What is the recommended anesthesia management for hepatectomies?

Anesthesia Management of Hepatectomies

For open hepatectomy, multimodal analgesia is the recommended approach rather than routine thoracic epidural analgesia, as epidurals cause hypotension and mobility issues that impair rapid recovery; for laparoscopic hepatectomy, multimodal analgesia with judicious IV opiates provides adequate pain control without regional techniques. 1

Analgesia Strategy by Surgical Approach

Open Hepatectomy

Multimodal analgesia is strongly recommended over routine thoracic epidural analgesia (TEA). 1 While TEA provides excellent pain control, it carries significant disadvantages that compromise recovery:

• TEA causes hypotension through sympathectomy-induced vasodilation, complicating fluid management and potentially causing acute kidney injury 1
• Postoperative coagulopathy after hepatectomy delays epidural catheter removal, increasing risk of complications 1
• TEA has higher technical failure rates and more frequent hypotensive episodes compared to alternatives 1

Preferred multimodal regimen components:

• Continuous wound infiltration (CWI) catheters with local anesthetic provide equivalent analgesia to TEA with lower complication rates and shorter hospital stays 1
• Intrathecal opiates combined with multimodal analgesia achieve similar results to TEA with lower likelihood of hypotension and reduced length of stay 1
• Transversus abdominis plane (TAP) blocks as supplement to standard analgesia improve pain control and reduce opiate usage 1
• Acetaminophen is safe after major hepatectomy if liver function preserved, but reduce dose to 2 g per day if significant parenchyma resected 1
• NSAIDs should only be used postoperatively if renal function is normal 1
• COX-2 inhibitors (parecoxib where authorized) added to PCA decrease postoperative pain 1
• Ketorolac infusion with IV fentanyl PCA improves analgesia and decreases fentanyl requirements 1

Laparoscopic Hepatectomy

Regional anesthesia techniques are not needed for laparoscopic liver surgery. 1 The smaller incisions and earlier gut function enable:

• Multimodal analgesia combined with judicious IV opiates provides functional analgesia 1
• Early transition to oral analgesia due to reduced analgesic requirements 1
• IV parecoxib infusion provides superior analgesia compared to IV fentanyl infusion 1

Intraoperative Fluid Management

Maintain low central venous pressure (CVP below 5 cmH₂O) with close monitoring during hepatic transection to minimize blood loss. 1

• Use balanced crystalloid as maintenance fluid, preferred over 0.9% saline or colloids 1
• Implement goal-directed fluid therapy after liver resection to optimize cardiac output and restore tissue perfusion, particularly beneficial for patients with comorbidities and reduced cardiac function 1

Temperature Management

Maintain perioperative normothermia (>36°C) using multimodal temperature management during both open and minimally invasive liver surgery. 1 Use circulating water garments or forced warm air 1

Pre-anesthetic Medication

Avoid long-acting anxiolytic drugs, particularly in elderly patients. 1

• Do not use preoperative gabapentinoids or NSAIDs 1
• Dose-adjust preoperative acetaminophen according to extent of resection 1
• Preoperative hyoscine patches can be used for high-risk PONV patients but avoid in elderly 1

Prophylactic Measures

Nasogastric Intubation

Routine prophylactic nasogastric intubation is not recommended as it offers no postoperative benefits and may increase hospital length of stay 1

Antiemetic Prophylaxis

Use multimodal approach with at least 2 antiemetic drugs such as dexamethasone and ondansetron for PONV prophylaxis 1

Antimicrobial Prophylaxis

Administer antibiotic prophylaxis (such as cefazolin) within 60 minutes before surgical incision, with no benefit extending into postoperative period 1

• Use chlorhexidine-alcoholic solution for skin preparation rather than povidone-iodine, as it lowers surgical site infection rates 1

Thromboprophylaxis

Start low molecular weight heparin or unfragmented heparin postoperatively unless exceptional circumstances make this unsafe 1

• Use intermittent pneumatic compression devices to further reduce thromboembolic risk 1

Special Considerations for Liver Disease

When managing patients with underlying liver disease:

• Fentanyl is the preferred opioid as it doesn't produce toxic metabolites and blood concentration remains stable in cirrhosis 2
• Hydromorphone is relatively safe as its half-life remains stable even with liver dysfunction 2
• Avoid codeine in cirrhosis due to metabolite accumulation causing respiratory depression 2
• Limit tramadol to 50 mg within 12 hours as bioavailability increases 2-3 fold in cirrhosis 2
• Implement bowel regimen with stimulant or osmotic laxatives to prevent constipation and potential hepatic encephalopathy 2

Postoperative Management

Encourage early oral intake with normal diet after hepatectomy. 1

• Maintain normoglycemia (<8.3 mmol/L) with insulin therapy 1
• Establish early mobilization (out of bed) from operative day until discharge 1

Critical Pitfalls to Avoid

• Do not routinely use TEA in open liver surgery within ERAS protocols due to hypotension risk and delayed catheter removal 1
• Do not place routine prophylactic nasogastric tubes as they increase pulmonary complications and hospital stay 1, 3
• Do not routinely place abdominal drains for hepatectomy without biliary reconstruction 1
• Do not use full-dose acetaminophen (>2 g/day) if significant liver parenchyma resected 1
• Do not use NSAIDs if renal function is abnormal 1