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Liver Surgery (Guide)HepatectomyPreoperative 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 carr ied a ~ 20% mortality rate. This was

decreased by two major advances first, the recognition that most of the bleeding is

venous in nature, a nd second, better appreciation of hepatic anatomy. Some surgeons

advocate placing a central line in all hepatectomy pa tients, maintaining CVP < 5 and

even using venodilators .

Risk: mortality < 5%. Over the short ter m, mor tality 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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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 hilumwith 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, orboth 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 theeffects 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% forminor 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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