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Primary biliary cirrhosis As with PSC, patients with primary biliary cirrhosis often pres - ent insidiously with malaise, lethargy and pruritus or abnormal liver function tests prior to becoming clinically jaundice. The condition is largely confined to females ...

Primary sclerosing cholangitis PSC is a chronic cholestatic liver disease of unknown aetiology , although a genetic predisposition is likely owing to its asso ciation with ulcerative colitis. It produces di ff use, progressive inflammation and fibrosis with stru...

Re-do surgery Close follow-up identifies recurrent isolated liver metastases and if CT and PET exclude additional disease repeat resection is appropriate when possible. The operative approach must take into account the consequences of previous surgery and hype...

Recurrent or refractory abscesses Recurrent abscesses usually occur when the initial lesion was large, abscesses were multiple or there is continued commu - nication with the biliary tract. It can be di ffi cult to confirm whether a liver abscess is recurrent or ...

Resection options Segmental resections Hepatic resection traditionally involved the formal removal of the right (segments V–VIII) or left (segments II–IV with/ without I) hemiliver to ensure the largest possible clearance. Although anatomical resection remain...

Segmental anatomy The liver is divided into functional right and left ‘units’ along the line between the gallbladder fossa and the middle hepatic vein (Cantlie’s line). Understanding the internal anatomy of the liver facilitated safe liver surgery and Couinaud...

Surgical approaches to liver trauma When a laparotomy is indicated, especially when CT scanning is not possible, a ‘rooftop’ incision (see Figure 69.19 midline extension to the xiphisternum and retraction of the costal margins gives excellent access to the li...

Surgical approaches to resection of liver tumours Parenchyma-preserving resections that achieve adequate oncological clearance have emerged from an understanding of oncological principles and the impact of chemotherapy on hepatic function. Such resections pr...

Synchronous colon and liver resection Synchronous resectable liver metastases are frequently identified at the time of diagnosis. Treatment options include sequential, delayed and simultaneous resection strategies. Resection of the colonic primary followed by...

The blood supply to the liver The liver is composed of eight segments ( Figure 69.1 ), each supplied by terminal branches of the portal vein (80% of the blood flow) and hepatic artery (20%) and drained by bile ducts and hepatic veins. The shape of the segme...

The hilum of the liver The porta hepatis is a pronounced transverse fissure on the visceral surface of the liver running between the cephalad end of the fissure for the ligamentum teres and the gallbladder fossa. The neurovascular structures and lymphatics run...

The venous drainage The IVC occupies a groove on the posterior surface of the liver that drains into it via three large veins immediately below the diaphragm. The suprahepatic IVC immediately traverses the diaphragm to enter the right atrium, but below the li...

Abdominal wall closure and laparoscopic port closure Abdominal wound closure technique The surgical technique involved in abdominal wall closure varies from hospital to hospital with practice heavily influenced by local opinion and training exposure. The object...

Abdominal wall closure and laparoscopic port closure Abdominal wound closure technique The surgical technique involved in abdominal wall closure varies from hospital to hospital with practice heavily influenced by local opinion and training exposure. The object...

Advanced vessel-sealing devices Advanced laparoscopic procedures have driven a parallel explosion in novel technologies that facilitate the perfor mance of such procedures. This is particularly the case for vessel-sealing devices. Monopolar diathermy still pl...

Alternatives to sutures Skin adhesive strips Self-adhesive tapes may be used where there is no tension and the wound is clean; for example, adhesive strips are used following clean procedures on the face. Tissue glue - Tissue glue can be used as a means of pr...

DRAINS IN SURGERY In 1887 Lawson Tait suggested ‘when in doubt drain!’. This edict has been criticised and the value of routine drain place - ment has been scrutinised. Drains are inserted to allow fluid that might collect in a body cavity to drain freely to th...

Draping Draping is the process of forming a sterile perimeter around the operating site using disposable or reusable sterile sheets. The drape sheets ideally serve to form a fluid-resistant barrier; they are antistatic, flame resistant, lint free and, although w...