Post-hemi-hepatectomy Care
11/11/10
SP Notes
OHOA pages 550-551 (Part II Notes)
- major surgery
- perioperative mortality = 3%
- usual indication = metastatic colorectal adenocarcinoma or cholangiocarcinoma
- complications common post operatively
INTRAOPERATIVE
- be prepared for catastrophic blood loss (10U crossmatch)
- use shorting acting drugs that ideally minimally metabolised by liver
- invasive monitoring
- massive access (12Fr CVL or 7.5Fr Swan-Ganz introducer)
- thoracic epidural effective
- preserve hepatic blood flow (use isoflurane or desflurane)
- keep CVP 0-2mmHg and SBP 70-80mmHg (decreases bleeding and congestion)
- actively warm
- subarachnoid morphine
- remifentanil
- clonidine 1-2mcg\kg IM
1. perihepatic dissection
2. identification of vascular anatomy
3. may use intraoperative U/S to pinpoint lesions
4. resection
- resection causes bleeding that may need to be controlled using Pringle’s Manoeuvre
(intermittent cross clamping of vascular inflow) -> may cause ischaemic injury
POSTOPERATIVE
- bleeding/coagulopathy -> day 3: INR 1.2-1.8 + on LMWH! -> just when you want to pull epidural!
- hypothermia
- anaesthesia: partially reversed, N+V, pain, excessive analgesia
- cardiovascular: hypotension (mult-factorial), acute coronary syndrome, CVA, arrhythmias
- respiratory: atelectasis, pleural effusions, early infection, TRALI
- renal: oliguria, ATN -> ARF
- gastric stasis
- VTE risk
- sepsis
Jeremy Fernando (2011)

- pre-morbid conditions: UC -> primary sclerosing cholangitis, metastatic disease, steroids, immune state, nutrition
- coagulopathy -> bleeding: multifactorial
- pathophysiological cardiovascular changes: increased splanchnic blood flow, increased Q
- liver dysfunction: early sign = low urea day 1
- liver failure: within 72 hrs (jaundice, encephalopathy, coagulopathy, transaminitis)
- cholangitis
- respiratory: right pneumo/haemothorax, right diaphragmatic dysfunction
- gastrointestinal: ileus, ascites, haemorrhage, anastomotic leak
- renal: hepatorenal syndrome
- metabolic: hyperlactataemia, hypernatraemia, hypokalaemia
Jeremy Fernando (2011)