This chapter discusses open and laparoscopic approaches to the drainage of pyogenic hepatic abscess. Currently, most liver abscesses are drained percutaneously under ultrasound or computed tomography (CT) guidance. Several factors have been shown to correlate with failure of percutaneous drainage, including large size, the presence of multiple loculations, and communication with the biliary tree. Each patient is approached selectively and the treatment approach based on clinical status and imaging findings.

When percutaneous approaches are not available, the patient has failed percutaneous drainage, or if an abscess is not amenable to percutaneous drainage, operative drainage remains an essential treatment option for these patients. In some instances of refractory liver abscess or necrosis, liver resection may be necessary for definitive treatment. Knowledge of the principles of liver surgery essential for safe performance of major hepatic procedures is discussed elsewhere.