Week 4 Summer Immersion: Harry Peng

This week I visited a hepatectomy on a liver cancer patient. The diameter of the tumor was around 16 cm. Two-thirds of the liver was removed. For a tumor of this size, the incision must be at least 5 cm larger than the tumor to allow the surgeon to take the whole tumor out. It is impossible to make an incision smaller than the tumor since breaking up the tumor would increase the risk of metastasis or other complications. 

Different than the pancreas, the liver has many delicate ducts and vessels. The Covidien LigaSure dissector, which can cauterize tissue for hemostasis and has faster cooling during the procedure, is normally used in organ dissection. However, the limitation comes when the surgeon wants to preserve the liver's parenchymal structure while removing the tumor. Another advanced surgical tool, CUSA, or cavitron ultrasonic surgical respirator, can emulsify target tissues, causing apoptosis of hepatocytes while avoiding damaging the extracellular matrix. 

CUSA is a perfect tool for liver parenchyma transection, enabling fragmentation, suction, and irrigation to occur simultaneously and allowing the surgeon to remove tissue with accurate control. There are normally two frequencies, 23 and 36 kHz, used to cause structures with high water content (i.e. cells) to undergo apoptosis. The 36 kHz handpiece is helpful during procedures requiring precision, tactile feedback, and delicate control, while the powerful 23 kHz handpiece fragments even tough, fibrous, and calcified tumors.

A good analogy to this procedure is that the liver is like a tree with many branches covered by leaves; one needs to clean up the leaves to expose the branches. If the leaves are the hepatocytes and liver ducts and vessels are the tree branches, the hepatocytes need to be cleared up to expose the liver ducts and vessels. Preserving the ducts and vessels during the procedure can ensure removing all the tumors while minimizing the damage to the liver for shorter patient recovery.

If the patient needs to undergo total hepatectomy, organ transplantation comes into play since the liver plays a critical role in homeostasis and no supplements exist to replace liver function totally. Patients undergoing organ transplantation will get immunosuppressive drugs. Since they are immunocompromised, common infections normal people get and will be able to recover from might quickly get worse and be lethal to them. Therefore, targeted immunotherapy to fight infection and boost immunity may be a research field largely beneficial to the organ transplant community.


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