Difference between revisions of "Hepatic resection"
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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. | |||
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Revision as of 07:35, 2 March 2022
Anesthesia type |
General +/- truncal block |
---|---|
Airway |
ETT |
Lines and access |
Large bore PIVs and arterial line necessary. Some surgeons require central access for CVP monitoring. |
Monitors |
Standard, consider CVP monitoring (generally not needed) |
Primary anesthetic considerations | |
Preoperative |
Ascites, coagulopathy |
Intraoperative |
CVP <5 to minimize bleeding |
Postoperative |
Bleeding, bile leak |
Article quality | |
Editor rating | |
User likes | 0 |
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. 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
Patient evaluation
System | Considerations |
---|---|
Airway | |
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 | 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 | Restrictive lung disease from the presence of ascites and pleural effusions |
Gastrointestinal | Portal hypertension may manifest as GI bleeding, gastric and esophageal varices, ascites, and portosystemic shunts.
Liver dysfunction can change drug metabolism |
Hematologic | Anemia, thrombocytopenia, coagulopathy |
Renal | End-stage liver disease can have associated renal insufficiency or renal failure. |
Endocrine | Hypoglycemia is common in patients with advanced disease, due to impairment in gluconeogenesis. |
Other |
Labs and studies
CBC for hemoglobin and platlets
CMP for sodium, potassium, creatinine, glucose, bilirubin
INR/coags
Type and cross x2 PRBCs
Operating room setup
Patient preparation and premedication
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
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
Monitoring and 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
Standard IV induction for most patients. Adjust if other comorbid conditions.
Consider RSI if large volume ascities.
ETT
Positioning
Supine
Maintenance and surgical considerations
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
Extubation in OR for almost all patients
Postoperative management
Disposition
Pain management
Potential complications
Procedure variants
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.
Variant 1 | Variant 2 | |
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Unique considerations | ||
Position | ||
Surgical time | ||
EBL | ||
Postoperative disposition | ||
Pain management | ||
Potential complications |