Difference between revisions of "Hepatic resection"

Hepatic resection
Anesthesia type	General ± Truncal block
Airway	ETT
Lines and access	Large bore IV Art line ± Central line
Monitors	Standard 5-lead ECG Temperature ABP ± CVP
	Primary anesthetic considerations
Preoperative	Ascites Coagulopathy
Intraoperative	CVP <5 to minimize bleeding
Postoperative	Bleeding Bile leak
	Article quality
Editor rating	In development
User likes	0

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Revision as of 22:53, 4 April 2022

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 platelets
CMP for sodium, potassium, creatinine, glucose, bilirubin
Coagulation panel
Type and cross PRBCs x2

Operating room setup

Patient preparation and premedication

Some protocols encourage 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

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
- 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

Have a vasoconstrictor 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 completed 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 most 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
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References

Top contributors: Mitchel DeVita, Tony Wang, Denisa Pavlickova and Chris Rishel

@@ Line 1: / Line 1: @@
 {{Infobox surgical procedure
-| anesthesia_type = General +/- truncal block
+| anesthesia_type = General
+± Truncal block
 | airway = ETT
-| lines_access = Large bore PIVs and arterial line necessary. Some surgeons require central access for CVP monitoring.
+| lines_access = Large bore IV
-| monitors = Standard, consider CVP monitoring (generally not needed)
+Art line
-| considerations_preoperative = Ascites, coagulopathy
+± Central line
+| monitors = Standard
+-lead ECG
+Temperature
+ABP
+± CVP
+| considerations_preoperative = Ascites
+Coagulopathy
 | considerations_intraoperative = CVP <5 to minimize bleeding
-| considerations_postoperative = Bleeding, bile leak
+| considerations_postoperative = Bleeding
+Bile leak
 }}
@@ Line 25: / Line 34: @@
 |-
 |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.
+|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.
+|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
@@ Line 52: / Line 62: @@
 === 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
+* CBC for hemoglobin and platelets
+* CMP for sodium, potassium, creatinine, glucose, bilirubin
-INR/coags
+* Coagulation panel
+* Type and cross PRBCs x2
-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. --> ===
 === 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)
+* Some protocols encourage 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
 === 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
+* 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<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
-or more large bore peripheral IVs
-Arterial line
+* 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.
+* Central line generally not needed to monitor CVP, limited fluid administration often sufficient
+** 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. --> ===
-Standard IV induction for most patients. Adjust if other comorbid conditions.
-Consider RSI if large volume ascities.
+* Standard IV induction for most patients. Adjust if other comorbid conditions.
+* Consider RSI if large volume ascities.
+* ETT
-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
-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. --> ===
-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.
+* Have a vasoconstrictor 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 completed patients can be resuscitated with fluids, typically requiring 2-3L of fluids
-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.
-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 most patients
-Extubation in OR for almost all patients
 == Postoperative management ==
@@ Line 117: / Line 125: @@
 == 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.
-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.
+* 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"
@@ Line 163: / Line 174: @@
 [[Category:Surgical procedures]]
+[[Category:General surgery]]
+[[Category:Hepatic surgery]]

Anesthesia type	General ± Truncal block
Airway	ETT
Lines and access	Large bore IV Art line ± Central line
Monitors	Standard 5-lead ECG Temperature ABP ± CVP
Primary anesthetic considerations
Preoperative	Ascites Coagulopathy
Intraoperative	CVP <5 to minimize bleeding
Postoperative	Bleeding Bile leak
Article quality
Editor rating	In development
User likes	0