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Aims: In hepatic right trisectionectomy (previously, trisegmentectomy), it is sometimes necessary to extend the resection to the left of falciform ligament to achieve tumour clearance. We have assessed the outcomes following such extended resections. Methods: Between 1993 and 2001, 112 patients underwent right trisectionectomy for malignancy. In 37 of these patients, resection extended to the left of falciform ligament (30: colorectal; 4: sarcoma; 2: neuroendocrine; 1: oesophageal). These resections were either contiguity or as a segment 2/3 metastasectomy. (M2, M3 or M2 + 3). In contiguity (IC) resections of either segment 2 (IC2) or 3 (IC3) or both (IC2 + 3) were done to achieve tumour clearance. Postoperatively, liver function was monitored for at least 1 week. Results: Of the 37 patients who underwent a right trisectionectomy extending beyond the falciform ligament, 19 had an IC resection (IC2 = 5, IC3 = 8, IC2 + 3 = 4). Seven patients had an IC resection and a metastasectomy (IC + M2 = 1, IC + M3 = 3, IC + M2 + 3 = 3). Thirteen patients had a segment 2 or 3 metastasectomy alone [median 2 (1–5) metastases]. The median hospital stay was 10 (6–23) days. There was one (2.7 per cent) in-hospital death. Three patients developed bile leak and two had postoperative haemorrhage that needed re-exploration. Thirteen patients (35 per cent) had transient hepatic dysfunction. Five patients died from recurrent disease and two from other causes. Twenty-nine patients are currently alive, five with recurrent disease. Conclusion: Right-sided liver resection can be extended across the falciform ligament safely, enabling clearance of the tumour with acceptable mortality.

Aims: The safety of major liver resection is improving with advances in surgical techniques and anaesthesia. We assessed the morbidity and mortality with major liver resection in patients over the age of 70 years. Methods: Between 1993 and 2001, over 500 patients underwent major liver resections. Of these, 55 (resection of three or more segments) were performed in the elderly. ASA grade, intraoperative blood transfusions, length of intensive care (ITU) and hospital stay, morbidity and in-hospital mortality were recorded prospectively. Results: Fifty-five patients (median age 73 (70–85) years; M:F = 23:22) underwent a major liver resection, the vast majority for colorectal liver metastases (colorectal: 42; hepatocellular carcinoma: 8; cholangiocarcinoma: 1; benign: 4). The median ASA grade was 2 (1–3). Only a third of patients had blood transfusion, median 3 (1–11) units. There were five in-hospital deaths (9 per cent) – four deaths were in the early period (n = 20, 1993–1997) and only one death in the latter period (n = 35, 1998–2001). Major morbidity was seen in 20 patients (36 per cent) (cardiac: 5; respiratory: 5; gastrointestinal bleed: 3; transient liver failure: 3; cerebrovascular accident: 1; intra-abdominal collection: 1; small bowel fistula and obstruction: 1). Only five patients needed ITU. The median hospital stay was 11 (5–139) days. Conclusion: Major hepatic resection can be safely performed in the elderly with low morbidity and mortality. However, these patients need careful cardiac and respiratory assessment, as these are the major causes for morbidity in the postoperative period.

Aims: Historically, surgical intervention for liver trauma has been the accepted method of treatment with an associated high percentage of nontherapeutic laparotomies however, conservative management is now advocated in the haemodynamically stable patient. We report our experience of the management of patients admitted with liver trauma. Methods: Retrospective analysis of 75 patients admitted with liver trauma over a 9-year period (1992–2001). Fifty-eight were men (median age 25 years; range 1–76 years). Injury severity was determined using the hepatic injury scale (HIS). Results: Sixty-three patients were referred from other hospitals. Seventy-two patients suffered blunt trauma. Six patients were classified as grade 5 on the HIS, 43 as grade 4, 17 as grade 3, 8 as grade 2 and 1 as grade 1. Fifteen patients underwent surgery at the referring hospital, which involved perihepatic packing in 80 per cent. Of the 48 patients treated conservatively at the referring hospital, 43 were successfully treated with further conservative management. In total 23 patients required laparotomy in our unit, 18 for liver related injuries. Procedures included 3 hepatic resections and 13 for hepatorrhaphy. Median blood requirement in our unit was 2 units. Four patients developed definite biliary complications treated with endoscopic stenting in three cases and percutaneous drainage in one. A further five intra-abdominal collections required percutaneous drainage. The mortality rate was 8 per cent. Conclusion: The majority of patients with liver trauma can be successfully treated with conservative management. In unstable patients initial surgical packing and transfer to a specialist unit is recommended.