HPB

Liver Resection

OPERATION: Liver Resection — [Right Hepatectomy / Left Hepatectomy / Right Hemihepatectomy / Bisegmentectomy / Segmentectomy / Wedge Resection] — [Open / Laparoscopic]
ANAESTHETIC: General anaesthesia with epidural / PCA
ANTIBIOTICS: IV cephalosporin at induction
POSITION: Supine. Urinary catheter. Nasogastric tube. Cell salvage in circuit. VTE prophylaxis.

INDICATION:
[Colorectal liver metastases / hepatocellular carcinoma / cholangiocarcinoma / other primary hepatic tumour / benign lesion]. Preoperative staging: CT three-phase / MRI liver [findings]. [PET-CT if colorectal metastases]. MDT discussed and resection agreed. [Future liver remnant volumetry performed — [volume] % estimated remnant]. [Portal vein embolisation performed [date] — restaged [volume] % remnant achieved].

PROCEDURE:
WHO Checklist performed. Abdomen prepared and draped widely.

INCISION:
[Right subcostal / bilateral subcostal (Mercedes / rooftop) / J-incision / midline] incision. Self-retaining retractor system applied.

EXPLORATION AND ASSESSMENT OF RESECTABILITY:
Peritoneal cavity explored — no evidence of extrahepatic disease. Liver surface inspected and palpated. [IOUS performed — confirmed [number] lesions, identified [additional / no additional] lesions, defined relationship to hepatic veins and portal pedicles].

HEPATIC MOBILISATION:
Falciform ligament divided to the suprahepatic IVC. Round ligament divided and ligated. [Right triangular and coronary ligaments divided to fully mobilise the right lobe, displaying the right hepatic vein and retrohepatic IVC / Left triangular ligament divided to mobilise the left lobe.] Hepatocaval ligaments controlled. [Caudate lobe dissected from IVC — short hepatic veins individually ligated and divided.]

HILAR DISSECTION:
Hepatoduodenal ligament dissected. Cholecystectomy performed. [Right / left] hepatic artery identified and confirmed by intraoperative Doppler. Vessel loops slung. [Right / left] portal vein branch isolated. [Right / left] hepatic duct identified. [Structures divided and ligated / stapled — ensuring contralateral supply preserved and confirmed by Doppler.]

PARENCHYMAL TRANSECTION:
Resection line marked on liver surface using diathermy following the ischaemic demarcation line after hepatic inflow occlusion [or following segmental anatomy as defined by IOUS]. [Pringle manoeuvre applied — [total ischaemic time] minutes / intermittent clamping 15 minutes on 5 minutes off]. Low CVP maintained throughout by anaesthetic team.

Parenchymal transection performed using [CUSA / water-jet / harmonic scalpel / clamp-crushing technique / combination]. Intrahepatic bile ducts encountered and ligated. Hepatic venous tributaries controlled with [haemostatic clips / absorbable sutures / vascular stapler]. [Middle / right / left] hepatic vein divided and oversewn / controlled with vascular stapler.

Specimen removed. Raw liver surface inspected — haemostasis and biliostasis achieved using [argon beam coagulation / haemostatic agent / direct suture ligation of visible ducts]. [Fibrin glue / haemostatic gauze applied].

BILE LEAK TEST:
Cholangiogram via cystic duct stump / direct bile duct cannulation — no bile leak from cut surface. [Minor duct identified and ligated].

DRAINAGE:
[Closed-suction drain placed adjacent to the cut surface / no drain].

CLOSURE:
Mass closure with loop 1-PDS. Skin stapled.

FINDINGS:
[Tumour / metastasis] — [number, size, location by segment]. Resection margins: [macroscopically clear — [estimated margin distance]]. [R0 / R1 / R2 resection — describe]. Remaining liver parenchyma [normal / cirrhotic / steatotic]. No extrahepatic disease.

SPECIMEN: Liver resection specimen [orientated and inked] to histopathology.
EBL: [Volume] ml. Cell salvage: [volume] ml returned. COMPLICATIONS: [None / describe].

POST-OPERATIVE INSTRUCTIONS:
Level 2 / HDU care. Daily LFTs, coagulation, FBC. Drain bilirubin measured on day 3 — if >3× serum bilirubin, bile leak suspected. [Epidural management via acute pain team]. Enhanced recovery — early mobilisation. Oncology MDT review with histology. Surveillance imaging at 3 months.