Severing of the A. hepatica propria or one of its main branches
- Consequences are unpredictable and can range up to lobe necrosis.
- Therefore, reconstruction of the main artery is mandatory, if necessary as a V. saphena interposition.
Arterial bleedings
- Can occur during dissection of the hepatic hilum, are usually well controllable.
- Due to the risk of injury to bile duct structures and further vascular injuries, bleedings in the hepatic hilum should not be blindly stitched, instead successive free preparation and targeted management.
- Arterial vessel leaks: direct suture with Prolene® 5-0 or 6-0
Injury to the large hepatic veins and/or the vena cava
- Can lead to air embolisms or massive bleedings!
- Tangential clamping with oversewing
- In severe cases, manual compression and temporary occlusion of the V. cava caudal and possibly also cranial to the liver after opening the diaphragm (suprahepatic clamping).
Bleedings from the resection surface of the liver
- PRINGLE maneuver, therefore prior looping of the Lig. hepatoduodenale.
- Targeted transfiction ligation, no deep mass suturing, they lead to necroses of the surrounding parenchyma and can result in injuries to adjacent vessels, e.g., thin-walled hepatic veins.
- In case of massive diffuse bleeding from the resection surface (usually due to coagulation disorders), temporary packing with abdominal cloths may also be necessary.
Prophylaxis of intraoperative bleedings
- Adequate access with sufficient exposure
- Generous mobilization of the liver
- Preliminary looping of the Lig. hepatoduodenale
- Intraoperative sonography with depiction of the vascular structures in the resection area
- Controlled parenchyma dissection
- Avoidance of overfilling of the venous system (low CVP)
Severing / Injury of the CHD
- Direct anastomosis if necessary over T-drainage or creation of a biliodigestive anastomosis
Air embolism
- Is favored by low or even negative CVPs.
- Avoid further entry of air by detection, clamping or oversewing of the entry site, immediate PEEP ventilation
Pneumothorax
- Can occur in tumors close to the diaphragm → intraoperative thoracic drainage.
Hollow organ injuries
- In pre-operated patients, especially after cholecystectomy or previous interventions on the stomach, adhesiolysis must be performed. In the process, hollow organs can be injured, which must be managed/sutured accordingly.