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Non-transplant surgery

An interview with Richard Laing, a surgical trainee in Birmingham who discusses surgical management of patients.
My name’s Richard Laing. I’m a general surgical registrar in the West Midlands. And I’m currently taking some out of programme experience to undertake some research at the University of Birmingham.
Well, there are generally two routes for any patient to come through to a hospital. And that is what we call elective and emergency routes. So the elective route would be the patient’s gone to see their GP because they’ve developed a problem of some sort. The GP then narrows down that problem and decides that that patient needs to come and see a liver or gall bladder surgeon.
And so they can be referred to us through an outpatient clinic. So the first time, we generally see them is in outpatients, if they come through the elective setting. The other route is if the patient is so unwell that if they need immediate treatment, they can come through the emergency department, or A&E. And so if we’re on call and we’re seeing emergency patients, we might get a phone call to go and see this patient in A&E. And we can admit them through that route. So if we see them through the outpatient setting, we generally sit down with the patient. We talk about why they’ve come to see us, why their GP has maybe sent them up.
Sometimes the patients aren’t aware of why they’ve been sent up. And then we go into the history of the problem. And we maybe spend 10-15 minutes talking to patients. And then we examine the patients depending on what we think is the problem. And similarly, if they come through an emergency portal like A&E, we’ll do the same thing. So we’ll ask them why they’ve come in. We’ll examine them. And then we’ll order a number of investigations.
If we split up the main procedures into procedures on the liver and procedures on the gallbladder, which is attached to the liver and is very closely associated with the liver because of the bile production and the gallbladder is a bile storage facility for the body. So if we look at the gallbladder, again, we’ve got elective and emergency procedures and there is some crossover between them. But generally speaking, the most common gallbladder operation we do is what we call a cholecystectomy, which is a gallbladder removal operation and the most common reason for that is because of gallstones.
So a patient may come to us because they’re getting recurrent pain and they see their GP. And that pain may not be severe enough for them to come into hospital, but it’s obviously having an impact on their life. And we’ll assess them in clinic for a gallbladder operation and a cholecystectomy. So that’s probably one of the most common operations we do. It’s changed a lot over the years. We used to do it through an open technique, which involved a large cut on the right side of the abdomen. But now we do it through keyhole surgery, which is how we do most of them nowadays. Between 80% and 90% of the gallbladder operations are through keyhole surgery.
It’s a day case procedure. So they come in and go home the same day. It’s usually very straightforward but it can be complicated if they’ve had lots of problems with it in the past.
And that’s the sort of operation that, although we do a lot of elective operations, you can see patients who need an emergency operation because of a very nasty infection. So there is a bit of crossover with that operation. If we continue to look at the gallbladder, obviously gallstones is the major problem. But there can be cancers of the gallbladder as well, which require a bigger operation, and patients would generally be in hospital for a number of days after that. And then if we look at the liver operations we do, and the vast majority of liver operations we do are what we call liver resections which is where we remove a segment of the liver.
And there can be a number of reasons for that. But again, the most common reason is because of a cancer and we’re seeing more and more patients now who have a liver cancer which has spread from elsewhere. And most commonly, that’s the bowel.
Historically, patients with bowel cancer– if they had spread of the cancer to the liver– it was really the end of the treatment for them with regards to curing the cancer. Patients would be what we call palliated, which means that we would keep them comfortable in the final period of their life. Nowadays, with improved surgical techniques, and better diagnoses, and quicker diagnoses, we can now remove those what we call metastases, which are parts of the cancer that have spread to the liver and we can remove them successfully and now cure patients who’ve had quite advanced cancers. And we’re finding nowadays that we can remove more and more metastases.
And we can even remove metastases that return further down the line as well. So there’s a number of techniques that we’re starting to use now. So that’s the most common operation we do on the liver. And as I’m sure my colleague will speak to you later about transplantation. And he’ll explain to you the way the liver’s made up. But generally speaking, there are two halves. There’s a right half and a left half. And in total, those two halves are split into a total of eight segments. And usually, the tumours are confined to one or two segments. And we can remove those segments quite easily without any long term detriment to the patient.
And what we find is that when we remove a piece of liver, over time the liver regenerates. And so the liver has a fantastic ability to regenerate over the following months after the operation.
So we sometimes remove the left half. We sometimes remove the right half; the right half being the bigger half. And sometimes we even do what we call an extended right resection, where we take even a bit more of the liver than we normally would do. The key is and the trick is to leave enough liver for them to still be able to function normally.
One of the complications of liver surgery and liver resections is if we take too much of the liver, or the piece of the liver that we leave behind doesn’t function as well as it should do and that can lead to very serious consequences.
So there are a number of other techniques, which we’re using nowadays to try and push the boundaries even further. We’re doing operations in two stages, where we go in and we tie off a bit of the blood supply to the area of the liver with the cancer and then we come out. And over the coming months, that piece of liver actually shrinks away and the healthy half regenerates and grows to compensate. Then we go in, again, several months down the line and remove the diseased part of the liver, leaving the larger, healthy part. So technology is enabling us to push those boundaries even further and save even more patients. So it’s an exciting time.
We have a fantastic interventional radiology service at Birmingham, which allows us to do various techniques where we can block off blood supply and circulation to parts of the liver that maybe have an area of disease in. Instead of putting a patient through an operation to tie off the blood vessel, we can do it through x-ray guidance - the patient’s still awake under local anaesthetic - and we can follow the blood vessel right to the liver. And we can what we call embolise the blood vessels, which means we basically cut the blood supply off.
That means that that area of the liver over time will shrink down and as I say, the other healthy parts will regenerate to compensate, allowing us to do further resection. So that is a real help and we’ve got a very busy liver surgery service here. We probably do between three and four, maybe even more, liver resections a week.

Your task: Watch this video interview with Richard Laing, a General Surgical registrar currently researching Liver Transplantation at the University of Birmingham and the Queen Elizabeth Hospital, in which he discusses non-transplant related surgical options for patients with liver and biliary disease and highlights new technologies that surgeons can apply to save your liver. Reflect on any new information or ideas, and share your thoughts with other learners in the comments area.

Make sure you recognise his distinctions between surgery on the liver and surgery on the biliary system. You can look back to the activities in week one to remind you of these features.

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Liver Disease: Looking after Your Liver

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