What are the key intraoperative steps for managing a patient undergoing hepatic resection?

Key Intraoperative Steps for Hepatic Resection

The most critical intraoperative steps for hepatic resection include maintaining low central venous pressure (below 5 cmH2O), using intermittent vascular inflow occlusion, and performing meticulous parenchymal transection with appropriate hemostatic techniques to minimize blood loss and reduce postoperative morbidity and mortality. 1

Anesthesia and Hemodynamic Management

• Low Central Venous Pressure (CVP) Technique:

  • Maintain CVP below 5 cmH2O during hepatic transection 1, 2
  • Strategies to achieve low CVP:
    • Judicious fluid restriction
    • Patient positioning (slight reverse Trendelenburg)
    • Vasodilators (e.g., nitroglycerin infusion)
    • Epidural anesthesia 3

• Fluid Management:

  • Use balanced crystalloids rather than 0.9% saline or colloids 1
  • Avoid excessive fluid administration which increases morbidity 1
  • Resume goal-directed fluid therapy after transection to restore tissue perfusion 1

• Temperature Management:

  • Maintain perioperative normothermia using multimodal approaches (circulating water garments, forced warm air) 1

Surgical Approach and Incision

• Incision Selection:

  • Choose appropriate incision based on patient's body habitus and tumor location 1
  • Avoid Mercedes-type incision due to higher incisional hernia risk 1
  • Consider minimally invasive approach when appropriate 1

• Minimally Invasive Surgery:

  • Laparoscopic liver resection is recommended for appropriate cases, particularly left lateral sectionectomy and resections of lesions in anterior segments 1
  • Requires surgeons experienced in both hepatobiliary and laparoscopic surgery 1

Vascular Control Techniques

• Inflow Occlusion Methods:

  • Intermittent portal triad clamping (Pringle maneuver) is preferred over continuous clamping 4
  • Apply in cycles of 15-20 minutes of occlusion followed by 5 minutes of reperfusion 4
  • Use with caution in patients with cirrhosis, fibrosis, steatosis, or cholestasis 4

• Total Vascular Exclusion:

  • Reserve for tumors that are large, deep-seated, hypervascular, or abutting hepatic veins/vena cava 4
  • Also indicated for patients with increased right-sided heart pressures 4

Parenchymal Transection Techniques

• Parenchymal Division:

  • Use ultrasonic dissection to skeletonize and identify vascular and biliary structures 3
  • Employ argon beam coagulation for hemostasis of the cut surface 3
  • Secure major vascular and biliary structures with sutures or clips before division 3

• Hemostasis:

  • Achieve meticulous hemostasis of the cut surface 3
  • Consider application of topical hemostatic agents on the resection surface

Biliary Management

• Bile Leak Prevention:
  • Identify and ligate biliary structures during parenchymal transection
  • Consider bile leak test with injection of saline or methylene blue into the bile duct
  • Secure major bile ducts with sutures rather than clips when possible

Completion Steps

• Abdominal Drainage:

  • Routine prophylactic drainage is not indicated for hepatectomy without biliary reconstruction 1
  • Evidence is inconclusive for hepatectomy with biliary reconstruction 1

• Omental Flap:

  • Consider using an omental flap to cover the cut surface of the liver after left-sided hepatectomy to reduce delayed gastric emptying 1

Avoiding Common Pitfalls

• Blood Loss Management:

  • Blood loss is a primary risk factor for morbidity and mortality 2
  • Meticulous attention to hemostasis throughout the procedure is essential
  • Transfusion requirements should be minimized as they correlate with worse outcomes 2

• Avoiding Bile Leaks:

  • Careful identification and ligation of biliary structures
  • Thorough inspection of the cut surface before closure

• Preventing Venous Air Embolism:

  • Keep the surgical field below the level of the heart when possible
  • Coordinate with anesthesia team when manipulating major hepatic veins

By following these key intraoperative steps with meticulous attention to technique, surgeons can minimize blood loss, reduce transfusion requirements, and improve overall outcomes in patients undergoing hepatic resection.