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THE limiting factor in the successful surgical management of many intra-abdominal pathologic processes is the presence of hepatic involvement. Extirpation of solitary, superficial lesions of the liver is carried out occasionally, but extensive resections are as yet uncommon. Too often, the criterion of inoperability is hepatic involvement per se, rather than the extent of the process within the liver. The functional reserve and regenerative capacity of the liver cells are often disregarded in this decision. This negative attitude has been engendered by the extreme vascularity and friability of hepatic tissue. Efforts to reduce the hazards of hemorrhage in hepatic surgery . . .

Historical aspects of liver surgery basic science considerations assessment and diagnosis surgical disorders and techniques hepatic trauma, tumours and resection special problems in liver surgery.

Rats, 10–14 weeks old, had 65% of the liver removed and were subsequently exposed to 5 ± 2°C for 5 days. The animals survived this treatment in good condition. At this time they were killed and oxy...

A series of 120 patients with liver rupture due to blunt trauma is presented. This includes all patients with this type of injury sustained over a 16-year period in Oslo, which has a population of 480,000. Of the 120 patients, 29 were dead on admission; 4 of these bled to death from liver rupture before reaching hospital and the remaining 25 had other injuries as well. Of the 91 patients admitted alive, 27 were not operated upon; 2 of them survived and from the histories, symptoms, and clinical and radiographic findings were thought to have minor liver injuries. The remaining 25 patients died, of whom 16 also had other injuries, while 9 patients succumbed to their ruptured liver only, bleeding to death in the first few hours after admission without being operated upon. Of the 91 patients who were admitted alive, 64 underwent operation with a mortality of 38 per cent. Four major liver resections were undertaken and all these patients survived. This is the treatment of choice in all bursting injuries of the liver and would probably have saved most of the 17 per cent who bled to death during operation or shortly afterwards. An effective plan for the care of the injured patient with liver rupture requires an adequate ambulance service, reorganization of the immediate reception and treatment at hospital, and the application of modern liver surgery. This again calls for centralized treatment of such patients.

Kulturen von solidem Yoshida-Sarkom und Walker-Carcinom der Ratte nehmen bei Zusatz von Serum von Ratten, das 48 Std nach einer partiellen Entfernung der Leber gewonnen wurde, aus dem Nahrboden um 27–84% weniger an radioaktivem Phosphat auf als bei Zusatz von Serum normaler Ratten. In vitro suspendierte Zellen aus Ascites-Geschwulsten der gleichen Stamme und Suspensionskulturen von Walker- und HeLa-Carcinom nehmen aus dem Suspensionsmittel bei Zusatz von Serum teilhepatektomierter Ratten ebenfalls signifikant weiniger Phosphat auf als bei Zusatz von normalem Serum. Eine Erklarung fur diese Hemmwirkung auf die Phosphorylierung ist nicht im Substratmangel zu finden. Suspensionen von Zellen des Ehrlichschen Mause-Ascites-Carcinoms nehmen dagegen in einem Medium, das Serum teilhepatektomierter Tiere enthalt, um 10–27% mehr Phosphat auf als unter Zusatz von Serum normaler Ratten. Das gleiche, von teilhepatektomierten Tieren gewonnene Serum wirkt demnach zum gleichen Zeitpunkt organspezifisch und nicht artspezifisch stimulierend auf die Phosphorylierungsprozesse der Leber und spezifisch hemmend auf die Phosphorylierung bestimmter Impftumoren und Tumorkulturen.

Zusammenfassung Serum von Tieren (Ratte, Maus, Hamster) das 48 bzw. 24 Std. nach der Durchfuhrung einer 60%igen Entfernung der Leber gewonnen wurde, steigert die Aufnahme von radioaktivem Phosphat aus dem Nahrboden durch explantierte Leber von Maus und Ratte in signifikanter Weise. Diese Wirkung ist demnach nicht artspezifisch. Sie ist organspezifisch. Auf explantierte Niere findet sich unter den gleichen Bedingungen keine Wirkung. Der deutlichste Effekt ist bei einem Zusatz von 20% Serum zum Nahrboden zu bestatigen. Der stoffwechselsteigernde Faktor ist thermostabil. Auch nach Erwarmen des Serums auf 100 ° ist die Wirkung nachweisbar. Explantation von embryonalem Leberhomogenat unter den gleichen Bedingungen zeigt nach der Kultur einen signifikanten Anstieg des hochmolekular, organisch gebundenen, mit Trichloressigsaure fallbaren aktiven Phosphates. Die sicherste Bestatigung der stimulierenden Wirkung im Serum gelingt bei Verwendung von etwa 1,0 mg schweren, in flussigem Medium suspendierten Explantaten im schnell rotierenden Rollerrohrehen-Apparat.

The incorporation rate of S35 DL-methionine into the perchloric acid-soluble (seromucoid) fraction of serum was studied in the same four dogs before and after a one-stage total hepatectomy. This incorporation rate was used as an index of seromucoid synthesis. In all dogs before hepatectomy there was a rapid incorporation rate reaching a maximum synthesis in approximately 6 hr after injection. After hepatectomy the average incorporation rate was reduced to about one-third of prehepatectomy levels. It is concluded that in the dog most of the perchloric acid-soluble (seromucoid) fraction is of hepatic origin whereas a smaller part is synthesized by extrahepatic tissues.

It is realized that intrahepatic cholangio-jejunostomy is an operative procedure of considerable risk and magnitude. Moreover, as noted in the first four cases mentioned, it may be performed for the purpose of relieving biliary tract obstruction in patients with very distressing symptoms with the additional hope of prolonging their lives. However, as demonstrated by the report of this last patient, an intrahepatic cholangio-jejunostomy may be a life-saving procedure and should have a definite, although limited place, in the armamentarium of every general surgeon.

SummaryDetails of a technic for repeated partial hepatectomy in the rat are presented. Up to 80% of the liver can be excised and aspirated at the first stage. Any one of the 3 principal lobes (right or left lateral or the median) will supported life after removal of all other remaining hepatic tissue. The caudate lobe will not support life if all other parts of liver are removed at the first stage. Following the restoration of liver additional partial removal of liver can be done by excision at the second and third stages. At all later stages the method of removing liver is that of aspiration. Careful attention to prevention of hypoglycemia, hemorrhage and infection insures uniform success of the procedure.

SummaryWhen hypothermia is induced in dogs prior to the production of liver anoxia by completely occluding the afferent hepatic circulation, the mortality rate of the procedure is greatly reduced (...

THE METHOD to be described in this paper is an extension of that of Markowitz, Yater, and Burrows.1The introduction of silicone by our colleague, Jacques, and the availability at surgical supply houses of blood vessel suture ready for use, together with considerable experience over the past two decades, has prompted us to publish this method in its present form. The operation of hepatectomy in the dog is a difficult technical procedure. When badly done the operation results in hemorrhage and shock; any studies made have to be considered in the light of these complicating factors. When done well hepatectomy results in a preparation that is seemingly normal for at least 12 hours; the duration of survival and the postoperative behavior following this time depend upon such uncontrollable circumstances as prothrombin, bleeding, and the general viability of the animal that has been selected essentially at random. Although the liver

Knowledge of the segmental and lobular structure of the liver (12, 13) has recently resulted in a more advanced fo~ of liver surgery. It is now technically possible to perform segmental resections lobectomies, and hemihepatectomies. For this type of surgery, better diagnosfie methods are required. Present roentgen technics include celiography (18), hepatic phlebography (16), percutaneous splenoportography (1, 2, 6, 7, 9, 14), and u~bilical (5, 11), hemorrhoidal (17), and direct portography (8, 10, 15). While not previously a routine procedure in clinical diagnosis of liver diseases, direct portography has recently been used by Ekengren and her co-workers (10) in postoperative follow-up of patients with a portocaval shunt. Their technic of direct Phrtography in animals resulted in good visualization of the intrahepatic portal vascualture and liver parenchyma (3). Direct portography has been employed routinely at Malmo General Hospital for the past two years as a complement to other diagnostic methods. This...

Current interest in hepatic resections 1 for various benign and malignant tumors has caused physicians at the Memorial Hospital to seek methods for decreasing blood loss. Bleeding from the point of suture has been most troublesome when the conventional eye-type needles and sutures are used. The doubled suture at the butt of the needle tears the thin liver capsule and vascular parenchyma, which results in massive blood loss during extended liver resections. After four years of extensive clinical and laboratory trial at the Memorial Hospital with various sizes of sutures (000 to 3) and needles (1.0, 2.0, 3.0, and 3.5 in.) with blunt and taper points, our final choice was a size 1 chromic gut suture swaged on a half circle 3.5-in. taper point needle with a diameter of 0.046 in. This atraumatic suture permits an adequate amount of tissue to be encompassed in a single bite and is large

OF THE numerous methods of repair of defects of the bile ducts, the two which are generally considered most dependable are direct end to end anastomosis of the distal and proximal segments of the duct and anastomosis of the proximal portion to the duodenum or jejunum. The first of these procedures is obviously the method of choice and, when the defect is short, is usually applicable. For strictures limited to the ampullary region with dilatation of the duct above, a choledochoduodenostomy or choledochojejunostomy affords an effective and physiologic means of overcoming the obstruction. In the presence of extensive destruction of the ducts, the problem is far more serious. Within recent years, hepaticojejunostomy with a supplementary enteroenterostomy, as suggested by Allen 1 and by Warren Cole, 2 has gained wide acceptance as a logical solution. After these procedures, however, one is confronted with the possibility of stricture at the site of

1. The present day concept is presented on the surgical approach to various lesions of the liver. 2. Thirteen cases are reported with a clinico-pathological analysis of disease of the liver, seven of which were primary malignant tumors of different types. 3. An attempt is made to classify various lesions of the liver. 4. A description is given of an effective technique in resection of large portions of liver.

SummaryChanges in serum proteins and mitotic activity in the liver of Lewis rats were studied after partial hepatectomy or sham operation, at intervals of 6 hours to 15 days. A rise of beta-globulin fraction roughly paralleled the rise in mitotic activity. Serum protein changes in sham-operated animals showed a similar trend but were less pronounced.

In the case reported herein prophylactic total right hepatic lobectomy was performed for invasive carcinoma of the gallbladder. The prognosis is good.

Although Brunn in 1870 removed a small hepatic tumor, the surgery of the liver does not seem to have attracted much attention until Lin, in 1886, successfully performed a partial resection. Since that date, however, more than 100 resections of portions of the liver have been reported. Among the exhaustive treatises on the subject those of Terrier and Auvray,1in France, and of Langenbuch,2in Germany, deserve especial mention. In America the name of W. W. Keen3of Philadelphia is intimately associated with the development of the technic of liver surgery. He has not only reported three cases of resection, in all of which recovered took place, but has also published an exhaustive review of the previous literature. Nor should it be forgotten that a Baltimore surgeon, Dr. Louis McLane Tiffany,4was one of the first Americans successfully to remove a tumor of the liver. The Nature of Hepatic Tumors.