Medical Oncologist
CION Cancer Clinics
Tests before liver surgery: what each one checks | CION Cancer Clinics
Before liver surgery, tests answer three questions: can the whole tumour be removed, will the liver left behind be strong enough, and is your body fit for a long operation. Scans look at the tumour, blood tests and volume measurements look at the liver, and heart and lung checks look at you. This page explains each test in plain words, and what happens if the results point away from surgery. At CION Cancer Clinics, a multidisciplinary tumour board weighs your liver function and your scans before recommending any treatment.
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Medically reviewed by Dr. Muralidhar MuddusettyConsultant Surgical Oncologist · MBBS (AIIMS), MS (Surgery, AIIMS), DNB (Surgical Oncology), MRCS (Edinburgh) · last reviewed October 2026, next review due October 2027
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On this page
- Why are so many tests needed before liver surgery?
- What exactly is being checked?
- What happens between the first scan and the operation date?
- What do the words on the pre-surgery reports mean?
- Are all these tests really necessary?
- What if the tests show surgery is not safe for me?
- What this page cannot tell you
- Common questions about tests before liver surgery
The short answer
Why are so many tests needed before liver surgery?
The tests before liver surgery answer three questions: can the tumour be removed completely, will the liver left behind be strong enough to keep you well, and is your heart, lungs and general health fit for a long operation. A liver tumour that looks small on a scan is only half the decision.
Why the liver itself is tested so carefully
After a resection, the remaining liver has to do the whole job while it regrows. A healthy liver copes with losing a large part. A liver scarred by cirrhosis or long-standing hepatitis may not. This is the most common reason a small tumour still cannot be removed, which we explain on why a small tumour sometimes cannot be removed.
Who this page is for
This page is for people being assessed for a liver resection, whether for primary liver cancer (HCC, or hepatocellular carcinoma) or for cancer that has spread to the liver from the bowel or elsewhere. The tests overlap, but the reasons behind some of them differ. Transplant assessment is a separate and longer process with its own page.
What the tests are for
What exactly is being checked?
Every test belongs to one of three groups. Knowing which group a test sits in makes the long list far easier to follow.
The tumour
Scans show how many tumours there are, how big, how close to the main blood vessels, and whether cancer has spread outside the liver.
- Triple-phase CT or liver MRI
- CT of the chest
- AFP and other blood markers
- PET-CT in some cases
The liver
Blood tests and scans show how well the rest of the liver works and how much of it will remain after the operation.
- Bilirubin, albumin, INR and platelets
- Child-Pugh and MELD scores
- Liver stiffness (FibroScan)
- Volume measurement on CT
The rest of the body
Checks that you can safely go through anaesthesia and recover.
- ECG and often a heart scan (echo)
- Chest X-ray, sometimes lung tests
- Kidney function and blood sugar
- An anaesthetic review
The extras some people need
An endoscopy to look for varices, swollen veins in the food pipe caused by portal hypertension (raised pressure in the liver's main vein). Hepatitis B and C tests. Blood group for the blood bank.
Not sure whether this applies to you?
Ask an oncologistIn what order
What happens between the first scan and the operation date?
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Your existing scans and reports are reviewed
Bring every scan disc and report you have. A good recent triple-phase CT or MRI may not need repeating. An older or poor-quality scan usually does.
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Blood tests and liver scoring
A single set of blood tests gives the Child-Pugh and MELD scores. These decide early on whether surgery is even worth assessing further.
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The tumour board looks at everything
Surgeons, oncologists and radiologists review the scans together and agree whether resection is the right option, or whether ablation, TACE or another approach fits better.
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Planning scans for the operation
If surgery is likely, the remaining liver volume is measured. If it is too small, portal vein embolisation may be offered first to grow it.
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Fitness checks and the anaesthetic review
Heart, lung, kidney and sugar checks come last, closest to the date, so the results are current when you are admitted.
On your report
What do the words on the pre-surgery reports mean?
- Bilirubin
- A yellow pigment the liver clears. A high level means the liver is struggling, and it is one of the strongest warnings against major surgery.
- Albumin
- A protein the liver makes. A low level suggests the liver, or your nutrition, needs support before any operation.
- INR
- How quickly blood clots. The liver makes clotting proteins, so a raised INR can reflect weak liver function.
- Child-Pugh and MELD
- Scores that combine several results into one picture of liver function. See Child-Pugh A, B and C explained.
- Future liver remnant
- The part of the liver that will be left after surgery, measured on CT. Too little remaining liver is a common reason to change the plan.
- ICG clearance
- A test some centres use, where a harmless dye is injected and its removal by the liver is measured. It gives an extra view of liver reserve.
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Commonly believed
Are all these tests really necessary?
"The tumour is small, so the surgery must be simple."
Size is only one part. A small tumour near a major blood vessel, or in a cirrhotic liver, can be harder to remove safely than a large one in a healthy liver. The tests exist to find this out before, not during, the operation.
"A PET-CT is the most complete scan, so we should ask for it."
PET-CT often misses primary liver cancer, so it does not replace a triple-phase CT or MRI. It is used in selected cases. Read why PET-CT often misses HCC.
"A biopsy is always needed before surgery."
Often it is not. Primary liver cancer can usually be diagnosed from the pattern on a good scan, especially in a liver with cirrhosis. Your team will explain whether a biopsy is needed in your case.
"Repeating tests is just a way to raise the bill."
A fair worry. Ask why each repeat is needed. The usual reasons are an old scan, a scan without the right phases, or results that have changed. A good team will answer plainly.
When surgery does not suit
What if the tests show surgery is not safe for me?
Sometimes the tests show that the operation would carry too much risk. The usual reasons are a liver too weak to recover, raised pressure in the liver's veins, too little liver left after removal, cancer outside the liver, or a heart or lung condition that makes a long anaesthetic unsafe.
This does not mean nothing can be done
Many people who are not suited to resection can have ablation, TACE, radiation or medicines, and some are assessed for a transplant. A small liver cancer in a weak liver is sometimes better treated by ablation or transplant than by resection. The same tests guide that choice, so none of them are wasted.
Sometimes the answer is to prepare first
Weak nutrition, uncontrolled sugar or recent heavy drinking can sometimes be improved before a second look. Read cancer surgery with cirrhosis for how the team prepares a liver for an operation.
Being straight with you
What this page cannot tell you
It cannot tell you whether your liver will pass these tests, or which of them you personally need. That depends on your scans, your blood results, the cause of any liver disease and your general health. Only your surgical team, with the tumour board, can put those together.
Who this does not apply to
People being assessed for a liver transplant follow a longer list set by the transplant centre. People having TACE or ablation need some of these tests, but not the full surgical work-up.
Where CION fits
CION's surgical oncologists assess and plan liver operations and review every case at the tumour board. CION arranges the scans, endoscopy and other tests through accredited diagnostic and hospital partners, and your team will tell you where each one takes place. Bring every report you already have. It often saves both time and money.
Ask for a written list of the tests planned and an itemised estimate before they begin.Questions we are asked
Common questions about tests before liver surgery
How long do the tests take to complete?
It varies. If your recent scans are good enough, the work-up can be finished fairly quickly. Extra steps such as an endoscopy, a heart scan or portal vein embolisation add time. Ask your team for a likely plan and date once they have seen your reports.
Do I need to fast for these tests?
Some, yes. Certain blood tests, scans with contrast and an endoscopy usually need an empty stomach for a few hours. You will be told for each test. Keep taking your regular medicines unless told otherwise, and mention any blood thinners or diabetes medicines.
Why is an endoscopy needed for a liver operation?
Cirrhosis can raise pressure in the liver's veins and cause varices in the food pipe. Finding them matters, because raised pressure makes liver surgery riskier. Read more on endoscopy to check for varices.
My kidney or sugar results are poor. Will surgery be cancelled?
Not necessarily. Diabetes and mild kidney problems can often be controlled before the operation. The team will treat them first and recheck. Very poor results may change the plan, and the team will explain the other options available.
Do I need hepatitis tests if I have never had hepatitis?
Yes. Hepatitis B and C often cause no symptoms for many years. Knowing whether either is present helps protect the liver after surgery, and hepatitis B in particular may need medicine to keep it controlled. A positive result is not a judgement on anyone.
Can tests done at another hospital be used?
Often, yes. Recent blood tests, a good-quality triple-phase CT or MRI, and heart reports can usually be reviewed rather than repeated. Bring the actual scan discs, not just the written reports, because the surgeons need to see the images themselves.
What does it mean if my AFP is normal?
AFP is a blood marker that is raised in many, but not all, primary liver cancers. A normal AFP does not rule cancer out and does not change the need for surgery. It gives a baseline that is useful for checking after the operation.
Who can explain my results to me?
Your surgical oncologist, ideally at a consultation where you can bring a family member. Write your questions down in advance. If you are unsure where to start, call the CION helpline and someone will arrange a review of your reports.
Your Specialists
Meet CION's liver cancer specialists. Bring your scan reports and liver blood tests.
Our medical and surgical oncologists plan liver cancer care together, weighing the tumour and how well your liver works before choosing surgery, a liver-directed procedure or medicines.
Medical Oncologist
Dr. C. Raghavendra Reddy
MBBS(Gold Medal), DNB(General Medicine), DM(Medical Oncology)(Gold Medal)
Medical Oncologist
Dr. Bharati Devi Gorantla
MBBS, MD(General Medicine), DM(Medical Oncology)(Adyar,Chennai), ECMO, MRCP SCE(UK)
Medical Oncologist
Dr. Owais Mohammed
MBBS, MD (General Medicine), DrNB (Medical Oncology), ECMO, MRCP SCE (Medical Oncology) (UK)
Medical Oncologist
Medical Oncologist
Surgical Oncologist
Dr. Muralidhar Muddusetty
MBBS (AIIMS), MS (Surgery) (AIIMS), DNB (Surgical Oncology), MRCS (Edinburgh)
Surgical Oncologist
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Sources
- Cancer Research UK — Surgery for liver cancer
- American Cancer Society — Surgery for Liver Cancer
- American Cancer Society — Diagnosing Liver Cancer
- Cancer Research UK — Diagnosing liver cancer
This page is general information, not a prescription. Do not change or stop any treatment based on what you read here. If anything is worrying you, contact your own treating team — or call our helpline and we will help you reach the right specialist.
Keep reading
Related pages
Who is suitable for liver surgery?How the test results turn into a yes or a noFuture liver remnant: the number surgeons calculateThe volume measurement explained in detailWhy a small tumour sometimes cannot be removedThe question most families ask after these testsArranging blood donors before liver surgeryThe other thing to organise before the operation
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Send us your scans and reports, and our team will tell you what is still needed and why. Nothing is repeated without a reason you understand. One helpline serves every CION centre.