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Liver Resection

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Background

 

  • Lobectomy, segmentectomy, or wedge resection

  • Indications for hepatic resection: hepatic metastases, benign & malignant primary hepato-biliary tumours, donation for transplantation, trauma

  • Liver = highly vascular; receives 25% of cardiac output; 80% supplies by portal vein, 20% by hepatic artery

  • ↑ risk of multi-organ dysfxn if underlying hepatic dz

 

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Considerations 

 

  • Potential for massive blood loss

    • Need for invasive monitors & access

  • Risk of postop liver dysfxn & coagulopathy

    • Risk of hypoglycemia during vascular occlusion & after resection

  • Altered drug metabolism in setting of liver dysfxn

  • Temporary occlusion of blood supply during liver resection (surgical technique to minimize bleeding) -->  ↓ CO up to 10%, ↑ LV afterload by 20-30%

  • Surgical manipulation may cause transient IVC compression & ↓↓ venous return

  • Potential co-morbidities: cancer 4M's (mass effects, medications, metastases, metabolic abnormalities), liver disease, EtOH, hepatitis C, carcinoid

 

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Goals​ & Conflicts

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  • Overall goals are to avoid & manage postop liver dysfxn, & minimize blood loss

  • Avoid hepatotoxins

  • Preoperative:

    • Assess adequacy of preop cardiopulmn fxn to tolerate surgery

    • Determine risk of postop liver failure

      • Depends on extent of resection & underlying liver dz

      • likely safe to remove 50-80% of liver in young pts w/ nl liver parenchyma

      • ↑ risk if sig EtOH consumption

      • Assessment of extent of liver dz

        • Child-Pugh B & C --> liver resection likely contraindicated

      • Pts may have portal vein embolization to induce liver hypertrophy preop

  • Intraoperative:

    • Arterial & central venous access, large bore IV access, rapid infusion system immediately available +/- minimally invasive CO monitoring

      • consider cell salvage esp if non-malignant lesion

    • Thoracic epidural must be carefully considered w/ risk of postop coagulopathy

      • Single-shot neuraxial opioids, IV opioid PCA, continuous wound infusion catheters are alternatives

    • Minimize CVP to ↓ blood loss

      • Minimize pre-resection IV fluids (max 1 ml/kg/hr)

        • titrate vasopressors to maintain optimal perfusion pressure

      • Reverse Trendelenburg positioning

      • Diuretics (Mannitol, furosemide)

      • NTG infusion

      • Minimize PEEP

    • Consider TXA

    • Maintain normothermia, nl pH, nl Ca2+ & normoglycemia

    • Monitor for & correct coagulopathy

    • Consider N-acetylcysteine to limit ischemia-reperfusion injury (mixed evidence)

    • Atracurium/cisatracurium preferred (unaffected by liver dysfxn)

  • Postoperative:

    • Monitor for postop liver dysfxn, coagulopathy

      • Glucose infusion, correction of coagulation & electrolyte abnormalities prn

    • Common to develop sig ascites (self-limiting) during 1st 48 hrs --> monitor for hypovolemia

    • Avoid acetaminophen until liver fxn returns to nl

 

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References

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