Total hepatectomy is performed predominantly for tumors, end-stage liver disease (e.g. cirrhosis), acute fulminant liver failure and failed allograft.
Be careful: there may be a metal stent in the bile duct. It can pierce through the glove and cause injury!
Weigh and measure (three dimensions) the liver.
Take photographs both before and after sectioning.
Examine the external (capsular) surface and describe it (nodularity [diffuse vs. focal, micro- vs. macro-], color, adhesions, lacerations). Palpate the entire specimen, noting its overall consistency (soft, friable, firm).
Since these specimens are often cirrhotic and may harbor nodules of hepatocellular carcinoma, the resection margins should be submitted, en face, for all specimens. This should be done prior to sectioning the liver. Margins include those of the bile ducts, gallbladder neck/cystic duct, hilar arterial / portal vein and hepatic/inferior vene cava.
Identify and dissect hilar lymph nodes. Sections through the hilum should be taken for cases of extrahepatic biliary atresia.
Serially section the specimen, at 1 cm intervals, in the transverse plane.
Measure and describe (color, texture, necrosis, hemorrhage, circumscription, solitary vs. multiple, right vs. left lobe) any masses or other lesions which are present. Measure distance to nearest margin(s) and note distance from surface.
In cases of primary sclerosing cholangitis (PSC), the common bile duct and its main branches (up to 3 cm from the hilum) should to be carefully examined and sampled.
For all type of specimens, all resection margins, cross-section (see Guideline & Procedure).
Hilum: two sections. More if involved by tumor or transplant for primary sclerosing cholangitis (PSC).
For cirrhotic liver: six representative sections (two sections can be placed in one cassette), two from each main lobe. Sample nodules that appear different from surrounding nodules to identify unsuspected hepatocellular carcinoma
For tumor specimen:
Tumor: six sections (more if very large tumor) taken from different-appearing areas. Include adjacent uninvolved liver and large vessel / duct in some sections.
Non-tumor liver: 2 - 4 random sections taken from different-appearing areas.
For failed allograft, 2 -3 sections of hepatic artery or portal vein thrombosis if identified. Otherwise, submit 5 -6 serial sections of the hilar region.
Gallbladder: one cassette containing three sections from different areas. More if involved by tumor.
Received without fixative/in formalin, labeled _____ and “_____”, is a total liver explant (__ g and __ x __ x __ cm) with attached gallbladder (__ cm in length, __ cm in diameter). The liver is _____ (soft, firm, friable). The external surface is _____ (color, smooth, micronodular, macronodular, adhesion-covered, lacerated). The hilar main vessels and ducts are opened to reveal ____ (e.g. stricture, thrombus, mass). The hepatic ducts and their main branches are ____ (e.g. patent, stenotic, obstructed by ___) and show ___ (e.g. impacted stone, periductal fibrosis). The liver is serially sectioned in 1 cm interval to show a ____ (color) diffusely multinodular cut surface, with nodules ranging from __ to __ cm in diameter. There is a __ x __ x __ cm _____ encapsulated / unencapsulated (color, irregular, nodular, necrotic, hemorrhagic, circumscription, cystic) mass in the _____ lobe, __ cm from the _____ margin and __ cm from the nearest _____ (anterior, posterior, inferior, superior) capsular surface. There is (no) main vessel or duct nearby / __ cm from the mass. No dominant nodule or mass in the remaining liver parenchyma. The gallbladder has a _____ (describe) external surface and a _____ (describe) mucosal surface, with a wall thickness of __ cm. It contains approximately __ cc of _____ (describe) bile and __ (number) _____ (describe) stones, measuring __ x __ x __ cm in aggregate and ranging from __ to __ cm in diameter. No/multiple lymph nodes with _____ (describe) cut surfaces, ranging from __ to __ cm in diameter, are present in the hilum. Representatively submitted as follows:
# __ = hilar bile duct and vascular margin, cross section.
# __ = hepatic vein margin.
# __ = mass / dominant nodule / mass, with adjacent vessel / duct.
# __ = mass / dominant nodule / mass, with adjacent liver.
# __ = mass / dominant nodule / mass, with serosal surface.
# __ = non-neoplastic liver
# __ = hilar area and lymph node (bisected).
# __ = gallbladder and cystic duct margin (inked blue)