Preoperative Evaluation and Questions: availability of blood (~ 4 units), as the liver produces all pro-coagulants other than factor VIII. Consider vitamin K (10 mg IV or SQ), which will not help during surgery but which may benefit the patient within 24 h (note that coagulopathy peaks at ~ 24 hr after surgery). Vasopressor infusions drawn up and ready, as the potential for large blood loss is real.
Background: originally, hepatectomy carried a ~ 20% mortality rate. This was decreased by two major advances – first, the recognition that most of the bleeding is venous in nature, and second, better appreciation of hepatic anatomy. Some surgeons advocate placing a central line in all hepatectomy patients, maintaining CVP < 5 and even using venodilators.
Risk: mortality < 5%. Over the short term, mortality is most closely correlated with blood loss. Overall, the three most important factors are blood loss, extent of resection, and condition of the liver (e.g., cirrhosis) / baseline hepatic function (platelets < 80,000, albumin < 3.5 g/L, varices, ascites, and elevated INR increase the risk of postop liver failure and may make surgery unadvisable). The risk of resection is normally highest in patients with primary HCC because the uninvolved liver is often cirrhotic
Bile leaks are a major complication and source of morbidity, occurring in as many as 20% of cases.
Induction/Airway: standard IV induction. Most patients have cirrhosis secondary to hepatitis, of hepatocellular carcinoma, thus liver function may be decreased
Lines and Monitors: two large-bore IVs, arterial line (frequent labs, esp. glucose), +/- central line
Preoperative Meds: cefoxitin (do not give SQ heparin (5000 U) until AFTER the epidural, if placed)
Mode of anesthesia: general +/- epidural (T6-8, inferior angle of scapula is approximately T7). If epidural is considered, beware the potential for coagulopathy. Also note that INR may increase and platelets may decrease following surgery – the extent of the coagulopathy is correlated with extent of resection (R2 = 0.52), blood loss (R2 = 0.45), and fluids (R2 = 0.36) [Siniscalchi A et al. Liver Transpl. 10: 1144, 2004]
Surgical Course: broadly, the most basic steps are 1) access 2) mobilization 3) inflow control (portal vein, hepatic artery, bile duct) 4) outflow control (hepatic veins) and 5)parenchymal transection. Recently the trend has moved away from “anatomical resection” (respects the portal triad) and towards “non-anatomic resection” (resection of a lesion with 1-2 cm margins, irrespective of hepatic anatomy).
The most common approach to an anatomic resection, in the most common order, is mobilization of the liver to be resected, dissection of inflow and outflow structures, division of the inflow, division of the outflow, and parenchymal transection.
Access: incision is upper midline, extending to right subcostal region (Lexus incision).
Mobilization: division of the triangular ligaments (frees the liver from the diaphragm). Mobilization off of the vena cava.
Inflow control: obtained by a variety of techniques (ex. dissection of the liver hilum with control of the portal vein and hepatic artery, dividing the bile duct within the liver substance. Or, alternatively, dissection of the intrahepatic inflow pedicle, etc.)
Outflow control: classically, the hepatic vein was divided extrahepatically, but can also be divided within the liver during parenchymal transection.
Parenchymal resection: numerous techniques, including ultrasonic irrigators, radiofrequency coagulators, and/or clamp crushing techniques can be used. In the past, surgeons would temporarily occlude the hepaticoduodenal ligament (main portal vein, hepatic artery, and common bile duct) for up to 20 minutes (ie initiate the Pringle maneuver), which was used to minimize blood loss. Most patients will tolerate this maneuver for 15–20 min. In some patients, it may be necessary to repeat the Pringle maneuver. The other blood-sparing technique is total vascular exclusion, accomplished by completely occluding liver inflow and outflow. With good surgical exposure modern surgical techniques, the Pringle maneuver is rarely necessary. If total vascular occlusion is used, consider elevating CVP to at least 12 mmHg by rapid fluid administration before cross-clamping
Intraoperative Goals and Events: minimized fluids to decrease bleeding and minimize capacity for diluational coagulopathy. Consider mannitol, furosemide, or both if extensive radiofrequency ablation leads to hemoglobinuria (and possibly postoperative acute tubular necrosis) 
EBL: up to 1L, but highly variable
Duration: 3-8 hours
Emergence: depends on blood loss. If blood loss requires significant resuscitation, consider keeping intubated and sending directly to ICU. Most patients, however, can be extubated at the end of the operation
Post-Operative Concerns, Transport, Disposition: PACU
Siniscalchi A et al. studied 30 ASA 1 adult-to-adult living donors to examine the effects of various intraoperative variables on post-operative liver dysfunction following partial hepatectomy. They found that INR may increase and platelets may decrease in proportion with extent of resection (R2 = 0.52), blood loss (R2 = 0.45), and fluids (R2 = 0.36) [Siniscalchi A et al. Liver Transpl. 10: 1144, 2004]
A review of more than 1800 liver resections over a 10-year period from a single, high volume center (MSKCC), showed an operative mortality rate was 3.1% (only 1% for minor resections). Median blood loss was 600 cc. In the MSKCC series, morbidity was mostly related to blood loss and extent of resection [Jarnagin WR et al. Ann Surg 236: 397, 2002]
A recent, randomized, controlled trial of 64 patients undergoing liver surgery suggested that sevoflurane preconditioning (end expiratory sevoflurane 3.2% for 10 minutes, 30 minutes prior to ischemia in patients otherwise receiving propofol-based TIVA) may improve the incidence of postoperative liver injury as measured by peak transaminases levels. Additionally, this study showed a reduction in all and severe complications (secondary outcomes) [Beck-Schimmer B et al. Ann Surg 248: 909, 2008]