Surgery for the Hepatic
Cripple
TODD A. NICKLOES, DO, FACOS, FACS
ASSOCIATE PROFESSOR
DIVISION OF TRAUMA/CRITICAL CARE
DEPARTMENT OF SURGERY
UNIVERSITY OF TENNESSEE MEDICAL CENTER-KNOXVILLE
For my father….
Surgery for the Hepatic Cripple
 First things first: Anatomy
 Couinaud classification
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The Couinaud classification of liver anatomy divides the liver into eight
functionally independent segments.
Each segment has its own vascular inflow, outflow and biliary drainage.
In the center of each segment is a branch of the portal vein, hepatic artery and
bile duct (except segment I).
In the periphery of each segment there is vascular outflow through the hepatic
veins.
Because of this division into self-contained units, each segment can be
resected without damaging those remaining.
For the liver to remain viable, resections must proceed along the vessels that
define the peripheries of these segments, (hence, the lines of resection parallel
the hepatic veins).
The centrally located portal veins, bile ducts, and hepatic arteries are
preserved (except in segment I).
Surgery for the Hepatic Cripple
Surgery for the Hepatic Cripple
 First things first:
 Couinaud classification







The Couinaud classification of liver anatomy divides the liver into eight
functionally independent segments.
Each segment has its own vascular inflow, outflow and biliary drainage.
In the center of each segment is a branch of the portal vein, hepatic artery and
bile duct (except segment I).
In the periphery of each segment there is vascular outflow through the hepatic
veins.
Because of this division into self-contained units, each segment can be
resected without damaging those remaining.
For the liver to remain viable, resections must proceed along the vessels that
define the peripheries of these segments, (hence, the lines of resection parallel
the hepatic veins).
The centrally located portal veins, bile ducts, and hepatic arteries are
preserved (except in segment I).
Segments numbering
There are eight liver
segments.
Segment 4 is sometimes
divided into segment 4a
and 4b according to
Bismuth.
The numbering of the
segments is in a
clockwise manner
(figure).
Segment 1 (caudate lobe)
is located posteriorly. It
is not visible on a frontal
view.
Surgery for the Hepatic Cripple
Surgery for the Hepatic Cripple
 Right hepatic vein divides the right lobe into anterior
and posterior segments.
 Middle hepatic vein divides the liver into right and left
lobes (or right and left hemi-liver). This plane runs from
the inferior vena cava to the gallbladder fossa. Also
provides venous drainage for segment 4B.
 Left hepatic vein divides the left lobe into a medial and
lateral part (and drains 4A).
 Portal vein divides the liver into upper and lower
segments. The left and right portal veins branch
superiorly and inferiorly to project into the center of each
segment
On a normal frontal view
the segments 1, 6 and 7
are not visible because
they are located more
posteriorly.
The right border of the
liver is formed by
segment 5 and 8.
Although segment 4 is
part of the left hemiliver,
it is situated more to the
right
Surgery for the Hepatic Cripple
Right hepatic vein
divides the right lobe
into anterior and
posterior segments.
(8/5 and 7/6)
Middle hepatic vein
divides the liver into
right and left lobes (or
right and left hemiliver).
This plane runs from the
inferior vena cava to the
gallbladder fossa,
Cantlie’s Line.
Left hepatic vein
divides the left lobe into
a medial & lateral part.
(4a/4b and 2/3)
Surgery for the Hepatic Cripple
Surgery for the Hepatic Cripple
The uppper left figure is a transverse image
through the superior liver segments, that are
divided by the hepatic veins.
LEFT: at the level of the right portal vein.
RIGHT: at the level of the splenic vein.
Surgery for the Hepatic Cripple
So who are we
talking about?
Surgery for the Hepatic Cripple
 Portal Hypertension
 Chronic increase in portal venous pressure (PVP)
 Due to a mechanical obstruction of portal venous system
Normal 5-10 mm Hg
 Varices begin to develop when PVP 10-12 mm Hg
 Therapeutic goal of treatment is hepatic venous pressure gradient
(HVPG) <12 mm Hg
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Etiologies
Pre-sinusoidal
 Sinusoidal
 Postsinusoidal
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Surgery for the Hepatic Cripple
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Pre-sinusoidal
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Sinusoidal
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Schistosomiasis
congenital atresia (hepatic fibrosis)
portal vein thrombosis (50% of pediatric cases)
Cirrhosis
NASH/NAFLD
Hepatic fibrosis secondary to hemochromotosis
Wilson disease
Congenital fibrosis
Postsinusoidal
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Budd-Chiari syndrome (hepatic vein thrombosis)
Congenital IVC malformation (web, diaphragmatic hiatus)
IVC thrombosis
constrictive pericarditis
CHF
Surgery for the Hepatic Cripple
 Most common cause of liver failure (& PH) in the US
 Intrahepatic/Sinusoidal
Alcohol induced cirrhosis
 Closely followed by viral hepatitis induced cirrhosis (50% of cases
worldwide)
 NASH/NAFLD
 Non-alcoholic steatohepatitis/non-alcoholic fatty liver disease
 Increasing in US as obesity increases
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• Obesity
• NIDDM
• Hyperlipidemia

Cryptogenic cirrhosis and HCC
• 4.5% increase in relative risk for obese patients
Surgery for the Hepatic Cripple
“Hey Doc, can
you fix this?”
Surgery for the Hepatic Cripple
“Hey Doc, can
you fix this?”
Should you?
Surgery for the Hepatic Cripple
 Contraindications to elective surgery in patients with
liver disease
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Acute hepatitis
alcoholic or viral
 Mortality of 10-13% if icteric
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Child’s class C
Fulminant hepatic failure
Severe chronic hepatitis
Severe coagulopathy
PT > 3 minutes on vitamin K
 Platelet count < 50,ooo
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Extrahepatic complications
Acute renal failure
 Cardiomyopathy/CHF
 hypoxemia
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Surgery for the Hepatic Cripple
“but Doc, I need
this done so I
can take care of
my dog! Why
won’t you help
me?”
Surgery for the Hepatic Cripple
Parameter
Points
Assigned
Points
Assigned
Points
Assigned
1
2
3
Ascites
Absent
Slight
Moderate
Bilirubin
< 2 mg/dl
2-3 mg/dl
3 mg/dl
Albumin
> 3.5 g/dl
2.8-3.5 g/dl
< 2.8 g/dl
PT
< 4 seconds
4-6 seconds
6 seconds
INR
< 1.7
1.7-2.3
2.3
Encephalopathy
None
Grade 1-2
Grade 3-4
Class A: 5-6 points
(well compensated)
0-15% mortality
Class B: 7-9 points
(significant functional
compromise)
15-45% mortality
Class C: 10-15 points
(decompensated
disease)
+/- 70% mortality
Child CG, Turcotte JG. Surgery and portal hypertension. Major Probl
Clin Surg 1964;1:1-85. [PubMed]
Surgery for the Hepatic Cripple
 MELD score
 Model for End-stage Liver Disease
 Originally developed to determine prognosis following a
transjugular intra-hepatic shunt (TIPS) procedure for liver
failure
 Widely used in the liver transplant arena to prioritize donor
liver allocation
 Recently validated as having direct correlation between MELD
score and 30 day postoperative mortality in non-transplant
procedures
Surgery for the Hepatic Cripple
 MELD score
 Simple rule of thumb
1% increase in mortality per MELD point if MELD score < 20
 2% increase per MELD point if > 20
 Easy to use at the bedside/clinic given PDA’s today
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MELD = 3.8[Ln serum bilirubin (mg/dL)] + 11.2[Ln INR] + 9.6[Ln serum creatinine (mg/dL)] + 6.4
where Ln is the natural logarithm
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(if hemodialysis twice in past week, value for Creatinine is automatically set to 4.0)
Note: If any score is <1, the MELD assumes the score is equal to 1.
Surgery for the Hepatic Cripple
 So, now everyone in the room knows the risk….
 If you must do surgery,
can we mitigate the risk?
Surgery for the Hepatic Cripple
 So, now everyone in the room knows the risk….
 If you must do surgery,
can we mitigate the risk?
Not really…..
Surgery for the Hepatic Cripple
 Let’s break it down
 Elevated INR
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In measuring PT/INR, a reasonable goal is to attempt correction with vitamin
K and fresh frozen plasma to achieve a prothrombin time within three seconds
of normal/INR < 1.5 prior to surgery.
Replacing the platelets
Recombinant factor VIIA (100 mcg/kg)
 temporarily corrects the prothrombin time
 limited by
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•
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high cost
transient effect
an absence of data showing improved outcomes in cirrhotics
the associated risk of thromboembolism
Tranexamic acid (TXA)
 1 gram over 10 minutes followed by 1 gram over 8 hours
 limited by
• high cost
• an absence of data showing improved outcomes in cirrhotics
Surgery for the Hepatic Cripple
 However,
 Evidence has accumulated that the prothrombin time does not
correlate with the risk of bleeding in patients with cirrhosis.
 Decreased levels of all liver synthesized pro-coagulant factors,
including the vitamin K dependent clotting factors (II, VII, IX, and
X) in patients with cirrhosis are widely recognized.
 Other liver-synthesized clotting factors that may contribute to
hypocoagulability include fibrinogen, factors V, XI, XII,
prekallikrein, kininogen, and plasminogen
 More likely related to a combination of this and HVPG
Surgery for the Hepatic Cripple
 Let’s break it down
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Elevated bilirubin
 Further evidence of hepatic failure
 Metabolism of heme products
 Make them water soluble for excretion
Surgery for the Hepatic Cripple
 Let’s break it down
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Elevated Cr
 Evidence of fluid shift to extravascular space secondary to
diminished hepatic protein synthesis
 Ascites
 Secondary to hepatic/splanchnic lymph accumulation
 Hyperaldosteronism with Na retention -> water retention
 Diuretics with Na restriction (1,000 mg daily)
• Spironolactone 25mg BID (max 400mg/d)
• counters the Aldosterone
• May lead to hepatorenal syndrome (appears like prerenal
azotemia)
Surgery for the Hepatic Cripple
 Let’s break it down
Elevated Cr
 Ascites
 Paracentesis with albumin replacement @ 1 gm/100
cc
• Hepatorenal syndrome is a threat
• Asterixis (neurologic changes) as ammonia level
increases
 These measures may provide transient improvements –
with a small window of opportunity
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Conundrum:
Patient presents with
portal hypertension and
active UGI variceal
hemorrhage not
amenable to
endoscopic/IR
interventions.
Surgery for the Hepatic Cripple
Think, man, think!
What can I do if I
absolutely must, but I
have some time….?
Not a lot…..
Surgery for the Hepatic Cripple
Think, man, think!
What can I do if I
absolutely must, but I
have some time….?
Not a lot…..
But…
Surgery for the Hepatic Cripple
TIPS Procedure
Transjugular
Intrahepatic
Portosystemic
Shunt
Surgery for the Hepatic Cripple
TIPS Procedure
25% of patients who
undergo TIPS will
experience transient
post-operative hepatic
encephalopathy…
Surgery for the Hepatic Cripple
TIPS Procedure
25% of patients who
undergo TIPS will
experience transient
post-operative hepatic
encephalopathy,…
but it will stop the
variceal hemorrhage.
Surgery for the Hepatic Cripple
TIPS Procedure
25% of patients who
undergo TIPS will
experience transient
post-operative hepatic
encephalopathy,…
but it will stop the
variceal hemorrhage.
And preserves the
anatomy for potential
transplantation reciept
Surgery for the Hepatic Cripple
Surgery for the Hepatic Cripple
Distal Splenorenal shunt
-aka Warren shunt
-lower rate of
encephalopathy
-utilized in variceal
bleeding
-Child’s A patients
-contraindicated in
refractory ascites as
may worsen ascites
-not an option in B/C
Surgery for the Hepatic Cripple
 Portocaval shunt
 End-to-side (Eck) fistula or side-to-side anastamosis
 May worsen ascites
 Will worsen encephalopathy
 Mesocaval shunt
 Graft between the IVC and Portal vein
 Worsens encephalopathy
 Side-to-side will lead to less ascites/hepatic failure
than end-to-side
Surgery for the Hepatic Cripple
 Peritoneovenous shunt
 LeVeen
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Denver
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Peritoneum to subclavian vein
Modification of LeVeen with subcutaneous hand pump
Rarely used secondary to DIC complications
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Contraindicated in variceal hemorrhage, SBP, hepatorenal
syndrome and existent coagulopathy
Surgery for the Hepatic Cripple
 Best advice
 Child’s A with variceal hemorrhage (MELD < 20)
Endoscopy
 Endoscopy again
 IR
 Splenorenal shunt (Warren)
 TIPS as fallback position
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Child’s B/C (MELD >20)
See above but skip the Warren shunt and go straight to TIPS
 Transplant service
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Surgery for the Hepatic Cripple
Bibliography
 Portal venous and segmental anatomy of the right hemiliver: observations
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based on three-dimensional spiral CT renderings MS van Leeuwen, J Noordzij,
MA Fernandez, A Hennipman, MA Feldberg and EH Dillon, Department of
Radiology, University Hospital Utrecht, The Netherlands
Planning of liver surgery using three dimensional imaging techniques. van
Leeuwen MS, Noordzij J, Hennipman A, Feldberg MA. Department of
Radiology and Surgery, University Hospital Utrecht, The Netherlands.
Clinical and anatomical basis for the classification of the structural parts of
liver Saulius Rutkauskas et al.
Clinic of Radiology, Institute of Anatomy, Clinic of Surgery, Kaunas University
of Medicine, Lithuania
Friedman LS. The risk of surgery in patients with liver disease. Hepatology
1999; 29:1617.
Greenfield’s Surgery Scientific Principles and Practices, 5th Ed, Lippincott
Williams & Wilkins, Philadephia, 2011:916.
Surgery for the Hepatic Cripple
Bibliography
 Child CG, Turcotte JG. Surgery and portal hypertension. Major Probl Clin Surg
1964;1:1-85. [PubMed]
 Malinchoc M, Kamath PS, Gordon FD, et al. A model to predict poor survival in
patients undergoing transjugular intrahepatic portosystemic shunts.
Hepatology 2000;31:864-71. [PubMed]
 Northup PG, Wanamaker RC, Lee VD, Adams RB, Berg CL. Model for EndStage Liver Disease (MELD) predicts nontransplant surgical mortality in
patients with cirrhosis. Ann Surg. 2005 Aug;242(2):244-51.
 Wada H, Usui M, Sakuragawa N. Hemostatic abnormalities and liver diseases.
Semin Thromb Hemost 2008; 34:772.
Contact me
 Todd A. Nickloes, DO, FACOS, FACS
 tnickloe@mc.utmck.edu