What factors affect bleeding during hepatectomy?

Factors Affecting Bleeding During Hepatectomy

The most significant factors affecting bleeding during hepatectomy include technical aspects of surgery, patient characteristics, and liver-specific factors, rather than traditional coagulation parameters. 1

Patient-Related Factors

• Male gender is independently associated with increased blood loss during hepatectomy 2
• Low prothrombin activity is a significant independent predictor of increased bleeding during liver resection 2
• Presence of cirrhosis, especially Child-Turcotte-Pugh class C, significantly increases bleeding risk during hepatectomy 1
• Obstructive jaundice is associated with higher intraoperative blood loss during liver resection 2
• Acute kidney injury increases bleeding risk, particularly in patients with acute-on-chronic liver failure undergoing procedures 1
• Hypofibrinogenemia has been identified as an independent predictor of bleeding in patients with acute-on-chronic liver failure 1
• Bacterial infections can significantly worsen bleeding risk during hepatectomy 1

Surgical and Technical Factors

• Longer hepatic transection time is independently associated with increased blood loss 2
• Total operating time directly correlates with bleeding risk during hepatectomy 2
• Surgeon's experience and technique significantly impact blood loss during liver resection 2
• Type of incision (J-shape or median incision) affects bleeding risk 2
• Extent of resection - major hepatectomy carries higher bleeding risk than minor resections 2
• Use of hemostatic devices significantly reduces intraoperative blood loss 2
• Central venous pressure (CVP) - lower CVP is associated with decreased blood loss during liver resection 1

Hemostatic Management Considerations

• Traditional coagulation tests (INR, PT) often overestimate bleeding risk in hepatectomy patients and do not reliably predict procedural bleeding 3, 1
• Viscoelastic testing (TEG/ROTEM) may better reflect actual coagulation status after hepatectomy, as patients often demonstrate normal or even hypercoagulable states despite elevated INR 3
• Platelet count below 50,000/μL may increase bleeding risk, though this threshold has not been well validated clinically 1
• Prophylactic blood product transfusion before procedures has not been shown to reduce bleeding risk and may paradoxically increase complications 1
• Thrombopoietin receptor agonists (avatrombopag, lusutrombopag) can increase platelet counts before procedures but have not demonstrated statistical differences in reducing procedural bleeding 1

Surgical Techniques to Reduce Bleeding

• Stroke volume variation (SVV) monitoring has shown better results than central venous pressure (CVP) monitoring in reducing blood loss during laparoscopic liver surgery 1
• Low central venous pressure technique decreases blood loss during hepatectomy 1
• Goal-directed fluid therapy targeting adequate cardiac output and end-organ perfusion may reduce morbidity 1
• Use of balanced crystalloids (e.g., Ringer's lactate) as maintenance fluid and colloids as volume expanders may optimize fluid management 1
• Laparoscopic approach can reduce blood loss when performed by experienced surgeons with appropriate equipment 4

Perioperative Management Strategies

• Anti-thrombotic prophylaxis with LMWH or unfragmented heparin should be started 2-12 hours before surgery to reduce thromboembolic complications 1
• Intermittent pneumatic compression devices can further decrease thromboembolic risk 1
• Preoperative steroid administration (methylprednisolone) may reduce inflammatory response but shows mixed results regarding complications 1
• Restrictive transfusion strategy (transfusion with hemoglobin <7 g/dl with a target of 7-9 g/dl) is recommended to avoid increasing portal pressure 1
• Routine use of tranexamic acid to decrease procedure-related bleeding is discouraged in patients with cirrhosis 1

Common Pitfalls to Avoid

• Overreliance on INR/PT values to predict bleeding risk, as these parameters often overestimate coagulopathy after hepatectomy 3, 1
• Unnecessary prophylactic blood product transfusions based solely on laboratory values, which may increase complications without reducing bleeding 1
• Excessive fluid administration can be as harmful as blood loss during liver surgery 1
• Focusing only on hemostatic parameters while ignoring technical aspects of surgery, which account for 75-90% of intraoperative and early postoperative bleeding 5
• Neglecting to treat underlying conditions like infections or acute kidney injury that may contribute more to bleeding risk than coagulation abnormalities 1