Liver surgery – an overview for patients and families

For patients, families, and primary care teams. From the team behind prehabforsurgery.com

If you are facing a planned liver resection – whether for hepatocellular carcinoma (HCC), colorectal cancer that has spread to the liver, cholangiocarcinoma (bile duct cancer), Neuroendocrine tumour, or a benign liver tumour – the weeks before the operation matter. The liver is the largest internal organ and the only one that regenerates after surgery, but that does not make the preparation any less important. Patients who arrive at surgery fitter, better nourished, and with optimised liver function recover faster, have fewer complications, and are more likely to be back to normal life within weeks rather than months.

This article walks through what a liver resection actually involves, who is suitable for one, what the pre-operative assessment looks like, and most importantly, what you can do in the weeks before the operation to improve your odds. It is not a substitute for advice from your own surgical team – it is a starting point for the conversations that follow.

New to prehab? Start with our complete guide to what prehab is.

What is a liver resection?

A liver resection – also called a hepatectomy – is the surgical removal of part of the liver. Surgeons think of the liver as being divided into eight functional units called segments, each with its own blood supply, bile drainage, and venous outflow. Resections range from removing a single segment (a segmentectomy, very small) to removing four or more segments together (a major hepatectomy, which can mean removing 60-70% of the total liver volume). The liver’s remarkable ability to regenerate means that even after a major hepatectomy, the remaining liver grows back to roughly its original size within 6-12 weeks in most patients.

Resections are described by the segments removed. The most common patterns are:

• Right hepatectomy (segments V, VI, VII, VIII) – removes the right side, about 60% of liver volume

• Left hepatectomy (segments II, III, IV) – removes the left side, about 35-40%

• Extended right or left hepatectomy – removes additional segments, often 70%+ of volume

• Segmental or wedge resections – smaller, focused removals of specific tumours

Increasingly, many resections can be performed laparoscopically (keyhole) or robotically rather than via open surgery – particularly for smaller or peripheral tumours. The choice depends on tumour location, size, your overall fitness, and your surgeon’s experience.

Why people have a liver resection

• Hepatocellular carcinoma (HCC) – primary liver cancer, often arising in the context of chronic liver disease (hepatitis B, hepatitis C, alcohol-related liver disease, fatty liver disease)

• Colorectal liver metastases – cancer that has spread to the liver from primary bowel cancer; one of the most common indications globally

• Cholangiocarcinoma – cancer arising from the bile ducts within or at the junction of the liver (intrahepatic and hilar / Klatskin tumours)

• Neuroendocrine liver metastases — secondary spread from primary neuroendocrine tumours

• Gallbladder cancer — sometimes requires removal of liver segments adjacent to the gallbladder bed

• Benign liver lesions causing symptoms or with malignant potential — large adenomas, focal nodular hyperplasia in some cases, cystic disease, haemangiomas with mass effect

• Living donor liver transplantation — donating part of the liver to a recipient (a major operation in an otherwise healthy person)

Each of these has different pre-operative considerations and different expected outcomes. The information below is general; your specific situation will be discussed with you at your pre-operative consultation.

Who is suitable for a liver resection?

Three factors determine whether you are a candidate, and they are assessed together in your multidisciplinary team (MDT) meeting:

1. Disease factors

The tumour must be technically removable – meaning the surgeon can take it out while leaving enough functional liver behind. For cancers, the disease should not have spread beyond the liver to other organs in a way that makes resection futile. Modern imaging (CT, MRI, sometimes PET) is excellent at staging – but a few decisions still depend on what is found at the time of operation.

2. Liver factors

The portion of liver remaining after surgery – the future liver remnant (FLR) – must be large enough to maintain normal function. In a healthy liver, an FLR of 25-30% of total liver volume is usually sufficient. If the underlying liver is diseased (cirrhosis, chemotherapy-related injury, steatohepatitis), more is required – sometimes 40% or higher. If the planned remnant is too small, surgeons can use techniques like portal vein embolisation (PVE) or two-stage approaches (including ALPPS – associating liver partition and portal vein ligation for staged hepatectomy) to grow the remnant before the definitive operation. These are specialist techniques performed in HPB centres.

3. Patient factors

Your general fitness, heart and lung function, nutritional status, and any other medical conditions all influence whether the operation is safe. Older patients can undergo major liver surgery successfully if otherwise fit; younger patients with poor functional reserve may not. Decision-making is about biological age, not chronological age.

The pre-operative assessment journey

Once your case has been discussed at MDT and resection is recommended, you can expect:

• Detailed imaging – typically triphasic CT and MRI with liver-specific contrast (Primovist / gadoxetate). Sometimes additional PET-CT. The surgical team uses these to plan the operation in detail and calculate FLR volume.

• Liver function tests – beyond standard bloods, sometimes specialist tests like indocyanine green clearance (ICG) or hepatobiliary scintigraphy to quantify functional reserve.

• Cardiopulmonary exercise testing (CPET) — increasingly standard for major hepatectomy. Measures your aerobic capacity and predicts post-operative risk. Results are used both for risk stratification and to guide prehab.

• Anaesthetic assessment — particularly important for patients with heart, lung, or kidney conditions.

• Nutritional assessment by a dietitian — many liver surgery patients are deconditioned or sarcopenic at presentation, and addressing this pre-operatively materially improves outcomes.

• Hepatology review — if there is underlying liver disease (cirrhosis, viral hepatitis), additional optimisation may be needed before surgery is safe.

• Discussion of consent — risks, benefits, alternatives, expected hospital stay, expected recovery timeline.

This work-up takes 2-6 weeks typically. Use this window actively — it is your prehab opportunity.

What to do in the weeks before surgery – the practical prehab list

1. Cardiopulmonary fitness

The single highest-yield prehab intervention. Even 3-4 weeks of structured exercise – brisk walking 30-45 minutes most days, with some interval-style higher-intensity sessions if your team agrees – measurably improves outcomes. The ERAS Society guidelines for liver surgery specifically recommend cardiopulmonary prehab where time allows. If your CPET results are at the lower end, your team may refer you to a structured prehab programme; if not, start yourself with progressive walking and stair-climbing.

2. Nutrition – particularly protein

Sarcopenia (loss of muscle mass) is common in cancer patients and is one of the strongest predictors of post-operative complications after liver surgery. Most patients benefit from increasing protein intake to 1.5g/kg/day for the four weeks before surgery — for a 70kg adult, that is approximately 105g of protein daily. Practical approach: a palm-sized portion of meat, fish, eggs, dairy, or legumes at each meal, plus snacks containing protein. A dietitian consultation if available is genuinely valuable; many HPB units have one embedded in the service. Oral nutritional supplements (e.g., Ensure, Fortisip) are often prescribed in the 2-4 weeks pre-op for patients with weight loss.

3. Alcohol cessation (essential if relevant)

If you drink alcohol regularly, stopping completely for at least 4-6 weeks before surgery is essential. This is true even for moderate drinkers — alcohol affects liver regeneration, blood clotting, and immune function. For patients with alcohol-related liver disease this is obviously critical. Your team will not lecture you, but they will quietly assess whether you have stopped — it affects what they offer and how they plan the operation.

4. Smoking cessation

Stop ideally 8 weeks before surgery; minimum 4 weeks. Smoking impairs wound healing, increases post-operative chest infection rate, and reduces liver regeneration. The free HSE Quit programme (quit.ie) and UK NHS Stop Smoking services have good evidence behind them; varenicline, nicotine replacement, and bupropion are all options to discuss with your GP. Even cutting down significantly helps if full cessation is impossible.

5. Glycaemic control if diabetic

Poorly-controlled diabetes is associated with worse outcomes after liver surgery — more infections, slower healing, increased complication rates. Aim for an HbA1c below 64 mmol/mol (8.0%) ideally, lower if achievable, before surgery. Work with your diabetes team to optimise in the 4-8 weeks pre-op. If you are using insulin, your perioperative regimen will need specific planning.

6. Vitamin K and coagulation

The liver makes most of the body’s clotting factors. If your liver function is impaired, your INR may be elevated. Vitamin K supplementation in the days before surgery is sometimes prescribed to optimise coagulation. If you take anticoagulants (warfarin, DOACs) or antiplatelets (aspirin, clopidogrel), your team will give specific instructions about when to stop these — typically 5-7 days pre-op depending on the drug and indication. Do not stop these medications without specific advice.

7. Iron status and anaemia

Many patients facing major liver surgery are anaemic, often from chronic disease or prior chemotherapy. Anaemia significantly increases the likelihood of needing blood transfusion during or after surgery, which itself is associated with worse outcomes. Iron infusion (ferric carboxymaltose or similar) in the 2-4 weeks pre-op can substantially improve haemoglobin levels. Ask your team to check iron studies if not already done.

8. Practical preparation at home

• Arrange help at home for the first 2-4 weeks post-discharge — laundry, shopping, cooking, lifting

• Sleep — get a recliner chair or extra pillows if a flat-lying position will be uncomfortable post-op

• Stock the freezer with easy-prepare meals high in protein

• Sort financial / work matters early — sick leave forms, insurance notifications, work handover

• If you have small children or care responsibilities, organise cover for at least 2-3 weeks

Recovery expectations

Modern liver surgery follows Enhanced Recovery After Surgery (ERAS) principles, which means early mobilisation, early eating and drinking, minimal use of opioids, and structured discharge planning. Realistic expectations:

• Hospital stay: typically 5-8 days for open major hepatectomy; 3-5 days for laparoscopic or robotic resections

• Day of surgery: 4-8 hours in theatre depending on complexity; recovery room overnight then to a high-dependency or surgical ward

• Days 1-3: pain control, early mobilisation (getting out of bed within 12-24 hours), reintroduction of diet

• Days 3-7: progressive recovery, removal of drains and lines, increasing mobility, education for discharge

• First week home: short walks, gentle activities, attentive monitoring for any complications

• Weeks 2-6: gradual return to normal activities; many patients return to office-style work at 4-6 weeks

• Months 2-3: full recovery for most; liver regeneration largely complete by 12 weeks; manual work or heavy physical activity from 8-12 weeks

Complications to be aware of

Liver surgery has improved dramatically over the past 20 years – in high-volume HPB centres, mortality for major hepatectomy is typically under 3% and morbidity is around 25-35%. Most complications are minor and resolve without intervention. Things to know about:

• Bile leak – bile leaking from the cut surface of the liver; usually managed with drains and resolves spontaneously over weeks

• Post-hepatectomy liver failure (PHLF) – the most feared complication, occurring when the remaining liver cannot maintain function; preventable with careful FLR planning

• Bleeding – uncommon in well-prepared patients, but the liver’s blood supply makes haemorrhage a known risk

• Wound infection – typically mild, treated with antibiotics; reduced by good prehab nutrition

• Chest infection – particularly in smokers and those with limited mobility; preventable with prehab exercise and physiotherapy

• Venous thromboembolism (DVT, PE) – prevented with blood thinners during admission and compression stockings

• Ascites – fluid collection in the abdomen, more common in patients with underlying cirrhosis

Long-term outlook

Long-term outcomes after liver resection depend hugely on the underlying disease being treated. For colorectal liver metastases, 5-year survival after curative resection is now in the 40-60% range — historically the disease was considered terminal. For HCC in a well-compensated liver, 5-year survival of 50-70% is achievable for early-stage disease. For cholangiocarcinoma, outcomes are more guarded but improving with better systemic therapy.

Surveillance after surgery typically involves regular imaging (CT or MRI) every 3-6 months for the first 2-3 years, then less frequently. The pattern depends on your specific disease — your team will give you a personalised plan.

Many patients return to full activity within 3-6 months and live well for years or decades after successful resection. Liver surgery is one of the most genuinely curative operations modern oncology can offer.

Resources

• Cancer charities by disease: Bowel Cancer UK (for colorectal liver metastases), British Liver Trust (for HCC and benign disease), AMMF — The Cholangiocarcinoma Charity

• Irish Cancer Society — irishcancer.ie — patient support, information line, financial advice

• Macmillan Cancer Support — macmillan.org.uk — practical and financial support for UK patients

• ERAS Society — erassociety.org — patient-facing materials on Enhanced Recovery principles

• Your local hepatobiliary unit’s patient information leaflets — ask if you have not received them

Evidence base

Key sources informing this article:

• Melloul E, Hübner M, Scott M et al. Guidelines for perioperative care for liver surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations. World J Surg 2016;40(10):2425-2440 (with subsequent updates).

• Abdalla EK, Adam R, Bilchik AJ et al. Improving resectability of hepatic colorectal metastases: expert consensus statement. Ann Surg Oncol 2006;13(10):1271-1280.

• Schadde E, Ardiles V, Robles-Campos R et al. Early survival and safety of ALPPS: first report of the International ALPPS Registry. Ann Surg 2014;260(5):829-836.

• Reddy SK, Pawlik TM, Zorzi D et al. Simultaneous resections of colorectal cancer and synchronous liver metastases: a multi-institutional analysis. Ann Surg Oncol 2007;14(12):3481-3491.

• Snowden CP, Prentis JM, Anderson HL et al. Submaximal cardiopulmonary exercise testing predicts complications and hospital length of stay in patients undergoing major elective surgery. Ann Surg 2010;251(3):535-541.

• Sanchez-Velazquez P, Muller X, Malleo G et al. Benchmarks in pancreatic surgery: a novel tool for unbiased outcome comparisons (referenced for benchmark methodology applicable to liver surgery).

• NICE — Hepatocellular carcinoma: management overview (NG and clinical pathway documents).

• EASL Clinical Practice Guidelines: management of hepatocellular carcinoma. J Hepatol 2018 (and subsequent updates).

A final word

Liver resection is a major operation, but it is one of the most rewarding things modern surgery can offer — for many patients it is genuinely curative for diseases that were once considered terminal. The weeks before surgery are time you can spend actively improving the odds: exercise, eat well, stop drinking and smoking if relevant, optimise diabetes and anaemia, and engage early with your dietitian and physiotherapist. Patients who arrive at surgery having done this work recover faster and better than those who do not. The fact that you are reading this article suggests you are exactly the kind of patient who will benefit from doing the prep properly.

If anything in this article does not match what your own team is telling you, follow your team’s advice for your particular situation. This is a general guide; your care is specific.