Liver Cancer Surgery

Primary Liver Cancer (PLC) is a fairly common tumour that originates inside your liver. It is different from secondary liver cancer, in which cancer first develops in other parts of the body and later spreads to the liver. Like all other cancers, PLC also has various stages. The liver is the largest internal organ in our body located in the upper right area of your belly. It has blood supplied via 2 major blood vessels, which have a significant role in planning surgical removal of cancerous tissue or reducing it in size. However, if cancer reaches its advanced stage, the only path of treatment is through medications to ease symptoms like pain and discomfort, or chemotherapy, a combination of medicines especially used for cancer therapy, to prevent cancer from spreading. 

Liver cancer surgery, which is often called a ‘hepatic resection’, is an operation of the liver, which involves surgical removal of the cancerous cells from the organ. Deciding whether to go for it is often dependent on your age, liver function, health status and the stage of cancer present. The two main procedures in surgery of liver cancer include:

1. Liver resection: the removal of a piece of the liver which is cancerous
2. Liver transplant: the removal of the whole liver and its replacement by a new donated liver.

The cost of liver cancer surgery varies based on the level of complication of the surgery and stage of cancer, type of procedure used, type of healthcare facility, your health status, diagnostic procedures and other services availed before, during and after surgery. The cost ranges from INR 2,25,000 to INR 6,00,000.

If the damage to your liver by cancer is minimal and you are diagnosed at an early, then your team of doctors will advise you for ‘liver resection’. The liver has special types of cells that enable it to regenerate itself. Therefore, even a large chunk of this organ can be removed without any harm to your health. However, some people may have serious damage to the liver where it will not be possible to undergo this operation, for example, ‘Cirrhosis’, which is caused mostly by alcoholism, hepatitis B or hepatitis C, ascites (retention of fluid in the abdomen).

A day before surgery, you will be admitted into the hospital and the rest of the procedure is as follows:

• Some of the routine tests (blood test, chest X-ray, electrocardiogram/ECG, and so on) will be carried out again just to be sure you are fit to undergo the body-numbing procedure called general anaesthesia.
• You will be advised not to drink or eat anything a few hours before the surgery. You will be asked to give consent before the surgery, which is a statement saying that you have been informed about the possible risks and benefits of the surgery and you have agreed for the operation.
• You will be given a sterilized (germ-free) dress to wear for the operation.
• Once in the operation theatre, you will be prepared for the anaesthesia, and your heart, lungs and other body functions will be monitored throughout the procedure on different screens.
• A drip will be inserted in your wrist for giving you some essential fluids and medications while carrying out the operation. This ensures you are hydrated and your nutrients and fluids are balanced while you are unconscious.
• The anaesthesia will be introduced into your body by inhalation and injections. One specialist from each field will be available throughout your operation to ensure your safety (for example, an anaesthesiologist, a specialist in anaesthesia).
• Once the operation starts, the main aim of the surgery will be the removal of cancerous cells along with some margins of the healthy tissue (in order to safely remove even the minute spreads).
• After the procedure is over, you will be brought back to consciousness by the anaesthesiologists and physicians, and you will be transferred to the recovery room.

Liver Resection

• The operation is done under general anaesthesia, which means you will be asleep during the whole procedure.
• The doctors will thoroughly examine your liver and do an ultrasound to understand the involvement of the important blood vessels that supply our liver within the tumour.
• A cut will be made below your chest to gain access to the liver.
• A broader view is needed in order to look for the extent of the tumour cells in the liver, such as the nearby muscles, lymph nodes, and so on.
• The pressure on one of the veins, ‘the central vein’, is kept under control to ensure the least bleeding.
• The blood supply to the liver is maintained and appropriate surgical methods are followed to preserve this for the remaining liver to function.
• After removing the tumour cells and tissues, the remaining uncovered cut liver, the major veins and surrounding surfaces are inspected for any bleeding and if needed, absorbable stitches will be placed.
• ‘Thrombin glue’ is a medicinal glue that is sprayed on the treated liver to reduce the risk of any leakage of bile (digestive juice secreted by the liver)
• Finally, the surgeon may put a long draining tube attached to a bag before the cut is stitched back and the operation is complete.

Liver transplantation (OLT)

The only major drawback of a liver transplant is the scarcity of donors and waiting time may perhaps accompany the growth of the tumour. However, for the latter, your doctor will give you some adjuvant therapy, such as ‘percutaneous ablation therapy’ (destruction of inoperable tumours using radio waves in the liver through your skin). 

After the surgery, your care team will ensure to balance some of the important metabolic functions of your liver that may have been disturbed due to weakening of the organ during operation. These include:

• Blood glucose control
  Glucose control medications will be given to you to maintain your blood sugar levels after the surgery as the metabolism of sugar is affected.
• Blood clotting therapy
  There is usually a disarrangement in the blood clotting chemicals in the body (coagulopathy) after surgery. Your doctor may suggest a prophylactic/preventive fresh frozen plasma (cells of your blood that are responsible for clotting), and vitamin K to prevent excessive bleeding.
• Fluid and electrolyte balance
  Sodium restriction in your diet will be advised to you as after operation there is a shift in the electrolytes (essentials ions in your body) to protect your liver function.

You will be asked to stay in the hospital for a few days and will receive good nursing care during this time.

A personalised, well-designed approach based on your health condition will be employed for recovery at home. These are discussed below:

Nutrition

• Liver function and nutritional status are important to prevent postoperative complications and have a successful recovery. Hence, one shouldn't be lenient about the diet and should follow the doctor's instructions.
• Your doctor or your dietician will advise you over specific food items that you must avoid or take as this organ is a major part of our digestive system.
• High-protein and high energy foods are usually advised after liver cancer surgery.
• For specific dietary instructions based on other health conditions that you have and the extent of surgery, you should speak to your health team.

Exercise

• Your doctor will also advise you physiotherapy (lighter exercises) and watch for any signs of recurrence of cancer, pain, fever or infection.
• Excessive exertion should be avoided as it slows down the recovery and may also cause discomfort.
• Start with light exercises, such as walking and gradually level up to running. Consult your physiotherapist and get a personalised routine exercise schedule made for yourself.

Sleep and relaxation

• Adequate sleep is a must for recovery and one shouldn't compromise on it. A good sound sleep is really helpful in relaxing your body and letting the body use the energy to heal.
• A good 7 to 8-hour sleep is usually advised for better recovery.
• You may also try meditation and other relaxation techniques. Studies have shown that meditation and relaxation are helpful in relieving pain, boosting the immune system and regulating bodily systems.

Avoiding harmful substances

• Things like alcohol and tobacco (both smoking and chewing) are harmful to the liver and overall health after surgery. Both these products can cause the recurrence of cancer and make things difficult to be managed. 
• It is advised that you avoid the intake of alcohol and tobacco after surgery. Also, if someone else smokes in your house, make sure they do not smoke near you because inhaling tobacco smoke is equally harmful.

There are always some risks or complications associated with the operation, such as:

• Infection at the site of surgery
  Deep vein catheterization is a routine procedure after surgery where a bag is attached to a tube is placed at the site of operation. This tube drains out any clots and fluids, which may get contaminated and cause infection and fever.
• Diaphragm injury and pleural effusion
  This usually occurs as a result of an infection in the right side of the chest when there is an injury to the diaphragm (a thin muscle separating your lungs from the stomach and helps in breathing) or obstruction to any infection draining vessels that contain fluids and fight off infection (lymph) during or after surgery.
• Bleeding after surgery
• Development of a blood clot in your legs (deep vein thrombosis)
• Bile leakage
  This may further cause infection if not treated in time.
• Jaundice
  Jaundice is the yellowing of the skin and whites of the eyes.
• Liver failure
  Liver failure is a condition where the liver is not able to perform its function. 

Surgery is the first line of treatment in people with a single tumour and good liver function. The outcome is dependent on various factors that your doctor will consider before advising you surgery, such as your age, gender, other medical conditions that you have or had in the past, especially of the liver, overall health, habits and addictions like alcohol or drug abuse. The recurrence rate of the tumour is 50%, that’s why it is difficult to comment on the outcome of the surgery.

There will be an initial follow up after 4 weeks of surgery, which is standard after all operations. This is done to ensure that the wound has healed properly and check if you have any pain or swelling in the region. The follow-up after surgery will involve the evaluation of any failing liver functions and signs of recurrence will be tested using imaging tests like a CT scan or MRI.

Individuals with early-stage cancer show high overall survival. Recurrence may be seen after 5 years of the first operation. A 6-month interval for follow up is considered a suitable period for risk and benefit assessment of the operation. Most surgeons suggest a post-operative follow up of 3 months in the first 2 years, and after that, you will be asked to visit after every 6 months. This is called as the ‘optimal follow-up period’.

The feelings of distress come attached to cancer to every individual. The sense of hopelessness and fear are unfortunately alike to the loved ones and family members after diagnosis and during or after treatment. The various ways in which you can cope with this overwhelming situation could be:

• Keeping strength to stand by your family and friends in such a health crisis.
• Ask for help from counsellors and other medical professionals.
• Keeping faith.

Some of the basic tips that will give you a sense of control include reading more and more about cancer. Ask questions to your doctors and seek honest answers. It is most important that you express what you feel before during or after the treatment, more so emotionally.