In many pediatric centers, major hepatic resections are increasingly being performed by transplant surgeons or surgeons who care for adults. This undoubtedly results in fewer pediatric surgeons having the experience and training to perform the operations, which in turn results in more referrals to the transplant surgeons. Though obviously one should always take the path that is safest for the child given the resources available at one’s institution, the best way for pediatric surgeons to maintain their preeminence in this field is to continue to demonstrate that we can perform these operations safely and achieve excellent outcomes. This demands careful preoperative planning, meticulous technique, and attention to every detail of the operation and postoperative care.
Modern three-dimensional imaging allows us to define the vascular anatomy of the liver with a great deal of precision, and for any segmental or nonanatomic liver resection (anything more than a simple wedge biopsy) the surgeon should insist on having a CTA or MRA before going to the operating room. This is especially important when the indication for resection is a tumor, for which a well-done major resection can be for naught if the margin is inadequate or a second nodule is left behind. It is also important to understand whether the liver is healthy or cirrhotic to be sure that what remains will be able to regenerate.
Intraoperatively, the child should be carefully monitored, preferably with an indwelling arterial line and a central venous catheter. There is still no safe way to perform a liver resection through a tiny incision and a generous bilateral subcostal incision can mean the difference between a safely performed operation and an intraoperative disaster. The entire liver should be mobilized and all vessels, including the suprahepatic and infrahepatic IVC, the portal vein, and the hepatic artery should all be dissected and controlled with vessel loops or ties. For most major resections, the extrahepatic biliary anatomy should be defined as well, often starting with a cholecystectomy as a point of reference. Blood loss is minimized by ligating all vessels supplying or draining the segment to be removed, which sometimes entails dissecting out second-order branches of the portal vein and hepatic artery within the liver parenchyma. Control of the major hepatic branches can be difficult and whether it is safe to pursue this in a given operation is a matter of judgment. How to come across the liver parenchyma is a matter of preference and experience. The harmonic scalpel works well, though bile duct branches and larger vessels need to be recognized early and ligated individually. The parenchyma just beneath the liver capsule is usually more compact and less vascular for a depth of about a centimeter or two and this “rind” can be incised first with the electrocautery, exposing the deeper “pulp” of the liver where the larger vessels reside. After resection, bleeding from the raw surface of the liver is controlled with the argon beam coagulator and precise placement of absorbable figure-of-eight sutures as needed. Application of fibrin sealant is now customary, while the routine placement of drains is no longer considered obligatory.
Initial postoperative care should take place in the PICU, though most healthy children recover uneventfully. Much is made of the need to have plenty of phosphate substrate available to the regenerating liver, but this is rarely a significant issue if the child is provided adequate nutrition before and after the operation. Complete regeneration of the liver in a child with healthy liver parenchyma can occur within a few weeks of a major hepatic resection.