Liver resection

Surgical approach

• Open (subcostal/rooftop) or laparoscopic/robotic approach, mobilisation of liver (divide ligaments) and exposure of hilum/IVC
• Intra-op ultrasound to define lesions/vascular anatomy and plan transection plane
• Vascular inflow control as needed: Pringle manoeuvre (portal triad clamping) intermittent or continuous, selective inflow occlusion for segment/section
  • Typical cycles: 15–20 min clamp / 5 min release (varies by unit and liver reserve)
• Parenchymal transection (CUSA, harmonic, staplers), control of hepatic veins/IVC tributaries, haemostasis and bile leak control
• Low CVP technique often requested during transection to reduce venous bleeding, may require temporary IVC/hepatic vein control
• Potential for major haemorrhage and air/CO2 embolism (open hepatic veins, laparoscopy)

Anaesthetic management

• Type of anaesthesia: General anaesthesia with tracheal intubation, consider regional analgesia (epidural or alternatives) depending on coagulation and surgical approach
  • SGA generally inappropriate (long duration, aspiration risk, need for controlled ventilation and access)
• Duration: typically 3–8 hours (longer for major resections, redo surgery, vascular reconstruction, laparoscopy with complex lesions)
• Pain: moderate–severe (open major resections), moderate (laparoscopic). Plan multimodal opioid-sparing analgesia
• Key intra-op goals: maintain oxygen delivery, anticipate haemorrhage, facilitate low CVP during transection, avoid renal injury, maintain normothermia and correct coagulopathy
• Monitoring: arterial line, large-bore IV access, consider central access (for vasoactive drugs/rapid infusion) but balance against air embolism risk and line complications
  • Consider cardiac output monitoring in major resections/high-risk patients, consider TOE if high risk of embolism/major haemorrhage (expertise-dependent)
• Blood management: group &amp, crossmatch, cell salvage often used (case-dependent, discuss malignancy policy), rapid infuser available, massive haemorrhage protocol ready
• Post-op destination: HDU/ICU for major resections, significant blood loss, cirrhosis, or complications, otherwise monitored surgical ward with enhanced recovery

Indications and types of resection

• Indications: colorectal liver metastases, HCC, cholangiocarcinoma, benign tumours (adenoma), trauma, living donor hepatectomy
• Extent: minor (≤2 segments) vs major (≥3 segments), right/left hepatectomy, extended hepatectomy, segmentectomy/wedge
• Physiology: large hepatic venous capacitance, transection exposes hepatic veins → bleeding increases with higher CVP

Pre-operative assessment

• Assess liver function and reserve: history (alcohol, viral hepatitis, chemo-associated steatohepatitis), exam (portal HTN), labs (bilirubin, INR, albumin, platelets), imaging/volumetry
  • Risk stratification: Child-Pugh, MELD (more for transplant/advanced disease), presence of portal hypertension and future liver remnant (FLR) volume
• Cardiorespiratory assessment: major surgery, consider CPET if limited functional capacity, optimise anaemia and nutrition
• Renal risk: hepatorenal physiology, diuretics, ACEi/ARB, contrast exposure, baseline creatinine and electrolytes
• Coagulation: INR/PT, fibrinogen, platelets, note that conventional tests may not reflect balanced haemostasis in chronic liver disease—consider TEG/ROTEM where available
• Medication review: anticoagulants/antiplatelets, beta-blockers, diuretics, plan neuraxial only if coagulation acceptable and post-op anticoagulation plan compatible
• Aspiration risk: ascites, delayed gastric emptying, opioids, consider RSI when indicated

Intra-operative technique and monitoring (exam structure)

• Access: 2 large-bore peripheral cannulae, consider rapid infusion sheath, arterial line pre-induction for major resections
• Central venous access: not mandatory, if used, meticulous air-embolism precautions (Trendelenburg during insertion, occlusive dressings, de-airing), avoid unnecessary disconnections
• Monitoring: standard + invasive BP, temperature, urine output, frequent ABGs (Hb, lactate, electrolytes, ionised Ca), glucose, coagulation with TEG/ROTEM if bleeding
• Positioning: supine with arms out, consider slight reverse Trendelenburg, protect pressure areas, warming strategy
• Ventilation: lung-protective ventilation, avoid excessive PEEP during transection if it raises CVP and venous bleeding, tailor to oxygenation

Low CVP strategy (during parenchymal transection)

• Rationale: reduces hepatic venous back-bleeding and blood loss during transection, target often CVP ~0–5 mmHg (unit-specific, use trends rather than absolute numbers)
• How to achieve: restrict fluids pre-transection, avoid high PEEP, consider venodilators (GTN) and/or diuretics (furosemide) in selected patients, maintain anaesthetic depth, position (head-up) may help
• Maintain perfusion: use vasopressors (e.g., noradrenaline) to support MAP while keeping venous pressures low, aim adequate urine output over whole case rather than during transection
• Risks: renal hypoperfusion/AKI, hypotension, air embolism risk increased with low venous pressure, lactic acidosis if oxygen delivery compromised
• After transection: replete intravascular volume and correct coagulopathy, anticipate reperfusion/declamping haemodynamic changes

Haemorrhage and transfusion strategy

• Sources: hepatic veins/IVC, portal inflow, raw liver surface, adhesions in redo surgery, coagulopathy/hypothermia/acidosis
• Preparation: crossmatch (often 4–8 units or more depending on extent), fibrinogen, platelets available, rapid infuser, cell salvage policy, TXA per local protocol (balance thrombosis risk)
• Guided component therapy: use TEG/ROTEM + fibrinogen level, early fibrinogen replacement (cryoprecipitate/fibrinogen concentrate) common, maintain ionised calcium
• Massive haemorrhage: activate MHP early, prevent triad of death (hypothermia, acidosis, coagulopathy), consider permissive hypotension only if agreed and appropriate (often not in major hepatectomy)
• Air/gas embolism: suspect with sudden fall in ETCO2, hypotension, hypoxia, mill-wheel murmur, manage with 100% O2, flood field, stop insufflation (lap), aspirate via CVC if present, left lateral/head-down as appropriate, support circulation

Pringle manoeuvre and hepatic ischaemia

• What it is: clamping portal triad (hepatic artery + portal vein + bile duct) to reduce inflow bleeding
• Physiological effects: reduced venous return from splanchnic bed, potential haemodynamic changes, ischaemia-reperfusion injury risk (worse in steatotic/cirrhotic liver)
• Anaesthetic considerations: communicate clamp/unclamp, anticipate haemodynamic changes and metabolic load (lactate, K+), ensure adequate oxygen delivery and temperature control

Analgesia options

• Open surgery: thoracic epidural provides excellent analgesia but consider: intra-op low CVP (vasodilation), post-op coagulopathy risk, and VTE prophylaxis timing
• Alternatives: intrathecal opioid (single-shot), bilateral TAP/rectus sheath blocks, erector spinae plane block, wound catheters, PCA opioid + multimodal (paracetamol, cautious NSAIDs if renal risk/bleeding)
• Paracetamol: generally safe within dose limits, consider reduced dosing in severe liver disease/malnutrition (local policy). Avoid hepatotoxic combinations

Post-operative issues and complications

• Post-hepatectomy liver failure (PHLF): rising INR and bilirubin, hypoglycaemia, encephalopathy, lactate, risk increased with small FLR, cirrhosis/steatosis, major blood loss, sepsis
• Bleeding: surgical and coagulopathic, monitor drains, Hb, coagulation, consider TEG/ROTEM-guided therapy
• Bile leak and sepsis, pleural effusion/atelectasis, VTE risk, AKI (especially after prolonged low CVP, hypotension, nephrotoxins)
• Glycaemic control: risk of hypoglycaemia with reduced hepatic glycogen/gluconeogenesis, monitor glucose regularly

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