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Matthew Polasko, MD
Lauren Anderson, MD
Disclosures
No financial disclosures
No conflicts of Interest
Case History
42yr old M with metastatic colon cancer
presents for laparoscopic right hepatectomy
and sigmoidectomy• PMH
– s/p chemotherapy
• (avastin, cepecitabine, and FOLFOX)
– c/b bilateral foot neuropathy
– LIJ DVT
• s/p port placement
– currently on rivaroxaban held 72 hours prior to procedure
• PSH
– Inguinal Hernia Repair
• Meds
– Morphine
– Rivaroxaban
Case History
42yr old M with metastatic colon cancer
presents for laparoscopic right hepatectomy
and sigmoidectomy• NKDA
• Social History
– Hx of alcohol abuse
• 5’7’’ and 86 kg
• Labs:
– Hg 15, Plts 207
– Normal electrolytes and renal function
– Normal Coags
– No cirrhosis
Learning Objectives
• Review liver anatomy and blood supply
• Explain updated nomenclature for hepatic resection
• Summarize Anesthetic Management Principles of
Hepatectomy and the available evidence
• Identify intraoperative complications of hepatic
resection and discuss their management
Which figure below has the
longer middle segment?
Meet the Liver
Frequently Tested Facts
Receives 25% cardiac output
Blood flow by volume
– Favors portal vein to hepatic artery by 70:30
Blood flow by O2 delivery
– (50:50) due to hepatic artery O2 content
Hepatic artery can compensate for portal vein
– Hepatic arterial buffer response
• Low portal vein flow accumulates local adenosine
– Adenosine vasodilates hepatic artery
Hepatic Blood Flow
What’s in a Name?
Claude Couinaud
Brisbane 2000
Brisbane 2000
Brisbane 2000
• Acute massive blood loss can occur
- Planned: Transection of the liver
- Unplanned: Unintentional transection of the liver and
surrounding vascular structures
o Adequate IV access and transfusion plan
• Acute hemodynamic changes
- Blood loss
- IVC compression
- Air embolism
o A line is common if not considered essential
• Be judicious with IV fluids
- Principle of minimal fluid restriction (low CVP) strategy
o Prior to resection ***
General Anesthetic Considerations
Anesthetic Plan
• GA-ETT
• Post-Induction:– A Line
– 2 x 14G IV
– TAP Block +/- post-op epidural
• Intra-op goals:– Minimize fluids pre-liver transection***
– Resuscitate post-liver transection
– Monitor for acute hypotension
– Standard management for colectomy portion
Risks of Resection
Post-op
• Post-hepatectomy liver failure
– > or = post op day 5
• Elevated INR and hyperbilirubinemia
– Spectrum of symptoms about 8% hepatectomy
– When severe
• Coagulopathy
• Infection
• Multi-organ failure
Portal Vein Embolization
Laparoscopic Versus Open Hepatectomy
Advantages
• Lower Length of Stay
• Lower EBL / Transfusion rate
• Lower minor complication rate
No Difference in mortality nor major complications
Low CVP (< 5 mmHg)
Low CVP (< 5 mmHg)
Low CVP (< 5 mmHg)
Cochrane Review Oct. 31st 2016 – methods describing decreased blood loss
• All RCTs evaluated were assigned low or very low quality of evidence
• All RCTs evaluated were assigned a high risk of bias
• Low CVP vs control: lower EBL, lower LOS, less operating time
• Normovolemic hemodilution + low CVP less transfusion than low CVP
Powering the studies for type I 0.05 and type II 0.2 to show 20% risk reduction:
Mortality Rate: 1.8% would need 38,000
Transfusion Rate: 22% would need 2,600
2013: International Survey of Liver Surgery Referral Centers:
42 Replied (29 Asia, 9 Europe, 4 North America)
Why practice a low CVP strategy
in laparoscopic hepatectomy?
Back to the case….
IVC Compression
Anesthesiology
Differential Decreased/Low/No ETCO2
0
20
40
60
80
100
120
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69
Time (Minutes)
"And Eternity in an hour"
ETCO2
SpO2
MV
RR
MAP
HR
Earlier ETCO2 35 CO2 Embolism ETCO2 25
0
20
40
60
80
100
120
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69
Time (Minutes)
"And Eternity in an hour"
ETCO2
SpO2
MV
RR
MAP
HR
“Durant’s Maneuver – A Case of “Dog”ma
Anesthesiology
Anesthesiology, 2007
Summary
• New Naming System Liver Resection – Brisbane
• Low CVP Strategy in Hepatic Resection
• Challenge the evidence to support it
• Paucity of data to support during laparoscopic cases
• CO2 Embolism – Left lateral decubitus
• A historical narrative with poor evidence that persists
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References
Questions??? Or…
Once More Unto the Beach!
