Anesthesia for Hepatic Resections
Dr Deidre Batty
Introduction:
Improved
understanding
of
segmental
anatomy of the liver has resulted in the evolution of
liver resection over the last 25 years. Resultant
improved perioperative outcome means that hepatic
resection is now the most effective and potentially
curative therapy for selected patients with benign
and malignant hepatobiliary disease. The current
approach to liver resection is aggressive because of
modern advances such as:
●
Enhanced
knowledge
of
functional
liver
anatomy
●
Appreciation of the functional reserve of the
liver and capacity for regeneration
●
Imaging modalities, including preoperative CT
scan and intraoperative ultrasound
●
Improved patient selection
●
Improved surgical technique.
●
Improved anesthetic management.
In this chapter we will focus on anesthetic
management
before,
during,
and
after
hepatic
surgery. The following factors make hepatic surgery
unique and challenging to the anesthetist:
●
Surgery is of long duration predisposing to
hypothermia, deep venous thrombosis, and drug
accumulation.
●
The large chevron (subcostal) incision causes
substantial postoperative pain.
●
Hemodynamic
manipulation
is
required
to
reduce blood loss and gain adequate surgical
access.
An
understanding
of
hemodynamic
changes during resection is required.
●
Warm ischemia time- understanding the limits
for safe resection time. Large resections can
predispose to hepatic insufficiency.
●
Hemorrhage can be sudden and dramatic. Be
prepared.
●
All
hepatic
surgery
patients
are
prone
to
developing
coagulative
impairment
perioperatively
(9%
have
delayed
epidural
removal if 3 or more segments are resected.)
This is linked to the extent of the resection and
length of operation.
●
Patients may well have received chemotherapy.
Some
agents,
particularly
those
used
for
downstaging
colorectal
metastases,
are
associated
with
steatohepatitis.
A
chemotherapy-free interval of at least 6 weeks is
recommended prior to resection.
Preoperative Assessment:
Your assessment must take into account:
●
The primary pathology
●
The site and volume of the planned resection.
●
Co-morbidities such as pulmonary disease, renal
dysfunction
and
cardiovascular
system
insufficiency
●
The presence of co-existing liver disease
●
The likelihood of blood transfusion. Bleeding is
more likely with repeat surgery, porta hepatis
(central) lesions, lesions close to large vessels,
large extended resections and in patients with
portal hypertension.
Work up usually involves:
●
Routine blood tests including complete blood
count
(hemogram),
electrolytes
and
renal
function, coagulation status and liver functions.
●
Electrocardiogram, chest x-ray, lung function
tests, liver imaging
●
Hepatitis B and C serologies
A mainstay of hepatic surgery is the Pringle
Maneuver, simultaneous occlusion of the hepatic
artery and portal vein for up to 60 minutes. The
Pringle
Maneuver
combined
with
low
CVP
technique constitutes a moderate hemodynamic
challenge. If in doubt about the cardiovascular
system status, a stress test or other assessment of
cardiac function is recommended.
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Anesthesia for Hepatic Resections
Dr Deidre Batty
The Pringle maneuver is occlusion of the hepatic artery,
portal vein and common bile duct, performed here with both a
latex
drain
and
a
vascular
clamp.
Source:
DOI:
10.5772/51775
The large upper abdominal incision means
that patients with respiratory co-morbidities such as
Asthma or Chronic Obstructive Pulmonary Disease
patients should be optimized preoperatively.
The following categories of patients are at
high risk of morbidity and mortality:
●
Patients
with
obstructive
jaundice:
Use
preoperative stenting of the to decompress the
biliary tract. Treat any infection that is present
and give Vitamin K 10mg intramuscular for 3
days prior to surgery.
●
Emergency surgery due to trauma or infection:
Make
sure
these
patients
are
adequately
resuscitated and work closely with the surgeon.
●
Cirrhotic patients. Childs A and B patients are
eligible for surgery and tend to tolerate liver
resections well, provided certain factors are
heeded. Volume to be resected must be carefully
assessed. Warm ischemia time limits must be
adhered
to
and
an increased incidence of
bleeding, perioperative hepatic dysfunction and
mortality must be understood and accepted by
the clinicians, patient and family.
However, patients with cirrhosis, impaired liver
function and inadequate coagulation may well
have
altered
cardiac
function
with
hyperdynamic circulation, portal hypertension
and
altered
pulmonary
reserve
with
hepatopulmonary syndrome. They are also at
risk of developing hepatorenal syndrome.
Intraoperative Management
No single anesthetic technique has been
proven to be superior to others. Thoracic epidural
analgesia is widely used for liver resection to
minimize anesthetic requirements intra-operatively
and to minimize pain postoperatively. Patients who
are coagulopathic or who otherwise cause concern
for epidural hematoma will be treated with general
anesthesia alone with postoperative morphine or
fentanyl, possibly delivered by Patient-Controlled
Analgesia if this is available. The thoracic epidural
anesthesia alternative (below) can also be utilized
for these patients by substituting spinal morphine
with low dose IV morphine.
Thoracic
epidural
for
upper
abdominal
surgery has the following advantages:
●
Optimal
pain
relief.
It
facilitates
early
extubation, mobilization and compliance with
physiotherapy.
●
Reduction
in
post
operative
pulmonary
morbidity: It attenuates reflex spinal inhibition
of diaphragmatic activity, decreases atelectasis,
and decreases respiratory failure in high-risk
patients.
●
Reduction in the incidence of paralytic ileus.
This benefit may be less when opiates are added
to local anesthetics.
●
A clinically significant reduction in cardiac
morbidity. Decrease in myocardial infarction
due to blockade of the T2 cardiac sympathetic
outflow with coronary vasodilation.
●
Improvement in patient-oriented outcomes such
as patient satisfaction and health related quality
of life.
●
An attenuation of the surgical stress response.
●
Earlier discharge due to all of the above
advantages.
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Anesthesia for Hepatic Resections
Dr Deidre Batty
Bilateral subcostal incision, typically used for major hepatic
surgery.
Thoracic Epidural is preferred in our institution
for:
●
Major open liver resection
●
Complex minor resection
i.e. with posterior or central position +/- redo
surgery +/- portal hypertension +/- IVC
involvement +/- biliary enteric anastomosis
●
Comorbidities
i.e. coagulation disorder where epidural
anesthesia is indicated for comorbidity
management intra/ and or postoperatively.
Alternatives to thoracic epidural are preferred in
our institution for:
●
Minor liver resection (<3 segments)
●
Minor open liver resection
●
Laparoscopic liver resection
●
Major or complex minor resection if thoracic
epidural is not possible/feasible
●
In scarce resource setting. (Thoracic epidurals
should be continued for at least 48hrs and
preferably 72 hours postoperatively for full
benefit and must be monitored in a high care
facility. Epidural alternative requires a minimum
of 24-hour high care monitoring because of the
risk of respiratory depression. It may be
preferable in a high bed pressure situation.)
Alternatives to thoracic epidural consist of:
●
Intrathecal morphine (ITM) at start of procedure
●
IV lignocaine and IV dexmedetomidine
infusions started prior to incision and continued
into high care for up to 24 hours.
●
Local bupivacaine at port sites for laparoscopic
work (Consider intrathecal and other lignocaine
dose given when calculating dose.)
●
If the case proceeds to open surgery stop IV
lignocaine half an hour prior to end of procedure
and add wound infusion catheters placed at the
end of surgery. 0.25% bupivacaine bolus plus
0.2 % infusion for up to 3 days postoperatively.
Consider intrathecal and other lignocaine dose
given when calculating dose.
These thoracic epidural alternatives emulate
the stress response reducing effects of epidural
analgesia, including sympatholytic effects
(dexmedetomidine), cytokine reducing effects
(lignocaine), and analgesic effects (spinal morphine,
wound infusion catheter).
Strategies for Hepato-Pancreatico-Biliary
Surgery
Monitoring and Induction
Continuous electrocardiography, oximetry,
capnography, and urinary catheter are required. A
14- or 16-gauge IV access is required. Most authors
recommend a second large peripheral line.
Arterial line and continuous venous pressure
(CVP) monitoring are required in all but the most
minor resections. Both are necessary if the low CVP
technique is to be employed. In low resource
settings, the anesthetist may have only one pressure
transducer, so it is acceptable to monitor the arterial
pressure continuously and the CVP intermittently
using the same transducer.
Temperature monitoring and whole-body
warming are required. Hypothermia contributes to
coagulation abnormalities. Large heat loss can
occur from the liver surface.
Anesthesia
Premedicate with low dose benzodiazepines
such as midazolam, titrate to effect.
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Anesthesia for Hepatic Resections
Dr Deidre Batty
Regarding the epidural catheter, we offer the
following advice:
●
Site the epidural at T9 – T10. Any higher than
this can lead to perineal and urinary catheter
discomfort
without
much
benefit
gained.
Insertion is also easier at this level (horizontal).
●
Bupivacaine is the usual medication for the
epidural. However, adding lignocaine to the
initial bupivacaine dose (3mls 2% lignocaine
plus
7mls
0.5%
Marcaine)
enables
quick
establishment
of
levels.
(It
is
advised
to
establish an adequate level prior to induction.)
●
Most
patients
require
10-15
mL
of 0.5%
bupivacaine to establish a block at T4-T5. One
can “paint the fence” after half an hour with half
the initial volume and concentration (5 - 7.5,mL
0.25% bupivacaine) and then maintain the block
with 3/4 of the original volume (7-12mL)
hourly.
This
can
be
done
with
a
0.25%
bupivacaine infusion but is best done with
hourly
boluses
for
maximal
hemodynamic
manipulation
and effect on CVP for liver
resection.
The ideal anesthetic technique is to maintain
a slow heart rate (60 -70 bpm) while vasodilating
the patient, dropping systolic blood pressure by
30% and lowering the CVP towards 5 mm hg.
Propofol induction aided by intravenous midazolam
with rocuronium works very well. (Cisatracurium is
used if there are concerns about renal function or
delayed rocuronium metabolism due to jaundice.)
Very little muscle relaxation is required due to the
high epidural.
Lung protective ventilatory strategies are employed
maintaining low peak pressures and normocapnia.
Elevated CO2 will lead to sympathetic stimulation
and splanchnic vasoconstriction.
Isoflurane and sevoflurane dilate the hepatic
artery and lower splanchnic vascular resistance-this
is beneficial during cross clamping. They also
maintain the hepatic artery/portal vein flow ratio of
70%:30%. Sevoflurane has the added advantage of
rapid wake up. This expedites communication with
the patient and early assessment of epidural levels
and efficacy. Avoid intravenous opiates if possible
due
to
the
risk
of
postoperative
respiratory
depression when combined with epidural opiates.
If narcotics are required in addition to an
appropriately
working
epidural,
preferably
use
fentanyl.
Nitrous
Oxide should be avoided if
possible as it decreases liver blood flow.
Patient ready for liver resection: Right internal jugular central
venous catheter (Red circle) allows measurement of central
venous pressure, which should be kept in the range of 5mmHg.
Thoracic epidural catheter (White circle) will allow for
adequate analgesia with minimal narcotics after a large
abdominal incision. Arterial line (Black circle) allows for
continuous measurement of blood pressure and control with
vasoactive medications, if necessary.
Hepatic surgery proceeds in the three steps,
each of which requires special consideration from
the
anesthetist.
These
are:
Exploration,
Parenchymal Transection, and Hemostasis. We will
consider each one separately:
Exploration: Mobilization with Vascular Control
The cornerstone of low CVP anesthesia is
fluid restriction until the hepatic parenchyma has
been transected. Fluid restriction combined with
vasodilation from the epidural leads to a state of
relative hypovolaemia. Use of a high epidural (T4)
(sympathetic blockade occurs up to two segments
higher than sensory blockade (T2) tends to suppress
any tachycardiac response resulting in lowered
Mean Arterial Pressure (up to 30% drop), stable
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Anesthesia for Hepatic Resections
Dr Deidre Batty
heart rate and low CVP. This is ideal for the
resection phase. During this initial phase, the
anesthetist will gradually allow these conditions to
be achieved.
The Exploration phase of the operation
involves.
●
Bilateral subcostal incision
●
Placement of a self-retaining retractor (such as
the Thompson retractor) for adequate exposure
●
Intraoperative ultrasound
●
Exclusion of extrahepatic disease.
●
Mobilization of the liver
●
Gaining vascular control
By the time the next phase will begin, the
CVP has drifted down to around 5 mmHg. If the
CVP does not drop appropriately one can use
0.25g/kg of Sodium Mannitol for diuresis.
If
general
anesthesia
alone
is
used,
nitroglycerine and furosemide can be employed to
lower the CVP.
In about 2% of patients an ongoing infusion
of vasoconstrictor is required to maintain adequate
Mean Arterial Pressure of 60mmHg and systolic
blood pressure of 90mmHg. This is best achieved
with a phenylephrine infusion titrated to effect. Very
low doses are usually required.
Parenchymal Transection
Once the liver is mobilized off the inferior vena
cava,
vascular
control
is
achieved,
and
intraoperative ultrasound has been used to confirm
the position and number of tumors. Resection now
begins. This is facilitated by intermittent clamping
of the porta hepatis, the Pringle Maneuver. The
patient should be 15 degrees Trendelenburg (head
down) to minimize the risk of air embolus. (In
reality surgeons generally prefer the patient slightly
head up.) Note that uncontrolled bleeding can occur
during this phase due to injury to the vasculature.
Liver mobilization can increase pressure on
the inferior vena cava, reducing venous return and
leading to hemodynamic instability. This can be
dramatic because relative hypovolemia has been
employed. Steps to correct this include asking the
surgeon to release pressure on the IVC, fluid bolus
to improve preload, and temporizing with ephedrine
boluses.
Mobilization of the liver by dividing its suspensory ligaments,
such as the right triangular ligament (Black arrow) and the
falciform / coronary ligament (White arrow) leaves the liver
much more mobile. Excessive pressure or torsion of the liver
after these ligaments have been released can lead to pressure
on the inferior vena cava and impaired venous return to the
heart.
Once transection is complete the surgeons
must move on to the following step and achieve
hemostasis.
Hemostasis
At this point the patient is volume repleted
with
the
appropriate
fluid:
crystalloid
for
maintenance and colloid, if available, for blood loss.
Central
venous
pressure
is
normalized.
The
surgeons may request the Valsalva maneuver to
increase the CVP and detect bleeding. Argon Laser
or high-power diathermy is utilized to coagulate the
liver surface. Procoagulant solutions, if available,
are sprayed over the surface to reduce the chance of
bleeding and bile leaks.
Once hemostasis is achieved, the patient is
closed,
anesthesia
is
reversed,
the
patient
is
extubated and transported to an intensive care unit
for postoperative care and epidural monitoring.
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Anesthesia for Hepatic Resections
Dr Deidre Batty
Completed hepatic resection (right anterior sectionectomy)
with hemostasis achieved. The middle hepatic vein (Black
arrow) and the right hepatic vein (White arrow) are adjacent
to the resection margins, demonstrating the potential for rapid
uncontrolled blood loss during hepatic surgery. Source: DOI:
10.5772/51029
Problems With The Low CVP Technique
The
presence of a low central venous
pressure and potential for wide open veins gives rise
to the risk of pulmonary embolus (Incidence 0.1 %.)
This
technique
also
allows
very
little
reserve. Patients are volume depleted, maximally
venodilated with a high epidural catheter. Potential
problems are:
●
The beta-blocked patient is relatively resistant to
ephedrine.
Phenylephrine
is
potentially
dangerous as an increase in SVR may induce
life threatening bradycardia.
●
The jaundiced patient with or without elevated
liver enzymes and the cardiovascular impaired
patient should not be intensively fluid depleted
because
of
the
potential
for
worsening
cholestasis
or
cardiovascular
instability
respectively.
●
Patients can still bleed:
●
Due to hepatic vein backbleeding.
●
Due to injury to hepatic veins near the IVC
during hepatic mobilization.
●
During
parenchymal
resection
to
gain
vascular control.
Bleeding during hepatic surgery, especially
from the venous system, is unpredictable and can be
massive requiring rapid and judicious resuscitation.
This may be difficult to do when there is little
reserve present.
The
low
CVP
technique
for
hepatic
resection does not appear to predispose to an
increase
in
renal
failure.
However
transient
asymptomatic increases in serum creatinine may
occur.
Postoperative Care
After surgery, patients require high care monitoring
with
emphasis
on
epidural
monitoring
and
hemodynamic stability. Hypoxia and hypotension
will put the liver remnant at risk for further
ischemic injury as will septicemia or drug toxicity.
These
patients
tend
to
have
a
hyperdynamic
circulation which resolves in 3-5 days. The increase
in splanchnic blood flow aids in rapid regeneration
of the liver. About half of all patients will develop
ascites and require volume expansion initially.
Glycemic control with an insulin infusion is
usually required. Hyperglycemia inhibits hepatic
regeneration. Hypoglycemia is extremely rare and
should raise concerns about ischemic liver damage.
Protection
against
stress
ulceration
is
advised
as
gastrointestinal
tract
bleeding may
precipitate
encephalopathy
in
an
already
compromised liver.
Patients
generally
continue
with
their
epidural infusions for 72 hours, maintaining a T4 -5
level with a 0.1 % bupivacaine /opiate infusion and
0.25% marcaine bolus as needed for “top-ups.”
For opiate infusion, morphine 0.05mg/mL or
fentanyl 2-4 mcg/ml can be added. Morphine has
the added advantage of providing analgesia for up
to 24 hours after removal of the epidural. At low
doses
of morphine (0.05mg/mL) there is less
incidence
of
nausea,
pruritus
and
respiratory
depression
over
3
days
than
when
higher
concentrations are used. Addition of an opiate to the
bupivacaine
infusion
is
necessary
to
prevent
tachyphylaxis, which will result in a need to
progressively increase infusion rates to maintain the
same sensory level.
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Anesthesia for Hepatic Resections
Dr Deidre Batty
Coagulation is altered postoperatively with
INR and platelets most commonly affected. In 9%
of cases, epidural removal must be delayed to 5
days postoperatively, or fresh frozen plasma infused
to drop INR to <1.5 prior to removal.
Hepatic and renal function are monitored
daily. Liver enzymes tend to rise in the first few
days starting to normalize by day 5. Expect rises in
transaminases of up to 1000mg/dL. Levels higher
than this again raise concerns of ischemic liver
injury which is more likely to occur with fatty or
cirrhotic livers, large resections and prolonged
warm ischemic time.
It is probably best to avoid paracetamol
(acetaminophen) initially. Remember that even in
segmental
resections,
the
liver
has had some
ischemic
time.
Non-steroidal
anti-inflammatory
medications
may
decrease
regeneration
and
predispose to acute kidney injury particularly in the
clinical setting of blood loss and cardiovascular
instability. For standardized orders, an “opt-in”
rather than “opt-out” policy with paracetamol and
NSAIDS is advised with reduction in doses as
appropriate.
Deep venous thrombosis prophylaxis should
be
implemented,
with
lower
limb intermittent
compression devices and low molecular weight
heparin started 6 hours postoperatively.
Patients undergoing large resections without
the benefit of epidural analgesia are more likely to
require postoperative ventilation.
Postoperative Morbidity and Mortality
Independent
predictors
for
postoperative
complications are.
●
ASA Classification
●
The presence of steatosis
●
The number of segments resected.
●
Simultaneous extrahepatic resection.
●
Perioperative blood transfusion lessens disease
free survival with colo-rectal metastases and
increases mortality to 11% if more than 2 units
are transfused.
Complications occur in about 20% of cases
and include pulmonary infection, intra-abdominal
abscess,
bile
leak,
postoperative
hemorrhage,
hepatic failure (1-3%) and renal failure (1-3%.)
Postoperative mortality is most commonly
due
to
myocardial
infarction,
cerebrovascular
accident, sepsis with multiorgan failure, pulmonary
embolism and duodenal perforation.
Conclusion:
Successful liver resection depends on:
●
Adequate
pre-operative
counselling
of
the
patient
●
A good knowledge of liver pathophysiology
●
A working team
●
The
ability
to
manage
intraoperative
hemodynamic challenges.
●
Good post-operative analgesia and care
“In some series, outcomes in liver resection have
been directly related to the ability of the anesthetist
to provide rapid, warm resuscitation, to maintain
perfusion & euthermia and to avoid acidosis.”
-The Society for Surgery of the Alimentary Tract
2006
Dr Deidre Batty, MBChB FCA(SA)
Department of Anaesthesia & Perioperative
Medicine
University of Cape Town
South Africa
October 2023
See also:
References- Further Reading
Guidelines- Anesthesia for Hepatobiliary Surgery
University of Cape Town Department of Anesthesia
and Perioperative Medicine
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