Eduovisual
Perioperative & Surgical Care
Hepatic resection: indications and complications
— Normal liver: FLR ≥20-25% of total liver volume
— Post-chemotherapy or steatotic liver: FLR ≥30%
— Cirrhotic liver: FLR ≥40%
— Hepatocellular carcinoma (HCC) in well-compensated cirrhosis (Child-Pugh A, no portal hypertension, bilirubin normal)
— Colorectal liver metastases (CRLM) — most common indication in the US; resection offers 5-yr survival 40-50%
— Intrahepatic cholangiocarcinoma, gallbladder cancer extension, hepatic adenoma >5 cm or symptomatic, neuroendocrine metastases, select benign lesions (giant hemangioma with symptoms), echinococcal cysts, hepatolithiasis, trauma
Step 3 management: Before referring for resection, obtain contrast-enhanced cross-sectional imaging (triple-phase CT or MRI), baseline LFTs, INR, platelets, AFP (HCC) or CEA (CRLM), and assess performance status. In cirrhotics, calculate MELD and Child-Pugh and screen for portal hypertension (platelets <100k, splenomegaly, varices, HVPG >10 mmHg are red flags).
Board pearl: A cirrhotic with HCC, portal hypertension, or bilirubin >1 mg/dL is better served by transplant or locoregional therapy (TACE, ablation), not resection.
— HCC: Often asymptomatic; surveillance-detected in cirrhotic patients. Late: RUQ pain, weight loss, decompensation (ascites, jaundice, variceal bleed), paraneoplastic hypoglycemia or erythrocytosis.
— CRLM: Found on staging CT at colorectal cancer diagnosis (synchronous) or on surveillance CEA rise/CT (metachronous).
— Hepatic adenoma: Young woman on OCPs; RUQ pain, occasionally rupture with hemoperitoneum and shock.
— FNH: Asymptomatic, found incidentally — does not require resection unless diagnosis uncertain or symptomatic.
— Hemangioma: Usually incidental; resect only if symptomatic and >5 cm.
— Echinococcal cyst: Travel/sheep/dog exposure, eosinophilia, calcified cyst with daughter cysts.
— Hepatitis B/C, alcohol use, NAFLD risk factors → cirrhosis assessment
— OCP, anabolic steroids → adenoma
— Prior colorectal cancer, breast, neuroendocrine → metastatic workup
— Chemotherapy history — oxaliplatin causes sinusoidal obstruction (blue liver), irinotecan causes steatohepatitis (yellow liver); both raise PHLF risk
— Functional status, cardiopulmonary comorbidities (major hepatectomy is a high-risk operation)
— Smoking, weight loss, prior abdominal surgery (adhesions)
Key distinction: FNH vs hepatic adenoma — both occur in young women, but FNH has a central scar on MRI, is hormone-independent, has no malignant or bleeding risk, and is observed. Adenoma is hormone-driven, can bleed (especially >5 cm) and undergo malignant transformation (β-catenin mutated subtype), and warrants OCP cessation ± resection.
Board pearl: A new liver mass in a cirrhotic that is >1 cm with arterial enhancement and venous/delayed washout on multiphase imaging is diagnostic of HCC — no biopsy needed (LI-RADS 5). Biopsy risks needle-track seeding.
— Jaundice, scleral icterus → contraindication to major resection
— Spider angiomata, palmar erythema, gynecomastia, testicular atrophy
— Caput medusae, splenomegaly, ascites → portal hypertension, generally precludes resection
— Asterixis, fetor hepaticus → overt encephalopathy, absolute contraindication
— Muscle wasting, sarcopenia → independent predictor of post-op mortality
— Hepatomegaly, palpable mass, RUQ tenderness
— Bruit over the liver suggests HCC vascularity or AV malformation
— Friction rub with subcapsular tumor
— Shifting dullness, fluid wave → ascites
— Tense, distended abdomen with peritoneal signs in ruptured adenoma or HCC = surgical emergency
— Ruptured hepatic adenoma or HCC → hemorrhagic shock (hypotension, tachycardia, peritonitis). Resuscitate, transfuse, angiographic embolization first, then delayed resection when stable.
— Cirrhotics often run baseline low SVR, high cardiac output, low normal BP — masks early hemorrhage.
CCS pearl: A patient with a known liver mass who presents with sudden RUQ pain, hypotension, and a drop in hematocrit → order stat type & cross, 2 large-bore IVs, NS bolus, CT angiography of abdomen/pelvis, surgery and IR consults. Bleeding hepatic adenoma is the classic Step 3 vignette in a young woman on OCPs.
Board pearl: Bilirubin, ascites, and encephalopathy — even subtle findings — disqualify Child-Pugh B/C patients from major resection regardless of how technically resectable the tumor appears.
— CBC — thrombocytopenia <100k suggests portal hypertension and hypersplenism
— CMP — bilirubin, AST/ALT, alk phos, albumin (synthetic function), creatinine
— INR/PT — synthetic function; elevated INR is a Child-Pugh and MELD component
— Hepatitis B surface Ag, anti-HBc, anti-HCV — etiology of underlying liver disease; HBV+ patients need antiviral suppression before and after resection
— Tumor markers: AFP (HCC — >400 ng/mL is highly suggestive), CEA (CRLM, baseline and trend), CA 19-9 (cholangiocarcinoma), chromogranin A (NET)
— Type and screen, coagulation profile
— Multiphase contrast-enhanced CT (arterial, portal venous, delayed) of abdomen/pelvis — characterizes the lesion and defines vascular anatomy (hepatic artery, portal vein, hepatic veins, IVC relationship)
— MRI with hepatobiliary contrast (gadoxetate/Eovist) — superior for small lesions, CRLM characterization, and distinguishing FNH (retains contrast in delayed phase) from adenoma (does not retain)
— Chest CT for metastatic staging in malignancy
Step 3 management: In a cirrhotic with a new hepatic nodule on screening US, obtain multiphase CT or MRI for LI-RADS classification:
— LR-5 (≥1 cm + arterial hyperenhancement + washout + capsule) = HCC, no biopsy
— LR-3/4 = follow-up imaging
— LR-M = probably non-HCC malignancy → biopsy
Board pearl: In CRLM, PET-CT is added when extrahepatic disease is suspected or to clarify equivocal lesions, but routine PET does not change management in clearly resectable disease per current NCCN guidance. Always image the chest before liver resection for any malignancy.
— Child-Pugh score — bilirubin, albumin, INR, ascites, encephalopathy. Class A required for major resection.
— MELD score — MELD ≥9-10 predicts increased post-op mortality; MELD >15 generally precludes resection.
— Indocyanine green (ICG) retention test at 15 minutes — used in Asian centers; ICG-R15 <14% supports major hepatectomy
— HVPG (hepatic venous pressure gradient) — gold standard; >10 mmHg = clinically significant portal hypertension, contraindicates resection. Surrogates: platelets <100k + splenomegaly, or varices on EGD.
— HCC: biopsy NOT required if LI-RADS 5 imaging in a cirrhotic — risks seeding and bleeding
— CRLM: Diagnosis usually inferred from known primary; biopsy if atypical or solitary lesion without known primary
— Indeterminate mass: Core needle biopsy under image guidance
— ECG, echocardiogram if cardiac history or major resection planned
— PFTs in smokers or COPD
— CPET (cardiopulmonary exercise testing) — VO2 max <12 mL/kg/min predicts high perioperative mortality
Key distinction: HCC requires confirmation of preserved liver function before resection (Child A, no portal HTN, normal bilirubin); CRLM resection is limited primarily by FLR adequacy and extrahepatic disease, since the underlying liver is usually healthy.
Board pearl: EGD for varices is part of pre-op workup in any cirrhotic. Significant varices = portal hypertension = no resection.
— Very early (0): Single <2 cm, Child A → resection or ablation
— Early (A): Single <5 cm or up to 3 lesions <3 cm, Child A-B → resection (if no portal HTN, bilirubin normal), transplant (Milan criteria), or ablation
— Intermediate (B): Multinodular, preserved function → TACE
— Advanced (C): Vascular invasion or extrahepatic spread → systemic therapy (atezolizumab + bevacizumab first-line)
— Terminal (D): Child C, poor performance → best supportive care
— Resectable + healthy liver + no extrahepatic disease → resection ± perioperative chemotherapy (FOLFOX)
— Borderline resectable: Conversion chemotherapy (FOLFOX/FOLFIRI ± biologic) → reassess
— Synchronous CRLM: Sequence varies — liver-first, classic (colon-first), or simultaneous depending on symptoms and tumor biology
— 5-year survival after R0 resection: 40-50%
— Hepatic adenoma >5 cm, β-catenin mutated, or symptomatic → resect; <5 cm → stop OCP, observe with imaging
— FNH → no resection unless diagnostic uncertainty
— Symptomatic giant hemangioma → resect
Step 3 management: A cirrhotic with a 3 cm HCC, Child A, no portal hypertension, normal bilirubin, and adequate FLR is a resection candidate. The same patient with platelets 70k, splenomegaly, and small varices is a transplant candidate (within Milan: single ≤5 cm or up to 3 ≤3 cm).
Board pearl: Transplant trumps resection for HCC with any portal hypertension because it treats both the tumor and the underlying cirrhosis. MELD exception points are granted for HCC within Milan criteria.
CCS pearl: Document multidisciplinary tumor board review before scheduling hepatic resection for any malignancy — Step 3 favors this answer.
— HBV antiviral suppression: All HBV-positive patients undergoing resection or chemotherapy need entecavir or tenofovir to prevent reactivation, started before surgery and continued long-term
— HCV: Direct-acting antivirals before or after resection per hepatology
— Stop hepatotoxic and bleeding-risk agents: OCPs in adenoma; warfarin bridged per protocol; DOACs held 48 hours; aspirin often continued for cardiac indications; clopidogrel held 5-7 days
— Beta-blocker continuation for cardiac patients; resume early post-op
— Nutritional optimization: Albumin, prealbumin; immunonutrition (arginine, omega-3) for 5-7 days pre-op in malnourished patients
— Low CVP anesthesia (CVP <5 mmHg) reduces hepatic venous backbleeding during parenchymal transection
— Pringle maneuver — clamping of porta hepatis for inflow control, 15 min on / 5 min off
— Avoid hetastarch (renal/coagulopathy risk); use balanced crystalloid
— Cefazolin within 60 min of incision; redose every 4 hours intra-op; add metronidazole if biliary anastomosis
— Mechanical SCDs intra-op; chemical prophylaxis (LMWH or UFH) starting 24-48 hours post-op balancing bleeding risk. Cirrhotics are NOT auto-anticoagulated despite elevated INR — they have rebalanced hemostasis and remain at VTE risk.
— Multimodal opioid-sparing: Acetaminophen (cap 2-3 g/day in liver patients), gabapentin, epidural or TAP block, low-dose opioids
— Avoid NSAIDs — bleeding, AKI, and hepatic stress
Board pearl: HBV reactivation during or after hepatectomy/chemo can be fatal. Always check HBsAg and anti-HBc and start nucleos(t)ide analog prophylaxis before treatment in any positive patient.
Step 3 management: Acetaminophen is safe in cirrhotics at ≤2 g/day, but NSAIDs are contraindicated due to renal and bleeding risk.
— Anatomic: Removes a Couinaud segment or section along vascular boundaries — preferred for HCC (microvascular invasion theory)
— Non-anatomic (wedge): Margin-preserving — preferred for CRLM to maximize parenchymal sparing
— Right hepatectomy: Segments 5-8 (~60% volume)
— Left hepatectomy: Segments 2-4
— Right trisectionectomy: Segments 4-8 (~75% volume) — high PHLF risk
— Left lateral sectionectomy: Segments 2-3
— Segmentectomy, bisegmentectomy for limited disease
— Open — large or complex resections, central lesions, vascular reconstruction
— Laparoscopic — increasingly standard for left lateral and minor resections (Louisville/Southampton consensus)
— Robotic — expanding role for posterior segments and major resections
— Minimally invasive approaches show lower blood loss, shorter LOS, fewer complications in selected cases
— Intraoperative ultrasound (IOUS) — mandatory; finds occult lesions, guides transection plane, defines vascular anatomy
— Parenchymal transection: CUSA, harmonic scalpel, stapler
— Inflow occlusion (Pringle) for hemorrhage control
— Total vascular exclusion for IVC or hepatic vein involvement
— PVE then resection 4-6 weeks later when FLR hypertrophies
— ALPPS for rapid hypertrophy in 7-14 days
— Liver-first approach in synchronous CRLM with asymptomatic primary
CCS pearl: Intra-operative orders that score well on CCS hepatectomy cases: type & cross 4 units PRBC, FFP available, central line, arterial line, foley, SCDs, prophylactic cefazolin, intra-op US, low CVP anesthesia communicated to anesthesia.
Board pearl: For HCC in a non-cirrhotic (e.g., fibrolamellar variant in young patients, HBV without cirrhosis), aggressive resection is appropriate as the liver tolerates major hepatectomy well — fibrolamellar HCC has the best prognosis of HCC subtypes.
— Age alone is not a contraindication — physiologic age matters more than chronologic
— Higher rates of cardiopulmonary complications, delirium, prolonged LOS
— Comprehensive geriatric assessment: frailty (Fried criteria, gait speed), cognition (Mini-Cog), polypharmacy, functional status
— Prehabilitation (4-6 weeks of exercise + nutrition + psychological support) improves outcomes
— Lower threshold for ICU recovery, delirium prevention bundles, early mobilization
— Consider minor resections, MIS approaches, and avoiding extended resections
— Child-Pugh A, MELD <9, no portal hypertension, normal bilirubin = resection candidate
— Child-Pugh B = high mortality; consider TACE, ablation, or transplant
— Child-Pugh C = absolute contraindication
— Portal hypertension (HVPG >10, platelets <100k + splenomegaly, varices) = contraindication to major resection; minor wedge resection of peripheral HCC may be considered selectively
— Adjust drug dosing; avoid sedatives that precipitate encephalopathy
— Pre-existing CKD increases post-op AKI risk
— Contrast-induced nephropathy: hydrate, minimize contrast load, gadolinium caution if eGFR <30 (NSF risk)
— Avoid nephrotoxins: NSAIDs, aminoglycosides
— Adjust LMWH (enoxaparin) dosing in CrCl <30
Step 3 management: A 78-year-old with a 4 cm CRLM, ECOG 1, normal LFTs, well-controlled HTN and DM is a resection candidate. Order prehabilitation, nutrition consult, cardiology clearance with stress echo if indicated, and proceed with minimally invasive approach if anatomically feasible.
Board pearl: Sarcopenia on CT psoas measurement independently predicts post-hepatectomy mortality — a modifiable target via nutrition and resistance training.
— Elective hepatic resection should be deferred until postpartum whenever possible
— Ruptured hepatic adenoma in pregnancy is a surgical emergency — estrogen-driven enlargement increases rupture risk in 3rd trimester; angioembolization preferred if stable, resection if uncontrolled bleeding
— HCC in pregnancy: rare; multidisciplinary management with MFM and surgical oncology; second-trimester resection feasible
— Imaging: US first, MRI without gadolinium second; avoid CT/ionizing radiation
— Hepatoblastoma — most common pediatric liver tumor (<3 yrs); elevated AFP; treated with neoadjuvant cisplatin-based chemo followed by resection or transplant per PRETEXT staging
— Pediatric HCC — older children, often HBV-related
— Mesenchymal hamartoma, hemangioendothelioma — benign lesions, resect if symptomatic
— Pediatric livers regenerate exceptionally well
— Healthy adult donates right or left lobe for transplant recipient
— Donor mortality 0.2-0.5%; ethics committee review mandatory
— Donor must have FLR ≥30-35%
— Endemic exposure history (Mediterranean, Middle East, South America)
— Albendazole pre-op and post-op to reduce recurrence
— Surgery: pericystectomy or formal resection; avoid spillage (anaphylaxis, dissemination); inject scolicide (hypertonic saline) into cyst before opening
— Blunt liver injury managed nonoperatively in 80-90% if hemodynamically stable
— Indications for resection: ongoing hemorrhage, devitalized parenchyma, bile duct disruption — typically damage-control packing first, definitive resection later
Key distinction: Hepatoblastoma (AFP markedly elevated, young child) vs hepatocellular carcinoma (older child, HBV/cirrhosis-associated) — both pediatric primary liver malignancies but distinct biology, staging (PRETEXT), and chemo regimens.
Board pearl: OCP cessation in hepatic adenoma can shrink lesions <5 cm; counsel against future hormonal contraception and pregnancy until lesion stable.
— On post-op day 5: bilirubin >2.9 mg/dL AND INR >1.7
— ISGLS grading: A (no change in management), B (deviation, no invasive treatment), C (invasive treatment, ICU)
— Risk factors: inadequate FLR, cirrhosis, steatosis, chemo-associated liver injury
— Treatment: supportive care, N-acetylcysteine, manage coagulopathy, dialysis, rescue transplant in selected cases
— Incidence 5-10%; ISGLS grade A-C
— Presents with bilious drain output, fever, RUQ pain
— Management: percutaneous drainage + ERCP with stent/sphincterotomy
— Intra-op blood loss is the strongest predictor of morbidity
— Post-op bleeding: hemodynamic instability, drop in Hgb → angiography ± embolization, return to OR if unstable
— Surgical site infection, intra-abdominal abscess, pneumonia, line sepsis, C. difficile
— Abscess: percutaneous drainage + culture-directed antibiotics
CCS pearl: POD 5 patient with rising bilirubin (4.2), INR 2.1, encephalopathy, oliguria → PHLF. Orders: ICU transfer, hepatology consult, NAC infusion, lactulose, broad-spectrum antibiotics, replace coagulation factors as needed for bleeding, evaluate for transplant.
Board pearl: Volume-outcome relationship is well-established for hepatectomy — refer to high-volume centers (>20 hepatectomies/year) to halve mortality.
— Minor resection (<3 segments, MIS): step-down or floor with telemetry
— Major resection (≥3 segments, open): ICU x 24-48 hours at most centers, especially with cirrhosis or comorbidities
— Hemodynamic instability or vasopressor requirement
— Respiratory failure / need for mechanical ventilation
— Rising bilirubin + INR (PHLF concern)
— Encephalopathy, asterixis, altered mental status
— Oliguria, AKI requiring CRRT
— Coagulopathy with bleeding
— Sepsis from intra-abdominal source
— Hepatology for PHLF, encephalopathy, ascites management
— Interventional radiology for bile leak drainage, hemorrhage embolization, biloma drain
— GI/ERCP for biliary stricture, bile leak stenting
— Infectious disease for complex intra-abdominal infections, fungal, or resistant organisms
— Transplant surgery for rescue liver transplant evaluation in PHLF
— Nutrition for parenteral nutrition needs, refeeding syndrome risk
— Palliative care for advanced disease or poor prognosis
— Tachypnea, hypoxia, hypotension, oliguria, altered mental status, new arrhythmia
— Increased drain output (especially bilious or bloody)
— Uncontrolled pain suggesting complication
Step 3 management: Post-op day 3 patient with fever 39°C, rising WBC, bilious drainage 400 mL/day from drain, RUQ pain → CT abdomen/pelvis with IV contrast, broad-spectrum antibiotics (piperacillin-tazobactam), IR drainage of biloma, ERCP with biliary stent to decompress and seal leak. Continue drain until output <50 mL/day.
CCS pearl: Always document goals of care and code status on admission and re-address before any escalation in a patient with metastatic or advanced disease.
Board pearl: ERAS (Enhanced Recovery After Surgery) protocols for hepatectomy reduce LOS and complications — early feeding, opioid-sparing, early mobilization, no routine NG tubes.
— HCC — cirrhotic background, arterial enhancement + washout, AFP elevation
— Intrahepatic cholangiocarcinoma — peripheral, delayed enhancement, CA 19-9 elevation, biliary dilation
— Mixed HCC-CCA — features of both, poor prognosis
— Metastases — most common malignant lesion overall; multiple, peripheral enhancement; colorectal #1, then breast, lung, melanoma, NET
— Hepatic lymphoma, sarcoma, angiosarcoma — rare
— Fibrolamellar HCC — young, non-cirrhotic, central scar, normal AFP — distinguishes from typical HCC
— Hemangioma — most common benign lesion; T2 hyperintense, peripheral nodular enhancement with centripetal fill-in
— FNH — central scar, hepatobiliary contrast retention, female, no malignant potential
— Hepatic adenoma — OCP/steroid use, β-catenin subtype risk for malignancy, bleeding risk >5 cm
— Simple cyst — anechoic, thin-walled, no septations
— Polycystic liver disease — often with ADPKD
— Biliary cystadenoma/cystadenocarcinoma — septations, mural nodules → resect
— Echinococcal cyst — daughter cysts, calcifications, exposure history
— Pyogenic or amoebic abscess — fever, leukocytosis, recent travel
Key distinction: FNH vs adenoma on MRI with hepatobiliary contrast — FNH retains contrast (functioning hepatocytes connected to bile ducts), adenoma does not. This single feature changes management from observation to resection.
Board pearl: A liver lesion in a non-cirrhotic adult is much more likely to be benign (hemangioma, FNH) than malignant — but in a cirrhotic, assume HCC until proven otherwise.
Step 3 management: For an indeterminate solid lesion, the next step is usually MRI with hepatobiliary contrast, not biopsy.
— Hepatic abscess (pyogenic, amoebic, fungal) — fever, leukocytosis, exposure history; managed with percutaneous drainage + IV antibiotics (or metronidazole for amoebic), NOT resection
— Inflammatory pseudotumor — mimics malignancy on imaging; biopsy clarifies
— Focal fatty infiltration / focal fatty sparing — geographic, no mass effect, no enhancement — non-surgical
— Hematoma — recent trauma or anticoagulation history
— Sarcoidosis, TB granulomas — multiple small nodules, systemic features
— Caroli disease — saccular intrahepatic bile duct dilation, recurrent cholangitis; may require resection if localized to one lobe
— Right adrenal mass (pheochromocytoma, adenoma) abutting liver
— Subdiaphragmatic abscess
— Duodenal or pancreatic mass invading liver
— Diaphragmatic hernia with herniated viscera
— Gallbladder mass extending into liver bed
— Budd-Chiari syndrome — hepatic venous outflow obstruction; presents with ascites, hepatomegaly; not a resection target — needs anticoagulation, TIPS, or transplant
— Portal vein thrombosis — alters operative approach; cavernous transformation may be a contraindication
— Hemochromatosis, Wilson disease, autoimmune hepatitis — underlying cirrhosis changes resection candidacy
Key distinction: Pyogenic liver abscess vs necrotic tumor — both can appear as a complex cystic lesion. Abscess: fever, leukocytosis, positive blood cultures (often Klebsiella in Asian populations, associated with colon cancer in Western populations — colonoscopy required). Tumor: stable systemic findings, tumor markers, pattern over time.
Board pearl: A Klebsiella pneumoniae liver abscess in a Western patient mandates colonoscopy to rule out colorectal cancer — strong association.
Step 3 management: Don't operate on what you can drain. Suspected abscess → diagnostic aspiration, drain, culture, antibiotics — not resection.
— Acetaminophen ≤2-3 g/day for pain; taper opioids quickly
— DOAC or LMWH for VTE prophylaxis — continue 28 days post-op for malignancy resection per ASCO/ASH guidelines
— HBV antiviral continuation (entecavir/tenofovir) — long-term in HBV+ patients
— Statin continued or initiated per ASCVD indications — no liver-related contraindication
— Resume home cardiac, antihypertensive, antidiabetic meds
— Discontinue OCPs in adenoma patients permanently
— PPI only if indicated (no routine prophylaxis after first week)
— Stool softener while on opioids
— CRLM: Adjuvant FOLFOX x 6 months post-resection if no neoadjuvant given; perioperative chemo (3 mo before + 3 mo after) is alternative
— HCC: No proven adjuvant chemo; atezolizumab + bevacizumab under investigation for high-risk patients (IMbrave050)
— Cholangiocarcinoma: Adjuvant capecitabine x 6 months (BILCAP trial)
— HCC post-resection: Triphasic CT or MRI + AFP every 3-6 months for 2 years, then every 6-12 months. Recurrence rate 50-70% at 5 years.
— CRLM post-resection: CEA every 3-6 months, CT chest/abd/pelvis every 6 months x 2 years, then annually; colonoscopy at 1 year
— Cirrhosis surveillance continues: US + AFP every 6 months
— Abstain from alcohol (mandatory in cirrhotics, recommended in all)
— Hepatitis A/B vaccination if non-immune
— Weight management, treat NAFLD
— Smoking cessation
Step 3 management: Start adjuvant FOLFOX 4-8 weeks after CRLM resection once recovered. Delay >12 weeks loses survival benefit.
Board pearl: AFP that fails to normalize after HCC resection predicts residual disease — short-interval re-imaging required.
— Surgery clinic at 2 weeks — wound check, drain removal, pathology review, pain assessment
— Surgery clinic at 6 weeks — full recovery assessment, return to activity, hernia surveillance
— Oncology follow-up at 4-6 weeks for adjuvant therapy planning in malignancy
— Hepatology at 4-6 weeks for cirrhotic patients — restage liver function
— LFTs at 2 and 6 weeks — expect mild elevation that normalizes; persistent elevation suggests biliary stricture or recurrence
— CBC, CMP, INR for synthetic function recovery
— Tumor markers at baseline post-op (should normalize) and per surveillance schedule
— Imaging at first surveillance visit (3 months) to establish new baseline
— No lifting >10 lbs for 6 weeks (open); 2-4 weeks (laparoscopic)
— Walking encouraged from POD 1
— Driving when off opioids and able to brake forcefully (usually 2-3 weeks)
— Return to desk work 2-4 weeks; manual labor 6-8 weeks
— Sexual activity when comfortable
— Air travel typically safe at 2 weeks
— High-protein diet to support regeneration (1.2-1.5 g/kg/day)
— Adequate caloric intake; small frequent meals
— Avoid alcohol permanently in cirrhotics
— Multivitamin; replete fat-soluble vitamins (ADEK) in cholestatic patients
— Screen for post-operative depression and anxiety, especially in cancer patients
— Cancer survivorship resources, support groups
— Caregiver burden assessment
CCS pearl: A patient at 2-week follow-up with persistent right shoulder pain and low-grade fever after right hepatectomy → suspect subphrenic abscess or pleural effusion → order CT abdomen/chest, drain if confirmed.
Step 3 management: DEXA scan and bone health are not routine after hepatectomy, but cirrhotics have higher osteoporosis risk — screen if other risk factors present.
Board pearl: Failure to gain back weight or persistent fatigue at 6 weeks warrants workup for anastomotic stricture, recurrence, or depression — don't dismiss as "expected recovery."
— Disclose mortality (1-5% routine, up to 10% in cirrhosis), bile leak, hemorrhage, PHLF, infection, VTE, need for transfusion, possible conversion from MIS to open, possibility of unresectability discovered intra-op
— Discuss alternatives: ablation, TACE, transplant, systemic therapy, observation
— In oncology cases, discuss realistic outcomes — 5-year survival rates, recurrence risk
— Use teach-back to confirm understanding; document
— Resection in borderline candidates (Child B, marginal FLR, advanced age with frailty) requires careful shared decision-making
— Multidisciplinary tumor board review is the standard — Step 3 strongly favors this answer
— Avoid futile surgery — document goals of care
— Independent donor advocate required
— Donor must be free to withdraw at any time
— Full disclosure of donor mortality (~0.2-0.5%) and morbidity
— Psychiatric evaluation to assess voluntariness, freedom from coercion
— Hand-off from inpatient to outpatient is the highest-risk window — medication reconciliation errors, missed drain removals, lost pathology results
— Schedule follow-up before discharge, send discharge summary to PCP within 48 hours, ensure imaging and labs are ordered
— Confirm patient understanding of red-flag symptoms (fever, jaundice, bleeding, increasing drain output)
— Universal Protocol (time-out) confirming patient, procedure, site, and laterality
— Surgical Care Improvement Project (SCIP) measures: timely antibiotics, normothermia, VTE prophylaxis, glucose control
— Specimen labeling — wrong-specimen errors can lead to wrong diagnosis
— Post-op handoff using structured tool (SBAR, I-PASS)
Step 3 management: A patient with metastatic CRLM and limited remaining options requests "everything possible." The right answer: explicitly explore goals of care, prognosis, and quality of life with palliative care consultation rather than offering high-risk resection without benefit.
Board pearl: Wrong-site liver surgery is rare but devastating — IOUS confirmation of lesion location before transection is now standard practice and a tested patient-safety concept.
Board pearl: The single most common Step 3 question on hepatic resection tests resection vs transplant decision-making in HCC — memorize the BCLC algorithm and Milan criteria.
Key distinction: Cirrhotic with HCC → check portal hypertension and bilirubin to decide resection vs transplant.
"55 yo M with HCV cirrhosis, Child A, platelets 180k, no varices on EGD, bilirubin 0.9, has a single 3 cm HCC in segment 6. AFP 250. Next step?"
→ Surgical resection (preserved function, no portal HTN, normal bilirubin)
→ Distractor: transplant (reserved for portal HTN or worse function), TACE (multinodular/intermediate), ablation (small <2 cm)
"62 yo with NASH cirrhosis, platelets 75k, splenomegaly, small esophageal varices, single 4 cm HCC."
→ Liver transplantation (within Milan criteria + portal HTN precludes resection)
"58 yo s/p sigmoid resection for stage III CRC, 18 months later CEA rises to 45, CT shows 2 liver lesions in right lobe, no extrahepatic disease. Next step?"
→ Multidisciplinary evaluation for hepatic resection ± perioperative chemotherapy
"26 yo F on OCPs for 8 years, RUQ pain, CT shows 6 cm hypervascular lesion not retaining hepatobiliary contrast on MRI. Next step?"
→ Stop OCPs, surgical resection (>5 cm, bleeding/malignancy risk)
"POD 5 after right hepatectomy, bilirubin 4.1, INR 2.0, encephalopathic, oliguric. Diagnosis?"
→ Post-hepatectomy liver failure (50-50 criteria); supportive care, transplant evaluation
"POD 4, fever, RUQ pain, drain output 500 mL bilious fluid, total bilirubin in drain >3x serum. Next step?"
→ Continue drainage + ERCP with biliary stent
"65 yo with K. pneumoniae liver abscess, no diabetes, US drained. Next step beyond antibiotics?"
→ Colonoscopy to rule out colorectal cancer
"Patient has resectable right lobe HCC but FLR calculated at 18% of total liver volume. Next step?"
→ Portal vein embolization to induce left lobe hypertrophy, then resect 4-6 weeks later
"HBsAg+ patient about to undergo hepatectomy for HCC. Which medication?"
→ Entecavir or tenofovir prophylactically
Board pearl: Step 3 stems often test the next best step rather than diagnosis — the question is rarely "what is it" and usually "what do you do now."
Step 3 management: When in doubt on a complex hepatic resection vignette, "refer to multidisciplinary hepatobiliary tumor board" is rarely wrong.
Hepatic resection is the curative-intent option for selected primary and metastatic liver tumors in patients with preserved hepatic function, adequate future liver remnant, and no extrahepatic or vascular disease — its success hinges on choosing the right patient, optimizing the right lobe, and recognizing complications early.
Board pearl: The most common Step 3 hepatobiliary stem asks resection vs transplant in HCC — answer hinges on portal hypertension, bilirubin, and Child-Pugh class.