*Safe hepatectomy requires optimization of the future liver remnant, preservation of inflow/outflow/biliary drainage, and recognition of normal versus concerning postoperative physiology.* --- ### Pre-operative planning 1. Assess [[Future Liver Remnant|sFLR]] (especially for any major resection) 2. Assess baseline liver quality → low threshold for background liver biopsy - Steatosis, fibrosis, chemotherapy-associated injury - oxaliplatin → sinusoidal injury - irinotecan → steatohepatitis 3. Assess for occult portal HTN → low threshold to calculate [[portal HTN |portal pressures]] - splenomegaly - varices, porto-systemic (caval) collaterals - thrombocytopenia - history of chronic liver disease or chemotherapy-associated liver injury 4. Review imaging for relevant anatomic variants - right posterior sectoral duct draining to left system (*~20%*) → critical before left / extended left - right hepatic artery traveling anterior to bile duct (*~15-25%*) - [[Portal Vein Anatomy|portal venous variations]] - other biliary variations 5. Consider the use of PHLF risk calculators - [TELLAPRIALBI calculator](https://tellaprialbi.howto.health/home) for prediction of PHLF 6. Optimize the future liver remnant preoperatively - nutrition, weight loss (steatosis reduction)→ consider recommending a preoperative [liver weight loss diet](https://www.royalberkshire.nhs.uk/media/annpjkhp/liver-reduction-diet-prior-to-bariatric-surgery_apr25.pdf) - biliary drainage → based on dilation on imaging ± labs (alk phos, bilirubin) --- ### Intra-operative principles *Preserve functional remnant quality, inflow, outflow, and biliary drainage.* **Avoid secondary injury to the future liver remnant:** - minimize inflow occlusion / ischemia - minimize blood loss and transfusion - preserve vascular integrity - maintain arterial and portal inflow - preserve hepatic venous outflow (avoid remnant congestion) - prevent biliary injury or devascularization **Recognize high-risk scenarios:** - small future liver remnant - chemotherapy-injured liver - underlying fibrosis/cirrhosis - extended hepatectomy **Technical considerations:** - assess for [[Intraoperative Biliary Leak Assessment|biliostasis]] - consider selective drain placement - biliary reconstruction - concern for bile leak or inadequate biliostasis - complex hilar dissection - high-risk transection surface --- ### Post-operative considerations *The postop period is an essential time for hepatocyte regeneration → avoid secondary insults to the regenerating liver remnant* ##### Postoperative Principles - maintain hepatic perfusion (avoid hypotension/sepsis) and evaluate inflow/outflow if recovery is abnormal - maintain adequate nutrition/caloric intake - recognize expected postoperative lab trajectories - identify evolving [[Post-Hepatectomy Liver Failure (PHLF)|PHLF]] early ##### Expected postoperative trajectories - AST/ALT → immediate rise then decline - INR → early peak (36–48 hr) then recovery - bilirubin → delayed peak (POD 4–6) then clearance - phosphate → POD2 nadir ([[Postoperative hypophosphatemia]]) - platelets → early decline (nadir POD2–3) then recovery ![[Pasted image 20260514134931.png|350]] *Graph @ [Dr. Steve Wigmore](https://profstevewigmore.wordpress.com/2012/12/19/why-do-people-develop-jaundice-after-liver-resection/)* | Concerning Feature | Potential Etiologies | | ----------------------------------- | ----------------------------------------------------------------------------------------------------- | | Persistent INR elevation | PHLF, inadequate liver remnant, ongoing ischemic injury, sepsis | | Rising bilirubin after POD5 | PHLF, biliary obstruction, bile leak/collection, sepsis | | Worsening transaminases | Ongoing ischemia-reperfusion injury, vascular compromise, congestion, sepsis | | Encephalopathy or lactate elevation | Significant hepatic dysfunction/PHLF, sepsis, inadequate hepatic clearance/perfusion | | Persistent thrombocytopenia | impaired regeneration, inadequate functional liver remnant, portal hypertension/splenic sequestration | *Findings are nonspecific and often overlapping; interpretation depends on operative context, remnant quality, and associated clinical findings.* --- ### References >[!quote]- Selected References >- [Dr. Steve Wigmore: Why do people develop jaundice after liver resection? 2012.](https://profstevewigmore.wordpress.com/2012/12/19/why-do-people-develop-jaundice-after-liver-resection/) >- [Schindl MJ, et al. The value of residual liver volume as a predictor of hepatic dysfunction and infection after major liver resection. Gut. 2005](https://pubmed.ncbi.nlm.nih.gov/15647196/) >- Additional references available on linked topic pages. --- **Page Information** Last Updated: June 2026 Maintained by: HPB Compendium Editorial Board