Hepatic resection

Hepatic resection

Anesthesia type	General ± Truncal block or epidural
Airway	ETT
Lines and access	Large bore IV Arterial 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
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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	Consider RSI for patients with ascites
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

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

Procedure variants

Hepatectomy for living donor liver transplant

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.

• 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