12/11/2015

LiverSurgery(Guide)

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Home / Encyclopedia / Liver Surgery (Guide)

Liver Surgery (Guide)

Hepatectomy
Preoperative Evaluation and Questions: availability of blood (~ 4 units), as the liver
produces all pro-coagulants other than factor VIII. Consider vitamin K (10 mg IV or
SQ), which will not help during surgery but which may benefit the patient within 24 h
(note that coagulopathy peaks at ~ 24 hr after surgery). Vasopressor infusions drawn
up and ready, as the potential for large blood loss is real.
Background: originally, hepatectomy carried a ~ 20% mortality rate. This was
decreased by two major advances first, the recognition that most of the bleeding is
venous in nature, and second, better appreciation of hepatic anatomy. Some surgeons
advocate placing a central line in all hepatectomy patients, maintaining CVP < 5 and
even using venodilators.
Risk: mortality < 5%. Over the short term, mortality is most closely correlated with
blood loss. Overall, the three most important factors are blood loss, extent of
resection, and condition of the liver (e.g., cirrhosis) / baseline hepatic function
(platelets < 80,000, albumin < 3.5 g/L, varices, ascites, and elevated INR increase the
risk of postop liver failure and may make surgery unadvisable). The risk of resection is
normally highest in patients with primary HCC because the uninvolved liver is often
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cirrhotic
Bile leaks are a major complication and source of morbidity, occurring in as many as
20% of cases.
Induction/Airway: standard IV induction. Most patients have cirrhosis secondary to
hepatitis, of hepatocellular carcinoma, thus liver function may be decreased
Lines and Monitors: two large-bore IVs, arterial line (frequent labs, esp. glucose), +/central line
Preoperative Meds: cefoxitin (do not give SQ heparin (5000 U) until AFTER the
epidural, if placed)
Mode of anesthesia: general +/- epidural (T6-8, inferior angle of scapula is
approximately T7). If epidural is considered, beware the potential for coagulopathy.
Also note that INR may increase and platelets may decrease following surgery the
extent of the coagulopathy is correlated with extent of resection (R2 = 0.52), blood
loss (R2 = 0.45), and fluids (R2 = 0.36) [Siniscalchi A et al. Liver Transpl. 10: 1144,
2004]
Positioning: supine
Surgical Course: broadly, the most basic steps are 1) access 2) mobilization 3) inflow
control (portal vein, hepatic artery, bile duct) 4) outflow control (hepatic veins) and
5)parenchymal transection. Recently the trend has moved away from anatomical
resection (respects the portal triad) and towards non-anatomic resection
(resection of a lesion with 1-2 cm margins, irrespective of hepatic anatomy).
The most common approach to an anatomic resection, in the most common order, is
mobilization of the liver to be resected, dissection of inflow and outflow structures,
division of the inflow, division of the outflow, and parenchymal transection.
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Access: incision is upper midline, extending to right subcostal region (Lexus incision).
Mobilization: division of the triangular ligaments (frees the liver from the diaphragm).
Mobilization off of the vena cava.
Inflow control: obtained by a variety of techniques (ex. dissection of the liver hilum
with control of the portal vein and hepatic artery, dividing the bile duct within the
liver substance. Or, alternatively, dissection of the intrahepatic inflow pedicle, etc.)
Outflow control: classically, the hepatic vein was divided extrahepatically, but can also
be divided within the liver during parenchymal transection.
Parenchymal resection: numerous techniques, including ultrasonic irrigators,
radiofrequency coagulators, and/or clamp crushing techniques can be used. In the
past, surgeons would temporarily occlude the hepaticoduodenal ligament (main
portal vein, hepatic artery, and common bile duct) for up to 20 minutes (ie initiate the
Pringle maneuver), which was used to minimize blood loss. Most patients will
tolerate this maneuver for 1520 min. In some patients, it may be necessary to
repeat the Pringle maneuver. The other blood-sparing technique is total vascular
exclusion, accomplished by completely occluding liver inflow and outflow. With good
surgical exposure modern surgical techniques, the Pringle maneuver is rarely
necessary. If total vascular occlusion is used, consider elevating CVP to at least 12
mmHg by rapid fluid administration before cross-clamping
Intraoperative Goals and Events: minimized fluids to decrease bleeding and
minimize capacity for diluational coagulopathy. Consider mannitol, furosemide, or
both if extensive radiofrequency ablation leads to hemoglobinuria (and possibly
postoperative acute tubular necrosis) [citation needed]
EBL: up to 1L, but highly variable
Duration: 3-8 hours
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Emergence: depends on blood loss. If blood loss requires significant resuscitation,

consider keeping intubated and sending directly to ICU. Most patients, however, can
be extubated at the end of the operation
Pain: 8/10
Post-Operative Concerns, Transport, Disposition: PACU
Other:
Evidence-Based Medicine:
Siniscalchi A et al. studied 30 ASA 1 adult-to-adult living donors to examine the
effects of various intraoperative variables on post-operative liver dysfunction
following partial hepatectomy. They found that INR may increase and platelets may
decrease in proportion with extent of resection (R2 = 0.52), blood loss (R2 = 0.45),
and fluids (R2 = 0.36) [Siniscalchi A et al. Liver Transpl. 10: 1144, 2004]
A review of more than 1800 liver resections over a 10-year period from a single, high
volume center (MSKCC), showed an operative mortality rate was 3.1% (only 1% for
minor resections). Median blood loss was 600 cc. In the MSKCC series, morbidity
was mostly related to blood loss and extent of resection [Jarnagin WR et al. Ann Surg
236: 397, 2002]
A recent, randomized, controlled trial of 64 patients undergoing liver surgery
suggested that sevoflurane preconditioning (end expiratory sevoflurane 3.2% for 10
minutes, 30 minutes prior to ischemia in patients otherwise receiving propofol-based
TIVA) may improve the incidence of postoperative liver injury as measured by peak
transaminases levels. Additionally, this study showed a reduction in all and severe
complications (secondary outcomes) [Beck-Schimmer B et al. Ann Surg 248: 909,
2008]

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Filed Under: Encyclopedia, Gastrointestinal and Hepatic Systems, L

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