Liver Anatomy (and HCC)External Anatomy Components of Hepatectomy Left RHV MHV LHV Right Outflow Hepatic veins Vena Cava Inflow Hepatic artery Portal vein Parenchyma Segmental Liver

Liver Anatomy (and HCC)

External Anatomy

Components of Hepatectomy

Left

RHV MHV LHV

Right

OutflowHepatic veinsVena Cava

InflowHepatic arteryPortal vein

Parenchyma

Segmental Liver Anatomy

Right liver Left liver

IV III

II

I

Left pedicleRight pedicle

Leftpedicle

VI

VVIII

VII

Portal Pedicles

7

84 2

6

54 3

CT Segmental Anatomy

1

?

Caudate

Components of Hepatectomy

Left

RHV MHV LHV

Right

OutflowHepatic veinsVena Cava

InflowHepatic arteryPortal vein

?Extrahepatic or intrahepatic control of inflow and outflow?

Parenchyma

Hepatic veins

Hepatic veins

Hepatic veins

Outflow Control

Extra-hepatic

Intra-hepatic

Left Liver Mobilization

LHV and MHV Control

Right Liver Mobilization

Outflow ControlRight Hepatic Vein Division

Extrahepatic Outflow ControlImportance of the Middle Hepatic Vein

• No liver hypertrophy• Large loss of normal liver

Extrahepatic Outflow Control

RHV

MHV LHV

IVC

Extrahepatic Outflow Control

Hepatic artery

CT Angiogram

Right liver Left liver

IV III

II

I

Left pedicleRight pedicle

Leftpedicle

VI

VVIII

VII

Inflow - Intrahepatic Pedicles

Portal Pedicles

Portal Pedicles

Portal vein - left

Main Pedicles

Right Main Pedicle

Hepatotomies for Inflow Control

For right pedicle control

Inflow ControlRight Pedicle Division

Intrahepatic Inflow Control

Extrahepatic Inflow Dissection

• Time consuming

• Difficult if previous RUQ surgery

• Associated with vascular/biliary injury on occasion

• Mandatory for perihilar tumors

Left Portal Vein

Inflow/Outflow Control?Hepatocellular Carcinoma

Anterior Sectorectomy

Colorectal metastases

Left Lateral Segment Right Posterior Sector

Hepatocellular carcinoma

HCC Features

DiagnosisCT/MR: Hypervascular on arterial phase with washoutAFP >500Biopsy

StagingLymph node involvementDistant disease

Treatment - Hepatic function, portal HTNResectionEmbolizationTransplant

Cirrhosis

“Hanging” Hepatoma

40 y.o. F with acute RUQ pain

Four patients with HCC

Portal vein

Tumor expanding portal vein

Tumor in posterior sectoralportal vein

Patient 2

Patient 1 Patient 3

Tumor in IVC andatrium

Tumor in middlehepatic vein

Tumor in lefthepatic vein

Patient 4

39 y.o. Caucasian female without risk factors

Sorafenib in Advanced HCC

NEJM 359:378-90, 2008

10.7 vs. 7.9 months

65 y.o. drinker with pain, AFP 40

10 year survivors HCC

Ann Surg Oncol 24:1358-66, 2017

10 year survivors HCC

Ann Surg Oncol 24:1358-66, 2017

50 y.o. Asian female with Hepatitis B

Liver tumor

Nodal met

Liver tumor

20 y.o. male with pain