Assessment of hepatic reserve for indication of hepatic resection: how I do it.
The perioperative outcome of hepatic resection has improved remarkably in recent years with improved surgical techniques and perioperative care. As a result, the indications of hepatic resection have been extended to include patients with borderline liver function, especially those with associated cirrhosis. For such patients, proper preoperative assessment of liver function reserve is essential to ensure a low incidence of postoperative liver failure and mortality. In our center, routine preoperative assessment of hepatic function reserve in all patients includes clinical assessment, liver biochemistry, coagulation profile, platelet count, and Child-Pugh classification. The indocyanine green clearance test is routinely performed for patients with chronic liver disease. For patients with cirrhosis undergoing major hepatectomy, computed tomography volumetry and laparoscopy are helpful in evaluating whether the remnant liver volume is adequate. In selected patients with small remnant liver, preoperative portal vein embolization can be employed to induce hypertrophy of the remnant liver even in the presence of chronic hepatitis and mild cirrhosis. Careful assessment of comorbid conditions of patients and meticulous surgical techniques to reduce bleeding and hypoxic injury to the remnant liver are complementary to the selection of patients with adequate liver function reserve, to minimize operative mortality.