Liver Tumor Resection Surgery

Liver resection surgery is the most common treatment for removing tumors that develop in a child’s liver. Liver resection surgery removes a part or section of a diseased liver, leaving as much of the healthy liver as possible.

The liver is an amazing organ with the rare ability to regenerate (regrow), even after part of it is removed. Liver resection surgery may be the most effective option in treating a child’s liver tumors to both prevent the spread of cancer and extend their length of life.

Rarely during liver resection surgery does the entire liver need to be removed. But when the whole liver is removed, a liver transplant is needed.

What are the types of liver resections?

Doctors will recommend one of two treatments depending on your child’s health and the size and location of their liver tumor.

These procedures include:

• Laparoscopic (lap-uh-row-SKOPP-ick) resection – Uses three or four small incisions to remove a benign or malignant tumor of the liver. This minimally invasive surgery offers faster recovery times with less pain and scarring.
• Traditional open resection – Accesses the liver by making one larger incision along the right side of the abdomen. The larger incision means a longer healing time and may come with more pain than laparoscopic surgery, but it allows the surgeon to palpate (feel) the tumor(s). It is often needed in the treatment of larger tumors or those close to the blood supply of the liver.

Liver resections are often the most effective way to stop the growth of a child’s liver tumors. Even if a tumor is benign, it can grow and put pressure on other body organs or affect the function of the liver itself. It is crucial to catch tumors as early as possible to eliminate their growth before they have time to spread or damage the liver.

Because the liver can regrow with high success, for most children, it is better to remove the tumor growth through surgery than to treat tumors with radiation or chemotherapy.

When the entire liver is diseased, surgeons may remove it and replace it with a transplanted liver from a deceased or living donor.

UPMC Children’s has performed more pediatric liver transplant surgeries than any other center in the United States, according to the United Network for Organ Sharing (UNOS).

What are liver resection risk factors and complications?

Not all tumors are cancerous, but malignant tumors can be harder to treat and more likely to spread to other regions of the body. That’s why it’s important to spot and treat liver tumors as early as possible to prevent the spread of cancer and deterioration of the liver.

Because cancer among children is not common and childhood liver cancer is even more rare, we suggest that all children with liver cancer be considered for clinical trials of other possible treatments.

Complications of liver resection

The main complications of liver resection are related to the vital structures in the liver next to the tumor. This includes injury and bleeding from blood vessels or damage/blockage of bile ducts. But the complications of liver resection surgery are not as severe as the complications of an untreated liver tumor.

Factors that increase the risk of complications after liver resection surgery include:

• Biliary issues — Bile leaks or strictures after liver resection or transplantation can cause infection, liver failure, and other problems.
• Bleeding – The liver has a lot of surrounding blood vessels. Pediatric and transplant surgeons are used to working in these areas, which decreases the risk of injury.
• Extent of resection — The larger the resection (portion of liver removed), the higher the risk of liver failure and other issues.
• Infections — Infections are a key concern in both liver resection and transplantation, particularly in infants and children. They can significantly impact outcomes.
• Underlying condition — The complexity of surgery and potential for complications vary based on the size, location, and type of tumor.
• Post-hepatectomy liver failure (PHLF) — When the remaining liver tissue left after resection is not enough to support normal liver function, PHLF can occur, causing serious illness and even death. This is very rare in children.
• Surgical site infections — Can cause pain, unplanned hospital readmissions, and increased illness.

How common are liver resections?

Liver resections are common procedures for treating pediatric liver tumors, even though these tumors themselves are rare. Pediatric liver resection surgeries are common because children’s livers have had less exposure to damaging factors than adults.

Because the liver can regrow, this procedure is the preferred treatment. It does not require a donor liver and still has very high success rates.

Liver resections are performed when tumors have grown in the liver but the liver is still healthy enough to heal after a section is removed. The goal of treatment is to eradicate tumor growth and any cancerous tissue near the tumor.

Successful liver resection surgery eliminates tumors entirely or to a degree that allows them to be monitored to spot any new growth. In some cases, resection surgery may be repeated if there is new tumor growth or possible spread.

What happens during a liver resection?

In either a traditional or minimally invasive (laparoscopic) liver resection, your child’s surgeon will:

1. Create an incision or incisions through which they can access the liver.
2. Remove the tumor growth from the liver.
3. Attempt to save as much healthy liver tissue as possible.
4. Close the incision or incisions with either surgical staples, stitches, and/or adhesive bandages.
5. Monitor your child’s recovery and pain management.
6. Scan your child for any signs of tumor regrowth.

Is liver resection right for my child?

Liver resection is often the right surgery for treating a tumor in a child’s liver. Children are the best candidates for resection. That's because most will not have liver damage that could complicate the organ's ability to function and regrow after surgery.

If your child has an otherwise healthy liver with a tumor, a liver resection surgery may be the best option.

In some cases, where the tumor has grown exceptionally large or is in a hard-to-reach area, doctors may suggest chemotherapy or radiation therapy to first reduce the size of the tumor before performing a resection surgery.

Before performing a liver resection surgery, your child’s doctors will perform a CT or MRI scan to view the tumor’s growth and ensure it has not spread.

Before surgery

Your child’s surgery team will give you instructions on how to prepare your child for surgery. Generally, you’ll be asked to have your child fast (not eat or drink anything) for about 12 hours before surgery.

When your child arrives for surgery, they will be given some preoperative anesthetics and prepped for surgery.

During surgery

A minimally invasive liver resection can be performed in a few hours.

• In this procedure, your child’s surgeon will make multiple small incisions. They'll insert tools and viewing scopes to remove the liver tumor(s) through these incisions.
• Incisions may be glued or just covered with a bandage.
• Traditional liver resection surgery can take about three hours for most tumors. Some more complicated or harder-to-reach tumors may take up to six hours.
• In the traditional open procedure, the surgeon makes a single, longer incision through which they'll remove the liver tumor.
• They may place a drain below the incision to allow bile and blood to flow out, away from the healing wound.
• The incision is then stapled, sutured (stitched), or glued and bandaged.

After surgery

After either procedure, your child will need time to heal under hospital staff care and observation.

• If your child has a minimally invasive resection, they will have only a few small incisions to heal. They can be released from the hospital in as little as two days.
• If your child has a traditional procedure, they may need to stay in the hospital for four to five days. This allows their healing to be monitored, their wound can drain properly, and their pain to be managed with an epidural or IV pain pump.
• If your child receives a drainage tube, it will need to be removed before discharge from the hospital.
• About one to two weeks after either procedure, your child will need to see the surgeon for an examination of the incision(s) and evaluation of their progress in activity level, diet, and pain management.
• About two months afterward, your child will need a follow-up appointment to evaluate the healing process and check for any new tumor growth. In both procedures, your child will need to return for periodic imaging scans to monitor tumor regrowth.

When general anesthesia is needed, there are important rules for eating and drinking that must be followed in the hours before the surgery.

One business day before your child’s surgery, you will receive a phone call from a nurse between the hours of 1 and 9 p.m. (Nurses do not make these calls on weekends or holidays.) Please have paper and a pen ready to write down these important instructions.

The nurse will give you specific eating and drinking instructions for your child based on your child’s age.

The following are the usual instructions given for eating and drinking. No matter what age your child is, you should follow the specific instructions given to you on the phone by the nurse.

For children older than 12 months

• After midnight the night before the surgery, do not give any solid food or non-clear liquids. That includes milk, formula, juices with pulp, coffee, and chewing gum or candy.

For infants under 12 months

• Up to six hours before the scheduled arrival time, formula-fed babies may be given formula.
• Up to four hours before the scheduled arrival time, breastfed babies may nurse.

For all children

• Up to two hours before the scheduled arrival time, give only clear liquids. Clear liquids include water, Pedialyte®, Kool-Aid®, and juices you can see through, such as apple or white grape juice. Milk is not a clear liquid.
• In the 2 hours before the scheduled arrival time, give them nothing to eat or drink.

Once your child has been registered for the surgery, a member of the anesthesia staff will meet with you to take your child’s vital signs, weight, and medical history.

A pediatric anesthesiologist — a doctor who specializes in anesthesia for children — will meet with you before the surgery. They will ask questions about your child’s health and about when your child last ate.

Because your child may have eaten more recently than is usually advised for surgery, the anesthesiologist may make adjustments to your child’s anesthesia. Once admitted, your child will not be able to have anything to eat or drink until after the operation.

• As the parent or legal guardian, you will be asked to sign a consent form before the anesthesia is given.
• If your child is very scared or upset, the doctor may give a special medication to help them relax. This medication is flavored and takes effect in about 10 to 15 minutes.
• If you wish, you may be allowed to go with your child to the room where the surgery will be done and stay while the sleep medication is given.
• Younger children will get their sleep medication through a “space mask” that will carry air mixed with medication. Your child may choose a favorite scent to flavor the air flowing through the mask. There are no shots or needles used while your child is still awake.
• Older children may choose between getting their medication through a mask or directly into a vein through an intravenous (IV) line.
• When your child has fallen asleep, you will be taken to the waiting room. If it has not already been done, an IV will be started so that medication can be given to keep your child sleeping throughout the surgery.

While your child is asleep, their heart rate, blood pressure, temperature, and blood oxygen level will be checked continuously. Your child will have a breathing tube placed while they are asleep. Your child might have a sore throat after the surgery.

To keep your child asleep during the surgery, they might be given anesthetic medication by mask, through the IV tube, or both. When the surgery is over, the medications will be stopped, and your child will begin to wake up.

After surgery, your child will be moved to the recovery room to allow the anesthetic to wear off. You will be called so that you can be there as they wake up.

• Children coming out of anesthesia react in different ways. Your child might cry, be fussy or confused, feel sick to their stomach, or vomit. These reactions are normal and will go away as the anesthesia wears off.
• While your child is in recovery, your surgeon will talk to you about the surgery. This is a good time to ask questions about pain medications, diet, and activity.
• When your child is awake enough, they might be given a Popsicle® or “slushy” to drink in the recovery room.
• Once the anesthesiologist sees that your child is recovering and their pain is controlled, they will be moved to their hospital room. This usually takes about an hour, but every child is different, so times may vary.

The most important role of a parent or guardian is to help your child stay calm and relaxed before the surgery. The best way to help your child stay calm is for you to stay calm.

• You are encouraged to talk to your child or hold their hand before the surgery, while sleep medication is given, and while in recovery.
• You may bring along a “comfort” item — such as a favorite stuffed animal or “blankie” — for your child to hold before and after the surgery.

During the surgery, your child will be given a numbing medication directly into the incision to relieve discomfort after the surgery.

After the surgery, your child will most likely have abdominal pain. Your child may take Tylenol^® or Motrin^®. If your child is still having pain, your child’s doctor may prescribe a stronger medication or a narcotic.

Before you go home, your doctor will prescribe pain medication for your child.

After your child is discharged and goes home, they should avoid strenuous activity for the next two to four weeks.

Bathing

Your child may take a shower one to three days after the surgery. Baths are allowed five to seven days after surgery.

Activity

Following the surgery, your child's activity needs to be somewhat restricted.

• Your child's surgeon will determine when they can resume normal activities.
• Your child may return to school when they feel up to it.
• Participation in contact sports and gym class is not permitted until cleared by the surgical team (typically two to four weeks after surgery).
• Swimming is permitted one to two weeks after surgery.
• Walking and stair climbing are encouraged.

If your child has a fever higher than 101.5 F, bleeding, or foul-smelling drainage from the area around the incisions, call your surgeon right away.

Also, call the doctor if your child has:

• Increased or unexplained pain.
• Increased swelling or redness at the incision site.
• Increased tenderness near the incision.
• Nausea, vomiting, diarrhea, or constipation that is not improving.

If you have any specific questions about your child’s surgery, you should discuss them with the surgeon before the surgery. After the surgery, you may call the Division of Pediatric General and Thoracic Surgery at UPMC Children’s and ask to speak with your child’s surgeon or speak with them during the follow-up visit, if needed.

If your child has any special needs or health issues you feel the doctor needs to know about, please call the Division of Pediatric General and Thoracic Surgery at UPMC Children's Hospital of Pittsburgh before the follow-up visit and ask to speak with a nurse. It is important to notify us in advance about any special needs your child might have.

At UPMC Children’s Hospital of Pittsburgh, every child diagnosed with a liver tumor receives an individualized treatment plan and family-centered care.

• Surgeons at UPMC Children’s have trained at the nation’s leading cancer treatment centers and have vast experience in pediatric liver tumor resection surgery. In addition, our cutting-edge research and the latest technology ensure our patients' best possible outcomes.