Hepatic resection - Revision history

Dpavlic1 at 13:43, 25 September 2024

2024-09-25T13:43:03Z

← Older revision		Revision as of 06:43, 25 September 2024
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	{{Infobox surgical procedure		{{Infobox surgical procedure
	\| anesthesia_type = General		\| anesthesia_type = General
	± Truncal block		± Truncal block or epidural
	\| airway = ETT		\| airway = ETT
	\| lines_access = Large bore IV		\| lines_access = Large bore IV
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	\|-		\|-
	\|Airway		\|Airway
	\|		\|Consider RSI for patients with ascites
	\|-		\|-
	\|Neurologic		\|Neurologic

Tony.Wang: Added living donor background

2023-01-26T16:10:26Z

Added living donor background

← Older revision		Revision as of 09:10, 26 January 2023
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	=== Hepatectomy for living donor liver transplant ===		=== Hepatectomy for living donor liver transplant ===
	~~Approach~~ is ~~similar~~ to ~~above~~, ~~however exquisite~~ attention to detail focused on adverse event prevention and safety given the altruistic and elective nature of this procedure.		Despite an increase in patients awaiting liver transplantation, donor organs remain limited. Live donor transplantation has emerged/evolved as a safe surgical practice, and allows for an increase in the donor pool in appropriately selected candidates with reduced waiting time, optimal recipient preparation, adequate surgical planning and marked reduction of cold ischemic time. In general, these transplant surgeries are planned months in advance. As a result, both donor and recipient candidates are thoroughly medically evaluated; cardiac studies, routine laboratory data, and functional testing is available for review. Patients will be admitted from home, and recipients are often well compensated with relatively low biologic MELD scores. Donor right (more common) or left hepatectomy is performed, and partial liver transplant occurs simultaneously in the recipient. Small-for-size syndrome has been described after split-liver transplantation, with clinical manifestations of cholestasis, coagulopathy, ascites, and GI bleed. Required graft-to-recipient body weight ratio is 0.8% to achieve graft and patient survival rates of 90% (Kiuchi et al, 1999), with ideal graft-to-body-weight of 1.5% (Heaton, 2003). Biliary complications are more common in live donor liver transplants.

			Exquisite attention to detail focused on adverse event prevention and safety given the altruistic and elective nature of this procedure.

	Donor partial hepatectomy is similar to standard liver resections.		Donor partial hepatectomy is similar to standard liver resections.

Chris.Rishel: Text replacement - "Art line" to "Arterial line"

2022-04-05T19:39:43Z

Text replacement - "Art line" to "Arterial line"

← Older revision		Revision as of 12:39, 5 April 2022
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	\| airway = ETT		\| airway = ETT
	\| lines_access = Large bore IV		\| lines_access = Large bore IV
	~~Art~~ line		Arterial line
	± Central line		± Central line
	\| monitors = Standard		\| monitors = Standard

Chris.Rishel at 06:53, 5 April 2022

2022-04-05T06:53:07Z

Show changes

Mitchel.DeVita at 14:35, 2 March 2022

2022-03-02T14:35:14Z

← Older revision		Revision as of 07:35, 2 March 2022
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	== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==		== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
	Hepatectomy for living donor liver transplant
			===== Hepatectomy for living donor liver transplant =====
			Approach is similar to above, however exquisite attention to detail focused on adverse event prevention and safety given the altruistic and elective nature of this procedure.


			Donor partial hepatectomy is similar to standard liver resections. Patients receive IV sedation with midazolam followed by a thoracic epidural for postoperative pain control (assuming no contraindications). Induction of anesthesia commences, followed by placement of large bore peripheral venous (14g/16g) and arterial catheter for BP monitoring. Central access is generally not required. Norepinephrine or phenylephrine can be utilized to maintain MAPs given the low volume/low CVP strategy during the dissection phase to minimize blood loss during dissection. Transfusion is rare.



	{\| class="wikitable wikitable-horizontal-scroll"		{\| class="wikitable wikitable-horizontal-scroll"

Mitchel.DeVita at 14:30, 2 March 2022

2022-03-02T14:30:53Z

← Older revision		Revision as of 07:30, 2 March 2022
Line 116:		Line 116:

	== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==		== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
			Hepatectomy for living donor liver transplant

	{\| class="wikitable wikitable-horizontal-scroll"		{\| class="wikitable wikitable-horizontal-scroll"

Mitchel.DeVita at 14:05, 24 February 2022

2022-02-24T14:05:47Z

← Older revision		Revision as of 07:05, 24 February 2022
Line 1:		Line 1:
	{{Infobox surgical procedure		{{Infobox surgical procedure
	\| anesthesia_type =		\| anesthesia_type = General +/- truncal block
	\| airway =		\| airway = ETT
	\| lines_access =		\| lines_access = Large bore PIVs and arterial line necessary. Some surgeons require central access for CVP monitoring.
	\| monitors =		\| monitors = Standard, consider CVP monitoring (generally not needed)
	\| considerations_preoperative =		\| considerations_preoperative = Ascites, coagulopathy
	\| considerations_intraoperative =		\| considerations_intraoperative = CVP <5 to minimize bleeding
	\| considerations_postoperative =		\| considerations_postoperative = Bleeding, bile leak
	}}		}}

	Hepatic resection involves either an open or laparoscopic approach to removal of ~~often~~ metastatic disease ~~from cancer~~, although other pathologies requiring resection ~~exist~~. In the past, hepatectomy was associated with up to 20% mortality rate. However significant improvements in surgical technique and management have resulted in large reductions in mortality and morbidity.		Hepatic resection involves either an open or laparoscopic approach to removal of liver neoplasms, such as adenomas, hemangiomas, FNH, and metastatic disease, although there are other pathologies requiring resection as well. In the past, hepatectomy was associated with up to a 20% mortality rate. However significant improvements in surgical technique and management have resulted in large reductions in mortality and morbidity.

	The surgical course includes four main phases: assessment, mobilization, parenchymal transection, and closure. ~~Keeping~~ central venous pressure (CVP) low through the first 3 phases ~~is crucial in preventing excessive hemorrhage~~. A low CVP makes the dissection phase easier (less distended hepatic outflow), and it minimizes venous back bleeding). Following parenchymal transection, patients can be appropriately resuscitated.		The surgical course includes four main phases: assessment, mobilization, parenchymal transection, and closure. One crucial aspect of hepatectomy management includes keeping central venous pressure (CVP) low through the first 3 phases of surgery. A low CVP makes the dissection phase easier (less distended hepatic outflow) and it significantly minimizes venous back bleeding. Following parenchymal transection patients can be appropriately resuscitated.

	== Preoperative management ==		== Preoperative management ==
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	\|-		\|-
	\|Neurologic		\|Neurologic
	\|		\|Patients with liver disease are at risk for encephalopathy 2/2 ammonia. Anesthetic requirements for patients with end-stage liver disease will often be reduced, due to underlying cerebral disturbances.
	\|-		\|-
	\|Cardiovascular		\|Cardiovascular
	\|		\|Significant liver dysfunction can result in systemic vasodilation from circulation of vasoactive mediators and vasodilators, as well as low grade endotoxin, which are not cleared by the compromised liver.
	\|-		\|-
	\|Pulmonary		\|Pulmonary
	\|		\|Restrictive lung disease from the presence of ascites and pleural effusions
	\|-		\|-
	\|Gastrointestinal		\|Gastrointestinal
	\|		\|Portal hypertension may manifest as GI bleeding, gastric and esophageal varices, ascites, and portosystemic shunts.

			Liver dysfunction can change drug metabolism
	\|-		\|-
	\|Hematologic		\|Hematologic
	\|		\|Anemia, thrombocytopenia, coagulopathy
	\|-		\|-
	\|Renal		\|Renal
	\|		\|End-stage liver disease can have associated renal insufficiency or renal failure.
	\|-		\|-
	\|Endocrine		\|Endocrine
	\|		\|Hypoglycemia is common in patients with advanced disease, due to impairment in gluconeogenesis.
	\|-		\|-
	\|Other		\|Other
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	=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===		=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===
			CBC for hemoglobin and platlets

			CMP for sodium, potassium, creatinine, glucose, bilirubin

			INR/coags

			Type and cross x2 PRBCs

	=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===		=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===
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	=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===		=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
			Consider truncal blocks such as transverse abdominis plane (TAP) or quadratus lumborum for post operative pain control.

			Can consider epidural for analgesia adjunct requiring a T6-8. Careful attention on the potential for coagulopathy. The extent of the coagulopathy is correlated with degree of resection

	== Intraoperative management ==		== Intraoperative management ==

	=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===		=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
			2 or more large bore peripheral IVs

			Arterial line

			Central line generally not needed to monitor CVP, limited fluid administration often sufficient. Generally only needed if unable to obtain peripheral IV access. However, some surgeons may require central line for CVP monitoring.

	=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===		=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
			Standard IV induction for most patients. Adjust if other comorbid conditions.

			Consider RSI if large volume ascities.

			ETT

	=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===		=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
			Supine

	=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===		=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
			Acceptable anesthetics can include TIVA, volatile, or a combination.

			One example of a balanced anesthetic could include: .5 Mac inhaled anesthetic, propofol infusion, ketamine infusion. Have a vasoactive agent available such as phenylephrine or norepinephrine.

			Keep central venous pressure (CVP) low through the first 3 phases of surgery, typically around 1L of fluids for most patients. Once complted patients can be resuscitated with fluids, typically requiring 2-3L of fluids

			There is a known risk of air embolism from open hepatic veins and this risk is exacerbated given an intentionally low CVP.

	=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===		=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
			Extubation in OR for almost all patients

	== Postoperative management ==		== Postoperative management ==

Mitchel.DeVita at 13:19, 24 February 2022

2022-02-24T13:19:06Z

← Older revision	Revision as of 06:19, 24 February 2022
Line 1:	Line 1:
		{{Infobox surgical procedure
		\| anesthesia_type =
		\| airway =
		\| lines_access =
		\| monitors =
		\| considerations_preoperative =
		\| considerations_intraoperative =
		\| considerations_postoperative =
		}}

		Hepatic resection involves either an open or laparoscopic approach to removal of often metastatic disease from cancer, although other pathologies requiring resection exist. In the past, hepatectomy was associated with up to 20% mortality rate. However significant improvements in surgical technique and management have resulted in large reductions in mortality and morbidity.

		The surgical course includes four main phases: assessment, mobilization, parenchymal transection, and closure. Keeping central venous pressure (CVP) low through the first 3 phases is crucial in preventing excessive hemorrhage. A low CVP makes the dissection phase easier (less distended hepatic outflow), and it minimizes venous back bleeding). Following parenchymal transection, patients can be appropriately resuscitated.

		== Preoperative management ==

		=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> ===
		{\| class="wikitable"
		\|+
		!System
		!Considerations
		\|-
		\|Airway
		\|
		\|-
		\|Neurologic
		\|
		\|-
		\|Cardiovascular
		\|
		\|-
		\|Pulmonary
		\|
		\|-
		\|Gastrointestinal
		\|
		\|-
		\|Hematologic
		\|
		\|-
		\|Renal
		\|
		\|-
		\|Endocrine
		\|
		\|-
		\|Other
		\|
		\|}

		=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===

		=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===

		=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
		NPO past midnight on night prior. Some protocols include use of clear carbohydrate beverage up to 2 hours prior to surgery.

		Avoid preoperative acetaminophen or gabapentin

		Consider Celebrex for multimodal pain control

		Consider scopolamine patch for PONV (do not give in patients with glaucoma)

		=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===

		== Intraoperative management ==

		=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===

		=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===

		=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===

		=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===

		=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===

		== Postoperative management ==

		=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===

		=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===

		=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===

		== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==

		{\| class="wikitable wikitable-horizontal-scroll"
		\|+
		!
		!Variant 1
		!Variant 2
		\|-
		\|Unique considerations
		\|
		\|
		\|-
		\|Position
		\|
		\|
		\|-
		\|Surgical time
		\|
		\|
		\|-
		\|EBL
		\|
		\|
		\|-
		\|Postoperative disposition
		\|
		\|
		\|-
		\|Pain management
		\|
		\|
		\|-
		\|Potential complications
		\|
		\|
		\|}

		== References ==

		[[Category:Surgical procedures]]

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