New Delhi: Complete mobilisation of the liver and careful examination of hidden areas in the upper abdomen are important to ensure that no cancerous tissue is left behind during complex abdominal cancer surgery, according to an AIIMS study.
The study by Dr M D Ray and his MCh Student Dr Anik Rathee from the Department of Surgical Oncology at Dr BRA-IRCH, AIIMS Delhi, highlighted the need for surgeons to carefully expose areas behind and around the liver, where cancer deposits can sometimes remain hidden.
The researchers also described a small high-risk area near the junction of the liver and a major vein(IVC) which they have termed “Ray’s triangle“, as an important area surgeons should be aware of while mobilising the liver.
The study, published in the Journal of the Egyptian National Cancer Institute, analysed 205 patients with ovarian cancer who underwent extensive surgery involving mobilisation of the liver at AIIMS between January 2014 and December 2025.
The researchers noted that removing all visible cancer is an important factor linked to better long-term survival in patients with advanced ovarian and other cancers involving the lining of the abdomen.
However, cancer deposits can be difficult to see on scans or may remain hidden beneath the liver, along the diaphragm, behind the liver or in other difficult-to-reach areas, they said.
The “complete” mobilisation of the liver allows surgeons to inspect these areas and remove any visible disease, the researchers said.
Among the 205 patients studied, complete or near-complete removal of visible cancer was achieved in 194 patients, or 94.6 per cent. Complete removal of all visible disease was achieved in 178 patients, while a small amount of residual disease remained in 16.
The researchers also recorded injuries to the right hepatic vein, a major vein carrying blood from the liver, in nine patients, or 4.4 per cent.
Seven of these injuries occurred among the first 100 patients, while two were reported among the subsequent 105 patients. The observed rate of such injuries fell from 7 per cent in the first 100 cases to 1.9 per cent in the later group. However, the researchers cautioned that the difference was not statistically conclusive.
Patients who suffered such an injury had higher average blood loss during surgery and stayed longer in the intensive care unit, the study found.
The researchers said the risk can be reduced by following a systematic approach, carefully identifying the blood vessels and avoiding forceful or blind movements while freeing the liver.
They said “Ray’s triangle” is not a formally recognised anatomical structure but a practical surgical warning area where the major vein, the liver and inferior vena cava meets.
The study included patients undergoing both planned surgery before chemotherapy and surgery after chemotherapy. In all cases, surgeons opened the abdomen through a midline incision and progressively freed the liver to examine the hidden areas.
In two patients, dense scarring made it unsafe to identify the normal tissue planes, and further removal was abandoned to avoid the risk of major venous injury.
The researchers concluded that successful surgery in advanced abdominal cancer requires more than removing disease that is immediately visible. A systematic examination of hidden areas, along with careful handling of the liver and nearby major vessels, can help improve the chances of removing all visible cancer safely.
