Hepatobiliary

PART ONE High Yield Anatomy

• What structures are in the portal triad?
• Common bile duct
• Proper hepatic artery (medial)
• Portal vein (posterior)
• Runs in hepatoduodenal ligament
• What separates the right and left lobes of the liver?
• Cantlie’s Line (line between gallbladder fossa and IVC)
• What numbers correspond to the anatomic liver segments?
• I = caudate lobe
• II-III = left lateral segments
• IV = left inferior anteromedial
• V = right inferior anteromedial
• VI-VII = right posterior lateral
• VIII = right superior anteromedial
• What is the venous drainage?
• 3 hepatic veins → drain into IVC
• Medial and left hepatic vein usually merge before draining into IVC
• What are the most common aberrant vascular anatomy?
• Replaced right hepatic - most commonly off the SMA, travels behind pancreas and CBD
• Replaced left hepatic - most commonly off the left gastric, travels in gastrohepatic ligament

During foregut surgery, take care not to ligate a replaced left traveling in the gastrohepatic ligament.

Figure 1 - Segmental anatomy of the liver Benign Biliary Disease

• What is the management of asymptomatic gallstones?
• Observation
• What about uncomplicated symptomatic cholelithiasis?
• Elective cholecystectomy
• How do you manage symptomatic cholelithiasis in pregnancy?
• Higher rates of spontaneous abortion with non-operative management
• Laparoscopic cholecystectomy during the second trimester
• Place ports via open Hassan technique
• Keep pneumoperitoneum as low as possible
• Place bump under right side to offload cava
• How do you manage acute cholecystitis?
• Early cholecystectomy if surgically fit

There is no benefit to waiting or “cooling off” acute cholecystitis with antibiotics.

• Cholecystostomy tube if unable to tolerate surgery
• If recovered from their critical illness → interval cholecystectomy
• Recurrent symptoms are common after cholecystostomy tube removal
• What is the management of suspected choledocholithiasis?
• Several acceptable approaches and much variability between institutions, but in general:
• Strong suspicion (CBD stone on imaging, clinical cholangitis, bilirubin > 3, dilated CBD > 6 mm) → consider preop ERCP for duct clearance
• IOC and possible CBD exploration if ERCP not available
• Moderate suspicion (abnormal liver tests other than bili, mild elevation in bili, clinical gallstone pancreatitis) → MRCP or IOC
• Low suspicion (no biochemical or imaging suggestive of CBD stone) → no further investigation prior to cholecystectomy
• CBD stones identified during IOC → flush + glucagon up to twice
• If small stone and large enough cystic duct → transcystic CBD exploration using fluoroscopic guidance or choledochoscope
• If not amenable to transcystic approach → either lap CBD exploration or postop ERCP depending on resources available and surgeon experience
• What if you can’t visualize the hepatic ducts on IOC?
• Pull catheter back and try flushing again

• Trendelenburg to see if change in imaging (back filling using gravity)

• Convert to open to investigate injury to hepatic duct
• Gallstone pancreatitis
• Do you need to perform ERCP?
• Only if clinical signs of cholangitis
• Stone will likely pass and no improvement of outcomes with early ERCP in patients with gallstone pancreatitis alone
• When do you perform cholecystectomy?
• Should be done during index admission after clinical pancreatitis resolves
• In severe cases with significant peripancreatic fluid collections → wait until fluid collections mature or regress → interval cholecystectomy at 6 weeks is acceptable, but an ERCP with sphincterotomy should be performed to reduce risk of complications during waiting period
• What is gallstone ileus?
• Small bowel obstruction caused by a gallstone (typically at IC valve) resulting from a cholecystoenteric fistula (usually fistula to duodenum)
• What is the Rigler triad?
• Bowel obstruction
• Gallstone seen in intestine
• Pneumobilia on imaging
• How do you treat this?
• Primary goal: relieve the obstruction
• Perform enterotomy proximal to obstruction and milk stone back and remove through enterotomy
• Should you perform cholecystectomy and fistula takedown at the time of enterolithotomy?
• No

• A combined procedure has higher morbidity and recurrence rates are low

• Can consider in select circumstances: patient stable and gangrenous cholecystitis present (in other words they’re stable and REALLY need their gallbladder out) 99% of the time the answer is enterotomy and milk the stone. Avoid cholecystectomy and fistula takedown.
• What are gallbladder polyps?
• Majority are benign hyperplastic polyps
• Management
• Symptomatic → cholecystectomy
• Asymptomatic → cholecystectomy if > 10 mm in size
• If over 18 mm → treat as gallbladder cancer until proven otherwise
• Polyps over 6 mm need serial imaging or consider surgery to avoid need for surveillance Portal Hypertension
• What is the hepatic vein pressure gradient (HVPG)?
• Gradient between the wedged hepatic vein pressure and the free hepatic vein pressure - requires passage of balloon catheter into hepatic vein under fluoroscopy
• Portal hypertension defined as (HVPG) > 6 mmHg
• What are the clinical effects of portal hypertension?
• Portosystemic venous collaterals, ascites, hepatic encephalopathy, splenomegaly
• What is the relationship between the site of increased portal resistance and the etiology of portal hypertension?
• Presinusoidal → e .g . schistosomiasis
• Sinusoidal → e .g . alcoholic cirrhosis, viral hepatitis
• Postsinusoidal → Budd-Chiari syndrome

• Many are mixed disorders (e .g . primary biliary cirrhosis has both presinusoidal and sinusoidal elements)

• What are the sites of collateral circulation?
• Where splanchnic venous system meets with systemic drainage
• Distal esophagus/proximal stomach (esophageal submucosal veins to proximal gastric veins)
• Rectum (IMV to pudendal vein)
• Umbilicus (vestigial umbilical vein to left portal vein)
• Retroperitoneum (mesenteric and ovarian veins)
• How do you treat it?
• Pharmacologic
• Splanchnic vasoconstrictors in acute setting = vasopressin, octreotide
• Non-selective beta-blockers for prophylaxis = nadolol, propranolol
• Endoscopic variceal banding
• Transjugular intrahepatic portosystemic shunt (TIPS)
• Used for acute or recurrent variceal bleeding, refractory ascites, Budd-Chiari syndrome, or hepatic hydrothorax
• What is the management of acute esophageal variceal bleeding?
• Resuscitate, transfuse, antibiotics, intubation for airway protection
• Octreotide → endoscopic treatment → TIPS if uncontrolled (balloon tamponade as temporizing measure)
• If rebleed after initial endoscopic control → 2nd endoscopy → consider TIPS
• What are the surgical options for portal hypertension?
• Gastroesophageal devascularization

• Generally reserved for patients with extensive portal venous thrombosis and no portosystemic shunt options

• Esophageal transection with division and anastomosis
• Rarely used since TIPS
• Devascularization procedures
• Total devascularization of the greater curvature and upper 2/3rd of the lesser curvature and circumferential devascularization of the lower 7 .5 cm of the esophagus
• Portosystemic shunts
• Selective shunts (e.g. distal splenorenal or “Warren” shunt)
• Decompress only part of portal venous system
• Good for variceal bleeding but does not help ascites
• Partial portosystemic shunts
• Type of side to side shunt where flow is calibrated by the size of the synthetic interposition graft placed between the portal vein and vena cava
• Nonselective portosystemic shunts
• Decompress the entire portal venous system
• Side to side portocaval shunt is most common
• High rate of encephalopathy and complicate later liver transplant Variceal bleeding → selective shunt. Ascites → nonselective shunt.

Figure 2 - Vascular anatomy of portosystemic shunts Liver Abscess

• What types of abscesses can be found in the liver?
• Pyogenic abscess (most common, > 80%)
• Usually secondary to biliary tract infection (E . coli most common pathogen), GI source (diverticulitis, appendicitis)
• Treatment = percutaneous drain and antibiotics
• Ameobic abscess

• Typical presentation is patient with liver abscess after travel to Mexico

• Get serology
• Treatment = metronidazole, rarely needs drainage
• Echinococcal cyst
• Hydatid cyst
• Characteristic double walled cyst on CT
• Check serology
• Treatment = albendazole followed by surgical excision
• Do not aspirate or spill → cause anaphylaxis Quick Hits
• What hepatic vein pressure gradient is typically required for variceal rupture?
• 12 mmHg
• What is the definition of portal HTN?
• 6 mmHg
• What are the components of the Child-Turcotte-Pugh score?
• Bilirubin, albumin, prothrombin time, encephalopathy, ascites
• What are the components of the Model for End-stage Liver Disease (MELD) score?
• Bilirubin, INR, creatinine
• What is the MELD score at which patients have a survival benefit for transplantation?
• 15
• What is the management of umbilical hernias in a cirrhotic with ascites?
• Ideally done in elective setting
• Medically control ascites first
• Control of ascites is key to reduce hernia recurrence and postoperative complications, such as wound infection, evisceration, ascites drainage, and peritonitis
• If medical treatment of ascites doesn’t work → intermittent

paracentesis, temporary peritoneal dialysis catheter or transjugular intrahepatic portosystemic shunt may be necessary

• Use mesh in the elective setting
• If patient eligible for transplant → repair hernia at time of transplant
• If complicated (incarcerated, strangulated, ruptured) → must repair urgently
• No mesh, close in layers (close peritoneum), sterile dressing

• Aggressive ascites control postop until healed Avoid leaving an intraperitoneal drain on the exam - patient can get hypotensive. Intermittent paracentesis is the standard.

• How do you manage symptomatic cholelithiasis in a patient with cirrhosis and ascites?
• Medically manage until cirrhosis is compensated, then laparoscopic cholecystectomy by an experienced liver surgeon .
• Replace clotting factors and platelets preop if necessary PART TWO Cystic Hepatobiliary Lesions
• What are choledochal cysts?
• Unknown etiology but likely secondary to an anomalous biliary-pancreatic duct junction with reflux of pancreatic enzymes (long common BP duct)
• Most are identified and treated in early childhood
• Can cause, pain, biliary obstruction, cirrhosis

• Carry malignant potential

• What is the Todani classification system and treatment by type?
• I - Fusiform dilation of extrahepatic biliary tree
• Resection with hepaticojejunostomy
• II - Saccular diverticulum of CBD
• Excision of cyst - likely with RNY biliary enteric reconstruction
• III - Dilation of intramural duct (choledochocele)
• Uncommon - approach transduodenally → transduodenal excision or sphincteroplasty
• IVa - Multiple dilations of intra and extra-hepatic ducts
• Hepatic resection and biliary reconstruction
• IVb - Multiple dilations of extra-hepatic ducts
• Excision and hepaticojejunostomy
• V - Multiple dilations of intrahepatic ducts (Caroli’s)
• Transplantation (can have one attempt at partial resection if isolated to one part of liver)

Figure 3 - Types of choledochal cysts

• How do you manage a simple hepatic cyst?
• No treatment if asymptomatic
• 100% recurrence rate with aspiration alone

• Laparoscopic cyst fenestration for symptomatic cysts → send capsule for pathology

• If concern for abscess, hydatid cyst, or malignancy → aspirate for cytology Hepatobiliary Tumors
• What are the characteristics of a hepatic hemangioma?
• Most common liver tumor, male predominance, equal distribution in liver
• Congenital vascular malformations, generally asymptomatic
• Can cause pain, compressive symptoms
• Rarely hemorrhage, inflammation, or coagulopathy
• Kasabach-Merritt Syndrome = hemangioma + consumptive coagulopathy
• Imaging
• CT: hypodense pre-contrast; peripheral → central enhancement in the arterial phase; persistent contrast on delayed series
• MRI: hypointense on T1; hyperintense on T2
• Treatment
• Asymptomatic → observation (regardless of size, no risk of rupture)
• Symptomatic → resection
• Focal Nodular Hyperplasia
• 2nd most common liver tumor, women 30-50 years old
• Completely benign, usually asymptomatic
• Imaging
• CT: well demarcated; rapid arterial enhancement with central stellate scar
• MRI: hypointense with central scar on T1; isointense with hyperintense scar on T2
• Treatment

• Nothing - no malignant potential, no bleeding risk

• Adenoma
• Rare, associated with OCP and androgen steroid use
• Malignant transformation in 10%
• Risk of rupture increases with size → 30% risk of spontaneous bleeding with tumors > 5 cm
• Can present with pain, abdominal fullness, abnormal LFTs, or bleeding from rupture
• Imaging
• CT: arterial enhancement with washout on portal phase; smooth surface with tumor capsule; no central scar
• MRI: mildly hyperintense on T1 and T2
• Treatment
• Small lesions → discontinue OCPs and it may regress
• Larger lesions (> 4 cm) or no regression after stopping OCPs → resect
• Ruptured → IR embolization, recover, then resect in elective setting Positive sulfur colloid uptake = functioning Kupffer cells → FNH Negative sulfur colloid uptake = absent Kupffer cells, from hepatocytes → adenoma

Figure 4 - Cross sectional imaging of benign hepatic lesions

• What are the features of hepatocellular carcinoma (HCC)?
• Risk factors (causes of liver inflammation)
• HBV, HCV, cirrhosis of any cause, inherited errors of metabolism (hemochromatosis, alpha 1 antitrypsin deficiency), aflatoxin
• CT scan: hypervascular lesions; hyperintense during arterial phase; hypodense during the delayed phase
• Characteristic lesion on imaging + elevated AFP = no biopsy needed
• Is there a role for PET/CT?
• No role in HCC

• What is the most common site of metastasis?

• Lung
• What is the management?
• Resection indicated for cure if solitary mass without major vascular invasion and adequate liver function (i .e . low grade with normal function or Childs A without portal hypertension)
• Resection is possible but controversial for limited major vascular invasion or multifocal disease that is resectable
• How much FLR (future liver remnant) is needed?
• No cirrhosis → 25%
• Childs A → 30-40%
• What if less than above but otherwise resectable disease?
• Consider preop portal vein embolization of diseased side
• No cirrhosis or Childs A and early stage → resection
• Moderate to severe cirrhosis and early stage → Transplant
• Must meet Milan criteria:
• One lesion < 5 cm
• 3 or fewer lesions all less than 3 cm and no gross vascular or extrahepatic spread

Figure 5 - Milan criteria

• Usually perform neoadjuvant chemotherapy prior to transplant
• Locoregional therapies should be considered in patients who are not candidates for surgical curative treatments, or as a bridge to curative therapy
• Ablation (radiofrequency, cryoablation, microwave) = best for small lesions < 5 cm
• Arterially directed therapies - transarterial chemoembolization (TACE)
• Consider for unresectable tumors > 5 cm
• External beam radiation therapy
• Also an option for unresectable disease
• Good for lesions not amenable to ablation or TACE due to tumor location
• What are the features of cholangiocarcinoma?
• Classified as intrahepatic or extrahepatic disease

• Risk factors (inflammation of bile ducts): primary sclerosing cholangitis, bile duct stones, choledochal cysts, liver fluke infections, HBV, HCV

• What is the management of intrahepatic cholangiocarcinoma?
• Preop biopsy is not necessary if radiographically and clinically suggested malignancy
• Diagnostic laparoscopy to rule out disseminated disease recommended
• Lymph node metastasis past porta hepatis and distant metastases contraindicate resection

• Multifocal liver disease is generally not amenable to resection Unlike hepatocellular carcinoma, transplantation is NOT an option for multifocal cholangiocarcinoma.

• Hepatic resection with negative margin is goal (formal anatomic resection, wedge resection, or segmental resection)
• What is the management of extrahepatic cholangiocarcinoma?
• Basic principle is complete resection with negative margins and regional lymphadenectomy
• Location is hilar, how do you resect?
• In order to be resectable, contralateral hemi-liver must have intact arterial/portal flow and biliary drainage uninvolved with tumor
• Reconstruction generally with Roux-en-Y hepaticojejunostomy
• Location is distal, how do you resect?
• Pancreaticoduodenectomy (Whipple)
• What are the features of gallbladder carcinoma?
• Risk factors: chronic inflammation, porcelain gallbladder (much lower risk than previously thought), polyps > 1 cm, typhoid infection, primary sclerosing cholangitis, IBD

• Many discovered incidentally at time of cholecystectomy for symptomatic gallbladder disease

• Surgical management
• T1a tumors (invades lamina propria) → cholecystectomy alone
• T1b and greater (invades muscle layer) → cholecystectomy with limited hepatic resection (typically segments IVb and V) and portal lymphadenectomy
• More extensive resection may be required for more advanced disease in order to obtain negative margins Quick Hits
• Patient with colorectal cancer and isolated liver metastasis receives neoadjuvant FOLFOX therapy, restaging shows complete radiologic response . Next step?
• Still perform hepatic resection as complete pathologic response is rare Same principle as rectal cancer that has clinically resolved after neoadjuvant
• Patient with asymptomatic cholelithiasis and a 5 mm gallbladder polyp . Next step?
• Cholecystectomy
• Risk of malignant transformation within gallbladder polyps has been linked to concurrent cholelithiasis → surgery recommended regardless of polyp size if concurrent stones
• Highest negative predictive value test for choledocholithiasis?
• GGT (beta-glutamyl transpeptidase) → normal GGT has 97% NPV
• How do you manage choledocholithiasis in patient with prior Roux-en-Y gastric bypass?

• Transgastric ERCP or advanced double-balloon endoscopy

• What is the significance of HCC found in young patient without cirrhosis?
• Fibrolamellar variant
• Better prognosis, recurrence is common
• Marker?
• Neurotensin
• Incidental finding of adenocarcinoma invading lamina propria layer of gallbladder following cholecystectomy . Next step?
• No further treatment → cholecystectomy alone is enough
• Incidental finding of adenocarcinoma following cholecystectomy . Next step?
• Stage
• Go back to OR for resection of segments IVb and V and portal lymphadenectomy
• Do you need to excise port sites?
• No benefit
• What is the significance of isolated gastric varices?
• Most commonly caused by splenic vein thrombosis secondary to pancreatitis
• Treatment = splenectomy
• Patient 4 weeks after hospitalization for car accident with liver laceration that was managed nonoperatively presents with upper GI bleed . Management?
• First step = EGD → you see blood coming from the duodenal papilla
• What is this?
• Hemobilia from hepatic artery-biliary duct fistula
• Treatment = angioembolization
• What segments do you take in a right liver resection?
• 5-8

• Left?

• 2-4 +/- caudate (1)
• Left lateral segmentectomy?
• 2-3
• Extended right?
• 5-8 + 4
• Extended left?
• 2-4 + 5 and 8

Figures