1. Department of Surgery Ruijin Clinical Medical College Shanghai Jiao Tong University

2. Anatomy The largest parenchymatous organ Weight about 1200 ～ 1500g Bilateral diameter about 25cm Antero-posterior diameter about 15cm Supro-inferior diameter about 6cm

3. Location & Shape In the right upper abdomen Beneath the diaphragm On top of the stomach, right kidney, and intestines Irregular Wedge shape, right side is blunt and thick while left side is flat and narrow

4. Location & Shape A diaphragmatic surface is umbonate, associate with the diaphragmatic muscle A visceral surface is thin and flat, close with stomach, duodenum, gallbladder, hepatic flexure of colon, right kidney and right adrenal gland

5. Associated ligaments Left and right triangular ligament Coronary ligament Falciform ligament Ligament teres hepatis Gastrohepatic ligament Duodenohepatic ligament

6. Hepatic ledicle Portal vein Hepatic artery Hepatic vein Bile duct Lymphoduct Lymph node and nerve

7. Hepatic vein Portal vein Hepatic artery

10. Lobes (tradition) inferior cava － gallbladder Right anterior lobe Right posterior lobe Left medial lobe Left lateral lobe

11. Lobes (tradition) Left medial lobe Left lateral lobe Falciform ligament

12. Lobes (tradition) Right anterior lobe Right posterior lobe

13. Couinaud fractionation method Commonly used in clinic Based on the distribution of hepatic fissure and hepatic vein in the liver Divide the liver into 8 segment  Caudate lobe as I segment  Left lateral lobe as  Ⅱ、Ⅲ segment  Left medial lobe as  V segment  Right anterior lobe as V 、Ⅷ segment  Right posterior lobe as Ⅵ、Ⅶ segment

14. Couinaud fractionation method

15. Traditional fractionation method I II III IVa IVb V VI VII VIII Caudate/Spigel lobe left posterolateral segment left anterolateral segment left superomedial segment left inferomedial segment right anteroinferior segment right posteroinferior segment right posterosuperior segment right anterosuperior segment

16. Histology of liver –Hepatic lobules Lobule central vein Sinus hepaticus Duct converge area Cholangiole

17. Central vein Sinus hepaticus Histology of liver

18. Sinus hepaticus portal pedicle Central vein Histology of liver

19. Physiologic Function Secrete bile 600 ～ 1000m1/day Metabolism function Make carbohydrate,protein and fat into glycogen Blood clotting function Liver is the place which synthesize and produce many kinds of blood clotting material Detoxification Detox through decomposition, oxidation and combination Phagocytosis or immunifaction Phagocytosis of Kupffer cell

20. Physiologic function of liver

21. Blood supply of liver hepatic artery 25 ％～ 30 ％ contain oxygen(40 ％～ 60 ％ ) portal vein 70 ％～ 75 ％

22. Blood supply of liver

23. Tumor of liver Benign and malignant Benign tumor is few The most common malignant tumor is liver cancer  primarily  secondary （ metastatic ）

24. Primary hepatic carcinoma Asia and north Africa has a high morbility: 164.6/100thousands Europe and north America has a low morbility: 1/100thousands Male:Female is 19.96/100t ： 8.07/100t Mean age ： China 33y Africa 37.6y Japan 56.5y America 64.5y

25. Primary hepatic carcinoma Cause the 3rd mortality in male while the 4th mortality in female in malignant tumor in china Often seen in southeast littoral Has a high morbility in the age group of 40-49y Male>Female

26. Primary hepatic carcinoma

27. Etiology and etiopathogenisis is not definite now Concerned with following factors  Hepatic cirrhosis  Virus hepatitis  Some chemical carcinogen like flavacin  environment factors

28. Primary hepatic carcinoma

30. Pathogenesy

31. Mechanism of tumor metastasis

32. Types Nodus: most common ， usually with hepatic cirrhosis Huge lump: less with hepatic cirrhosis or with level hepatic cirrhosis Suffusion ： least seen ， hard to be recognized with hepatic cirrhosis with naked eyes

33. Classification of tissue pathology Hepatic cell type the most commom （ 91.5 ％） Bile duct cell type Mixed type

34. Route of metastasis Disseminate in liver Hematogenous metastasis ： lung ＞ bone ＞ brain Lymphatic metastasis ： hepatic portal ＞ postperitoneum ＞ supraclavicular lymph nodes Direct spread Abdominal cavity plant ： few seen

35. Natural course Earlier subclinical stage :10months AFP Subclinical stage （ i ） :8-9months Imageology diagnosis Intermediate stage （ ii ） :4months symptom,physical sign Advaned stage （ iii ） :2months jaundice,abdominal dropsy distant metastasis,death

36. Natural course Earlier subclinical stage ： difficult to diagnosis Subclinical stage （ I ）： resect rate 60% 5year survive 50-70% Intermediate stage （ II ）： resect rate 20% 5year survive 15% Advanced stage （ III ）： lack of effective method extend life time

37. Clinical manifestation Lack of typical symptom in the earlier stage Frequent clinical manifestation  Pain in hepatic region, decreased appetite  Debility, athrepsy, abdominal distension  General and digestive symptom  Hepatauxe  Metastasis symptom, hypoglycemia, globulism

39. Complication Hepatic coma Upper gastrointestinal hemorrhage Rupture and hemorrhage of carcinoma Scondary infection

40. Diagnosis History Physical examination Laboratory examination Hematology exam CT 、 CTA USG MRI Liver biopsy

41. DiagnosisHistory

42. Physical exam jaundice hepatauxe abdominal dropsy vein communicating branch dyscrasia

43. Laboratory exam AFP ： quantitation ＞ 400  g/L Liver function ：  -GT 、 AKP 、 LDH Hematology exam Other tumor marker

44. Child classification athrepsy fine bestnutrition havenone cerebrosis highlownoneascites < 33-3.5> 3.5ALB g% > 32-3< 2BIL mg% CBA

45. Niveau diagnosis USG Radioisotopic hepatic scanning CT Selectivity celiac artery or hepatic angiography X-ray MRI Liver puncturation cytological examination

46. USG

47. CT Angiogram CT Scan

48. MRI

49. Diagnosis USG >1cm tumor CT ： plain scan strengthen 2cm tumor CTA 0.5cm tumor selective hepatic angiography 1cm tumor MRI 2cm tumor radionuclide scan identify hemangiomas

50. Normal liver Cirrhotic liver Metastatic cancer Punctura cytology

51. Treatment Early diagnosis ， early treatment Combined therapy Operation therapy the most effective therapy at earlier stage

52. Indication Limited carcinoma ， not exceed half liver Has not serious hepatic cirrhosis, has a good liver functional compensation Carcinoma has not encroached the first hepatic portal, the second hepatic portal and IVC No serious damage of heart, lung and renal function

53. Surgery type Local excision, sub hepatic segment,segment, lobe, half liver, right three lobes and irregularly excision Remain 30 ％ of the normal liver tissue Remian 50 ％ of the cirrhotic liver tissue

54. Other therapy Hepatic artery ligation Hepatic artery embolism Hepatic artery chemoembolization Liquid nitrogen frozen Laser gasification Microwave heat cure

55. Hepatic arterial chemoembolization

57. Puecuraneous ethanal injection

58. Treatment of recurrence Regular Follow-Up after radical excision Monitoring AFP and B-USG Excise the recurring tumor again

59. Liver transplantation Prostecdtive efficacy is not ideal The key issue is the recurrence of cancer

60. protooncogene Tumor suppressor gene Tumor Normal cell growth Alteration Absence p53(30-50%HCC) SCH 58500 (adenovirus contains normal human p53 ) Gene therapy

61. Survival rate of recurrence treatment

62. Recurrence in one year AFP>1000μg/L at the first operation tumor diameter>5cm cancer embolus in portal vein surgery incisal edge is positive Influencing factor of prognosis

63. Other disease hemangiomas of liver hepatic cyst hepatic abscess

64. Hemangiomas of liver usually angiocavernoma long course ， commonly seen in middle-aged patient female>male AFP normal prunosus shape, soft substance, can be pressed no therapy is needed if it’s diameter<5cm can be considered to resect if it is big and the patient has symptoms or influence liver function

65. Hemangiomas of liver

66. Hepatic cyst often with polycystic kidney has symptoms only it’s volume is large ： epigastric distention, pain, abdominal mass AFP normal, liver function normal USG 、 CT has diagnostic value treatment ： capsule wall partial excision

67. Hepatic cyst

68. Hepatic abscess Formed because of inappropriate therapy Including bacterium and Amoeba The most common is bacterial abscess

69. Bacterial liver abscess the common pathogenic bacteria is Bacillus coli or Staphylococcus source of the bacteria ： biliary tract portal vein hepatic artery diapyesis organs nearby

70. Bacterial liver abscess clinical manifestation ：  usually happen after some transmissibility disease, onset urgently  shake, high fever, hepatic region pain,hepatauxe  T 39 ～ 40 ℃， usually be remittent fever  toxic symptom such as profuse sweating, nausea, vomit, loss of appetite and debilitation

71. laboratory examination ：  Blood routine: WBC ， anaemia  X-ray ： raise of diaphragmatic muscle and limitation of movement ； liver shadow increased or has local eminence  B-USG can discern abscess which diameter 2cm Bacterial liver abscess

72. Diagnosis Differential diagnosis  Amebic liver abscess  Right subphrenic abscess  Liver cancer  Infection of biliary tract

73. Treatment  antibiotic drug  correct fluid and electrolyte balance  enough nutritional support  B-USG 、 CT guiding puncture drain  lobectomy of liver is reasonable if there is chronic local thick wall abscess Bacterial liver abscess

74. Thank you