AIM: To analyze the operative and perioperative factors associated with hepatectomy of benign hepatic lesions.

METHODS: A total of 827 condecutive cases of benign hepatic lesion undergoing hepatectomy from January 1986 to December 2005 in the Chinese PLA General Hospital were investigated retrospectively according to their medical documentation.

RESULTS: The effect of operative and perioperative factors on the outcome of patients were analyzed. Of the 827 cases undergoing hepatectomy for more than 3 liver segments accounted for 22.1%, 316 (38.21%) required transfusion of blood products during operation. The average operating time was 220.59 ± 109.13 min, the average hospital stay after operation was 13.55 ± 9.38 d. Child-Pugh A accounted for 98.13%. The postoperative complication rate was 13.54% and the in-hospital mortality rate was 0.24%. Multivariate analysis showed that operating time (P = 0.004, OR = 1.003) and albumin value (P = 0.040, OR = 0.938) were the independent predictors of morbidity and indicated that operating time, blood transfusion, complication rate, and LOS had a trend to decrease.

CONCLUSION: Hepatectomy for benign hepatic lesions can be performed safely with a low morbidity and mortality, provided that it is carried out with optimized perioperative management and an innovative surgical technique.

Hepatectomy is a dangerous and complex operation[1-6]. The choice of surgical treatment for benign hepatic lesion is controversial. Erdogan et al[7] reported that the indications for surgical resection of liver hemangioma are progressive abdominal pain and > 5 cm in diameter, which have been justified in patients with minimal or no symptoms, even in patients with giant hemangiomas. Yoon et al[8] performed 52 operations for 115 hepatic hemangiomas, enucleation was performed for 31 (60%) of the 52 patients who underwent surgical resection. Postoperative complications were found in 13 patients (25%) with no peri-operative death occurred. Of the 52 patients with symptoms before resection, 96% had resolution of their symptoms after operation. Chaib et al[9] suggested that hepatic adenoma should be removed in all cases, especially in female patients on oral contraceptives when their tumor was greater than 3 cm in diameter or when malignancy cannot be excluded. No postoperative death occurred in 24 patients with hepatic adenoma. Bile leakage occurred in 1 patient, intraperitoneal abscess in 1 patient, pleural effusion in 2 patients, venous thrombosis in 1 patient and wound infection in 1 patient. Ibrahim et al[10] suggested that indications for intervention in cases of benign liver tumors should include symptoms, suspicion of malignancy, or risk of malignant change. Liver resection for benign liver tumor is safe, but indications for intervention must be evaluated carefully. The presence of chronic parenchymal liver disease does not increase the morbidity of benign hepatic lesions in these patients. This study retrospectively investigated the perioperative predictors by reviewing 827 consecutive cases of benign hepatic lesion undergoing hepatectomy from January 1986 to December 2005 in Chinese PLA General Hospital.

Liver is the largest parenchymatous organ in the body which is deep seated in the epigastrium and protected by the bony thorax[11-14]. Liver has abundant blood flow and is a blest and indispensable organ, known as the “forbidden zone” or a “noli me tangere-do not touch me” organ. Liver surgery became possible in the second half of the 20th century and a rapid progress in liver surgery has been achieved in the latest 20-30 years[15,16]. Liver surgery for benign and malignant lesions mainly involves partial liver resection[17].

In the initial stage of liver surgery, the mortality is rather high due to the wide excision of liver and hepatectomy is only suitable for selective malignant lesions and the expected outcome is not good. However, the current surgical techniques make it possible to perform operations on liver. The safety is not inferior to other large intraabdominal operations. It was reported that the mortality of patients with liver tumors could be lowered to the minimum, even to zero[17,18]. Nowadays, surgery is a routine treatment modality for benign hepatic lesions. Zhi-Qiang Huang has reported two cases of intrahepatic bile duct stone (the secondary common benign hepatic lesion in China) treated with left external lobectomy or right hepatectomy since 1958, leading to wide application of hepatectomy for benign hepatic lesions in clinical practice[19-23].

In this study, retrospectively investigated 827 consecutive cases of benign hepatic lesions were retrospectively investigated in the Chinese PLA General Hospital, which provides some evidence-based data about the improved hepatectomy techniques.

In this series, the most common diseases were hemangioma and intrahepatic bile duct stone, accounting for 41.7 % (345/827) and 29.6% (245/827), respectively. It was reported that the incidence of intrahepatic bile duct stone is higher than hemangioma in China[24].

Hepatectomy can be divided into two categories: hepatectomy involving bile duct and hepatectomy not involving bile duct. Usually, hepatectomy involving bile duct has more complications. The operation procedure, mainly using regular segmental resection or lobectomy, therefore, has different characteristics. Intrahepatic bile duct stone is the representative of this kind of lesion. In 1958, our operation team first reported regular lobectomy for intrahepatic bile duct stone based on the theory that intrahepatic bile duct stone is a kind of segmental lesion with a strict distribution within the liver[25,26]. After more than 50 years, this conception has been well established and developed gradually[27]. In the present series, 202 cases of intrahepatic bile duct stone underwent anatomical hepatectomy, accounting for 82.4% of the total cases, with a complication rate of 16.3% (data not shown). Hepatectomy not involving bile duct is mainly for liver tumors. Hepatic hemangioma is the main representative of benign hepatic lesions[10,19,21,28], which grows slowly and recurs occasionally and can be radically resected. Because of the well-demarked border between the tumor and its normal liver tissue, enucleation is usually performed. In this series, the complication rate was 11.3%, lower than that of intrahepatic bile duct stone.

The postoperative complication rate of hepatectomy was 13.54% in this series. Multivariate analysis showed that operating time (P = 0.004, OR = 1.003) and albumin value (P = 0.040, OR = 0.938) were the independent predictors of morbidity of benign hepatic lesion. Operating time was the risk predictor and increased albumin value was the protection predictor. The study indicated that some surgical technical refining, for instance, optimizing surgical instruments, increasing the surgeon’s proficiency and co-operation level, should be taken into account to decrease the operating time so as to reduce complications.

The albumin value should be emphasized on the preoperative liver functional reserve evaluation. In this series, two patients died with a perioperative mortality of 0.24%. One was a case of liver trauma complicated by splenic rupture, hemorrhagic shock, and pelvic fracture, and died of blood loss and DIC. The other case had a sudden death because of ventricular fibrillation 15 d after operation.

The Chinese PLA General Hospital have performed, 2008 hepatectomies for benign and malignant lesions with a total perioperative complication rate of 14.44% and a mortality rate of 0.55%[29]. In this series, the perioperative complication rate and mortality were lower than the total perioperative complication rate and mortality, indicating that hepatectomy is safer for benign hepatic lesion than for malignant lesions.

In addition, multivariate analysis revealed that operating time, blood transfusion, complication rate, and hospital stay had a trend to decrease, indicating that surgical quality is improved.

In conclusion, hepatectomy is a safe procedure for benign hepatic lesions. Benign hepatic lesions should undergo aggressive surgical management when clinical presentations, diagnosis, society factors, and progress in liver surgery are considered. Reducing operating time and preoperative liver functional reserve evaluation play an important role in improving the operation quality.