of the lungs.

During an ascites puncture, the physician uses a hollow needle or cannula to remove fluid that has accumulated in the abdominal cavity. Since a newly occurring or increasing ascites ("ascites") is usually the expression of a serious illness, the causes must be found as quickly as possible. In addition, the ascites can cause such discomfort that relief by draining (draining) of larger amounts of fluid is necessary.

Diseases that can lead to ascites include:

  • Cirrhosis
  • Acute liver damage
  • Closure of the liver vessels

What do you do with an ascites puncture?

Ascites puncture is usually performed on the patient lying down. So that the doctor finds the optimal and safest puncture site and does not injure any organs or vessels, he uses an ultrasound device to find her and marks her on the patient's body. To reduce the risk of infection, he first disinfects the puncture site. He then injects a topical anesthetic into the tissue so that the patient feels the puncture less painful. The further course depends on whether the ascites puncture is performed for diagnostic or therapeutic purposes.

Ascites puncture: diagnostic procedure

To assess the accumulated fluid the doctor requires only small amounts. With a hollow needle, which he pricks carefully through the abdominal wall, he can draw a sample of the accumulated in the abdominal cavity liquid in a syringe. This sample is then tested in the laboratory for color, cell count, protein content, bacteria and many other parameters.

Performance for therapeutic purposes

Therapeutic ascites puncture is also called paracentesis in medicine. The doctor first determines the most suitable location for the puncture by means of an ultrasound image and then introduces the hollow needle through the abdominal wall. This is connected via a small plastic tube with a thin tube. Over this now the liquid can drain off well. If the ascites is sufficiently relieved, the doctor removes the hollow needle and covers the puncture site sterile.

What are the risks of an ascites puncture?

A purely diagnostic ascites aspiration is a very safe procedure and involves little risk for the patient. By contrast, ascites drainage for therapeutic purposes has a higher complication rate. Possible dangers that the patient should know are:

  • Persistent leakage of fluid through the puncture channel
  • Infections of the peritoneum (peritonitis)
  • Bauchdeckenabszess
  • Bleeding
  • Injury of surrounding structures and organs

What should I watch for after an ascites puncture?

If you have been given tranquillizer for ascites, your ability to drive is significantly reduced. Unless you stay in the hospital anyway, you should arrange for someone to pick you up in advance.

If you have received a therapeutic ascites aspiration that has taken several liters of fluid, you will be given an infusion as a protein / fluid replacement.

A liver transplant is the surgical transplantation of a liver or parts of a liver into a liver patient. The donor liver comes either from a deceased or - in a partial donation - from a relative. Read all about liver transplantation, when it is necessary and what problems can occur.

When do you need a liver transplant?

For patients with acute or chronic liver failure, transplantation is the only way to survive. Common reasons for the functional failure of the liver are:

  • Cirrhosis of the liver (for example due to alcohol abuse, hepatitis, medicines or chemicals)
  • Malignant cancers
  • Congenital metabolic disorders of the liver (hemochromatosis, Wilson's disease and others)
  • Congenital malformations (for example, the bile duct)

For each patient, the physician determines the so-called MELD (Model for End-Stage Liver Disease) score. This is calculated on the basis of various laboratory values and serves to classify the severity of the liver disease. In the doctor's letter, the doctor often cuts off the liver transplant with LTx.

How are the first days after the liver transplant going?

Since this is a relatively large procedure, the patient is first taken to the intensive care unit for about two to seven days after surgery. This is usually followed by another one to two weeks on the normal ward of the transplant center. During this time, the drug therapy is optimally adjusted. In addition, the patient receives physiotherapeutic support to prepare him for his everyday life.

Liver transplantation: risks

In addition to the general surgical risks such as blood clots or wound infection that every surgical procedure entails, some typical complications can occur in liver transplantation:

  • Non-function of the graft, eventually a second transplant will be necessary
  • Increased risk of bleeding
  • Closure of the hepatic artery
  • Bile duct stenosis (narrowing of the biliary tract)

Since the patient must take after a liver transplant medication that suppress the immune system, there is a significantly increased risk of infection.

In a rejection reaction, the body does not accept the foreign organ because the immune system turns against it. Possible signs of a rejection reaction are: weakness, rapid fatigue, increased temperature for several hours, loss of appetite, abdominal pain, clay-colored stools, dark urine and yellowing of the eyes and skin.

Basically, after the transplantation, the underlying disease may recur or the liver may fail again. Then a new liver transplant must be carried out.

Liver transplantation: life expectancy

Thanks to the medical advances of recent years, the life expectancy of liver transplant patients has significantly improved, in particular through advances in immunotherapy. On average, the one-year survival rate is over 90 percent, the 10-year survival rate is over 70 percent. Life expectancy after liver transplantation is primarily dependent on the patient's overall health and illness.

Most cysts are innate harmless malformations. The cystic cavities release a clear fluid that can cause the cyst to permanently grow. Very large cysts then displace the liver tissue and press on the surrounding organ in the abdomen. In rare cases, the cyst is caused by infection.

Patients increasingly complain of a feeling of pressure in the abdomen, discomfort, lack of appetite or feeling of fullness. Many have or are suspected of having one or many cysts in the liver.

One or more very large liver cysts that cause discomfort can be surgically operated on.

Preoperative preparation

If you go to the surgeon with all the findings, he will check if surgery makes sense to you and what surgery should be performed. You will then be informed about the planned procedure as well as possible complications and consequential disorders, and usually a binding surgery appointment can be arranged immediately. The same day they are presented to the anesthetist who discusses anesthesia with you. However, additional examinations may also be necessary to accurately assess your surgical and anesthetic risk.

Surgery

On the day of the operation, you will be sober in the hospital two hours before surgery. You can still eat normally for up to 6 hours before surgery and drink at will up to 2 hours before surgery. At the hospital, you will be prepared and taken to the operating room.

The surgery is performed as a minimally invasive procedure via small incisions. As a result, a large belly cut can almost always be avoided. This will help you recover quickly and have little pain.

The goal of the surgery is to remove the upper layer of the cyst. This relieves the cyst and the cyst fluid flows into the abdominal cavity. The peritoneum of the abdominal cavity absorbs the fluid so that patients no longer suffer from the cyst.

After the operation

After you have awakened from the narcosis, you can drink directly and eat yoghurt. After a few hours you can already walk down the hall. With optimal pain therapy, you will be largely painless. The next morning, you will have your breakfast at the table as normal and during the day as a healthy person. On the 4th day after surgery, you can go home at the latest. The analgesics are taken even further and the wound monitored by a doctor. The healing process is completed after 2 weeks.

It is possible to surgically remove up to 75 percent of the liver (segmental resection, hemihepatectomy). If, however, the entire organ has to be replaced (hepatectomy, liver resection), a donor organ is necessary (liver transplantation, liver transplantation). Common to all these liver operations is the progression and extensive removal of liver tissue.

Liver surgery begins with a skin incision along the costal arch or incision in the right upper abdomen. After spreading the muscles, the surgeon can open the abdominal cavity. Belly cloths and abdominal frame keep the surgical wound stable. Subsequently, the liver flap or segment to be removed is isolated.

Ways to avoid heavy bleeding

The problem with a large segmental resection is the heavy bleeding that results from the dissection of the diseased part of the liver. These usually prevent surgeons from temporarily disconnecting the portal vein, so that the blood supply to the liver is severely restricted (so-called pringle maneuver). Due to the lack of blood supply, however, the residual liver, which is to be preserved, exposed to an oxygen deficiency. This deficiency damages the residual liver (hypoxemia), increases the risk of complications and may promote liver failure.

The problem of oxygen deficiency caused by the Pringle maneuver can be avoided by experienced surgeons. In addition to excellent knowledge of the individual anatomy and a careful and clear surgical technique, this also requires measures that reduce bleeding tendency:

  • The gentle separation of tissue layers by a water jet (water jet dissection) - this tissue is not cut open, but forced apart.
  • General anesthesia with deep central venous pressure, so that the blood reflux and thus the blood loss is lower.

With the help of these gentle measures, the lack of oxygen deficiency can be avoided by disconnecting the blood supply. Christoph A. Maurer in a study after. These can be viewed on his Leading Medicine Guide expert profile. Patients benefit from faster recovery and improved liver function.

After isolation of the liver part to be removed from the bloodstream bile ducts and portal veins, which lead into the liver section concerned, severed. Now the liver tissue can be cut directly and the segment or liver lobes removed.

The remaining part of the liver often needs to be re-fixed and stabilized by drainage. Finally, the abdominal wall is sutured and the wound is protected with sterile dressing material.

Wedges excision in liver cancer

A special form of segmental resection is wedge excision. In this surgical procedure, liver cancer is excised from the healthy liver tissue without regard to segment boundaries. Liver surgery itself is analogous to classic segmental resection.

In portal hypertension or in preparation for liver transplantation, a transjugular intrahepatic portosystemic shunt (TIPS) surgery closes a bypass circuit for the hepatic tract so that part of the portal blood does not drain through the liver but directly into the inferior vena cava.

Under general anesthesia, the jugular vein (internal jugular vein) is punctured and an angiographic catheter inserted over the right atrium into the superior vena cava. From here, the catheter penetrates via the inferior vena cava into the hepatic vein. By means of a hollow needle, a cut is then made through the liver tissue through the catheter into the portal vein. The portal vein can then be permanently connected to the hepatic vein by means of a balloon catheter (shunt). At the end, the doctor removes the angiographic catheter again and the puncture site on the neck is connected in a sterile manner.

2018-06-08 Liver Surgery GermanMedicalGroup + 49 (7221) 39-65-785 Flugstrasse 8a 76532 Baden-Baden Germany Liver Surgery Liver Surgery Liver Surgery
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