Hepatic Resection

Preoperative considerations before hepatic resection involve risk assessment as for other major abdominal procedures. Significant anemia and coagulopathy, if present, should be corrected preoperatively. Decisions regarding the choice and dosing of anesthetic drugs should account for any baseline hepatic parenchymal dysfunction, as well as the potential postoperative dysfunction resulting from resection of a major portion of the liver parenchyma.

Although the risk of significant intraoperative blood loss is well known and the need for appropriate monitoring and sufficient vascular access to permit rapid transfusion is widely accepted, overall fluid management during major hepatic resection is controversial. At some centers, fluid and blood administration is used liberally beginning early in the course of resection with the goal of increasing intravascular volume as a buffer against sudden blood loss. Other centers favor maintenance of a low central venous pressure during resection to minimize blood loss from hepatic venous radicals, major hepatic veins, or the vena cava. These sites typically contribute to most bleeding during hepatic resection. Notably, reduction of intrahepatic venous pressure can also be achieved by using a modest degree of the Trendelenburg position, an approach that will potentially maintain or even increase cardiac preload and cardiac output, as well as reduce the risk of air embolism from disrupted hepatic veins. In patients without preexisting renal dysfunction, the latter approach does not appear to have a significant impact on postoperative renal function.^[210]

Although basic postoperative management concerns are similar to those of other major abdominal procedures, several aspects of care are notable. Intravenous fluids should include phosphates, which are needed to facilitate liver regeneration and avoid severe hypophosphatemia. Decreased clearance of hepatically metabolized drugs is important in selecting and titrating methods of postoperative analgesia.