Difference between revisions of "Hepatic resection"
| 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 | 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. | 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 == | ||
| Line 25: | Line 25: | ||
|- | |- | ||
|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 | ||
| Line 50: | Line 52: | ||
=== 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. --> === | ||
| Line 63: | Line 72: | ||
=== 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 == | ||
Revision as of 06:05, 24 February 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
| Variant 1 | Variant 2 | |
|---|---|---|
| Unique considerations | ||
| Position | ||
| Surgical time | ||
| EBL | ||
| Postoperative disposition | ||
| Pain management | ||
| Potential complications |