When possible, and particularly in patients with no prior abdominal operations and peripheral liver lesions, minimally invasive surgical techniques should be employed. Use of laparoscopic techniques for resection or ablation has become the standard of care for small (<5 cm) peripheral lesions [33]. Several groups have proven that minimally invasive surgery is safe in patients with mild liver disease [34].

Anticipating and preparing for problems that can arise when operating on cirrhotics is half the battle of a successful resection. Close communication with the anesthesia team in the perioperative setting is critical. We do not recommend use of a central line, but do require two large bore IVs as well as an arterial line in cases where high blood loss is possible. It is critical that central venous pressure (CVP) be maintained at or below 5 mmHg until parenchymal transection is complete [35–37]. Restrictive transfusion policies can also be of benefit, and these along with blood product resuscitation protocols should be established with anesthesia colleagues in advance of the surgery [38]. Some of the more challenging aspects of surgery in cirrhotics and ways to combat them are listed in Table 12.2. Generally, surgeons should be prepared for robust collateral veins in unexpected locations with the propensity toward vigorous bleeding secondary to increased portal pressure. The more prominent collaterals are often visible on preoperative imaging. However, meticulous dissection techniques should be employed at all points of dissection in order to avoid vascular injury.

Regarding abdominal entry, standard port placements for left and right robotic and laparoscopic hepatectomies have been described at length [39, 40]. When comparing open with laparoscopic resections in a case-matched study of patients with CLD, one group found that major complications were observable but not significantly more common in the open group, while there was no difference in margin status or long-term survival [34]. For open procedures, the authors generally prefer a so-called inverse L-shaped incision with the option to carry the incision to the left and make a so-called mercedes incision if needed. In cirrhotic patients, great care must be taken to ligate or preserve if possible any recanalized umbilical veins.

In terms of parenchymal transection, some authors advocate use of ultrasonic dissector combined with bipolar electrocautery in cirrhotics [41]. While others note that a less tedious method involves precoagulation and a combination of vascular sealing devices and staplers for larger vessels [42]. In practice, laparoscopically, the authors utilize cautery to enter Glisson’s capsule, and then the laparoscopic LigaSure is used for crush-clamp, sealing, and cutting (Covidien, Minneapolis, MN), with intermittent use of staplers as needed for larger vessels for the vast majority of patients. If a liver is particularly fibrotic, crush-clamp techniques are not as useful and can result in excessive trauma. In these instances, a combination of blunt and thermal dissection techniques is utilized, and a harmonic endoshear device is utilized. The laparoscopic argon beam coagulator is used to obtain hemostasis and biliary stasis from the cut liver’s edge. Of note, both laparoscopically and robotically, Weck clips are utilized rather than metal ones in order to facilitate continued use of vessel-sealing devices. Robotically, the authors utilize similar technique, except that we are able to employ the robotic vessel sealer and stapler tools for added flexibility. For open hepatic resections, the authors employ a combination of crush-clamp and impact LigaSure (Covidien, Minneapolis, MN) for parenchymal transection. Larger vessels are divided with a stapler. When suturing for bleeding, the authors encourage use of silk material, as it does not melt when in contact with thermal cautery or other thermal vascular control agents.

With regard to hilar vascular occlusion (aka the Pringle maneuver), some authors recommend little to no vascular clamping in cirrhotics. Most acknowledge that some cases mandate use of vascular occlusion but that the time should be limited in patients with cirrhosis again to optimize postoperative liver function. Use of intermittent versus continuous clamping has been analyzed by many different authors who have reached disparate conclusions. However, the general consensus is that in terms of morbidity and mortality, there is no difference between the two techniques [37, 43]. That being said, few studies have looked at this issue specifically in cirrhotics.

The authors do not use drains following liver resection as they have been shown in multiple studies to result in increased infectious complications [44]. This remains true in resections of cirrhotics [45]. Should an infected biloma develop postoperatively, our preference is to perform interventional radiology-guided drainage. There is minimal controversy in the literature regarding drain placement following minor resections of noncirrhotic livers; however, there exists some disagreement in the data when cirrhotics with demonstrable preoperative portal hypertension [46]. The authors reserve drain placement for extremely rare occasions such as hepaticojejunostomy creation to tenuous secondary or tertiary radicles.

Increased rates of postoperative morbidity following liver resections in cirrhotics are typically attributed more to poor patient protoplasm than to surgical technique. Cirrhotics have more comorbidities and are at higher risk for POLF and thereby postoperative mortality, more especially following major hepatectomy [42, 47]. POLF is an insidious problem that can result in a frustrating and terrifying march toward postoperative mortality. Because POLF following resection for malignancy can inherently not be remedied with liver transplantation, identification of patients at risk for such a course, and then making every effort to maintain perfusion and biliary continuity in the liver remnant, is critical. Several systems have been developed to identify patients who are on a course toward POLF, the most prominent of which are the so-called 50–50 criteria and the International Study Group of Liver Surgery (ISGLS) criteria [30, 47]. The 50–50 criteria state that patients with bilirubin >50 μmol/L and prothrombin time <50% (INR > 1.7) on postoperative day (POD) 5 have a mortality risk exceeding 50% after hepatectomy [47]. Subsequent prospective validation of the 50–50 criteria has verified this and adds that patients meeting 50–50 criteria on POD 3 are also at high risk for mortality [48]. The ISGLS also utilizes liver function derangements on POD 5 as a guide and further classifies POLF into grades A, B, and C. Risk factors for postoperative mortality taking all comers include meeting the 50–50 criteria, age over 65 years, and presence of severe hepatic fibrosis [47]. Table 12.3 summarizes the two predominant POLF systems.