Complications - Left lateral liver resection, open

1.1a Bleeding

Arterial bleeding

• May occur during dissection of the hepatic hilum but usually is easily managed.
• Due to the risk of injury to bile duct structures and other vessels, bleeding in the hepatic hilum should not be blindly suture ligated, but better managed by successive dissection and specific measures under direct view.
• Arterial leakage: Direct suture with Prolene® 5-0 or 6-0.
• Reconstruction is mandator in accidental transection of a major artery, possibly by reanastomosis with a saphenous vein graft.

Venous bleeding

• e.g., from the portal vein, is much more difficult to manage: Under local control, first attempt to gain overview, then clamp the vein close to its trunk and possibly suture it.

Bleeding from the inferior vena cava

• May at times be hard to control.
• When there is retrohepatic bleeding while freeing the liver, most often the inferior vena cava has not yet been exposed enough for tangential clamping. In this case the only thing to do is to grab and obstruct the IVC, best with forceps, then free the lesion and suture it. It is helpful in such situations to first vessel loop the inferior vena cava inferior to the liver.
• When the inferior vena cava is bleeding at the level of its confluence with the hepatic veins, often the only management possible is by manual compression.
• In difficult situations it may become necessary to temporarily clamp the inferior vena cava cephalad and caudad of the liver. This may even require incising the diaphragm at the caval foramen.
• Caution: There is the risk of air embolism!

Bleeding from the hepatic resection area

• Targeted suture ligation
• No deep bulk suture ligations because they result in necrosis of the surrounding parenchyma and may lead to injury of adjacent vessels, e.g. thin-walled hepatic veins.
• In diffuse bleeding: Coagulation, e.g., with an argon beamer.
• Massive diffuse bleeding from the resection area (most often due to coagulopathy) may require temporary packing with towels.

Preventing intraoperative bleeding

• Adequate access with sufficient exposure
• Generous freeing of the liver
• Preliminary hilar ligatures in anatomical lobectomies
• Intraoperative ultrasonography with visualization of the vascular structures at the area of resection
• Controlled dissection of the parenchyma
• Avoiding venous system overload (low CVP)
• Careful management of the area of resection

1.1.b Compromised arterial blood supply

• As a matter of principle, when dissecting the hilum care must be taken to prevent accidental injury to and ligature of the wrong artery. This would result in a significant complication.

1.2 Biliary leaks

• With gallbladder present: Occlude the common bile duct and manually compress the gallbladder while simultaneously inspecting the resection area of the liver; possibly targeted suture ligation
• With the gallbladder already removed: Check with methylene blue or Lipovenös® (lipid emulsion) via the cystic stump: After methylene blue or Lipovenös® has been pressure injected into the bile duct system, bile leakage will be easily visible as discharge of blue solution /white lipid.

1.3 Air embolism

• Air embolism (in laparoscopic procedures: CO₂embolism) may result from an inadvertent or unnoticed opening in small hepatic veins and manifests by sudden tachycardia, hypotension, arterial hypoxemia, arrhythmia and increased CVP. Low and even negative CVP encourages air embolism.
• Prevent further entry of air by detecting, clamping or suturing the point of entry, and immediately start PEEP ventilation.

1.4 Pneumothorax

• May occur in tumors close to or infiltrating the diaphragm → intraoperative chest tube

1.5 Transection of the common bile duct

• If after accidental transection of the common bile duct both stumps display good blood supply, they may be anastomosed directly, possibly supported by T-tube drainage.
• A possibly compromised blood supply necessitates hepaticojejunostomy.

1.6 Injuries to hollow viscera

• Many patients with previous surgery, particularly after cholecystectomy or gastric procedures, require adhesiolysis. This may result in injury to hollow viscera.

2.1 Secondary bleeding

Secondary bleeding in liver procedures may be due to insufficient intraoperative hemostasis; however, in many cases it is caused by disorders of coagulation and fibrinolysis, aspects which must be considered in the indication for revision surgery. If coagulation status is mostly unremarkable and bleeding impacts on hemoglobin level: Emergency relaparotomy!

Perihepatic hematoma

• Ultrasound/CT-controlled drainage, depending on the extent; possibly relaparotomy
• Formation of subphrenic and subhepatic abscesses possible

Subcapsular hematoma

• Usually, the body will absorb small hematomas while larger ones may rupture
• In case of revision surgery manage the hematoma area of the parenchyma with the argon beamer.

Central liver hematoma

• Central arterial bleeding within the hepatic parenchyma may result in the formation of pseudoaneurysms which may undergo secondary rupture due to pressure and necrosis in the immediate vicinity; in this case rapid relaparotomy may be indicated
• Diagnostic work-up with ultrasonography and CT, possibly selective arterial embolization

2.2 Biliary fistula

• Patient stable without signs of peritonitis: Leave target drainage in place, monitor drainage volume; will often cease spontaneously.
• Specific diagnostic work-up if drainage volume >100 mL/day; attempt ERCP with stenting.

2.3 Pleural effusion

• Concomitant pleural effusion is sometimes seen after right hemihepatectomy, less frequently on the left side.
• Depending on the extent, it may require drainage.

2.4 Pneumonia

• Postoperative pulmonary infection is not uncommon, particularly whenever patients do not comply with the required postoperative respiratory exercises
• Continuous administration of oxygen via nose cannula or mask is not always helpful because this may result in shallow breathing.
• Prevention: Rapid postoperative ambulation, Bird ventilator, TriFlo inspiratory exerciser, CPAP mask, physiotherapy/respiratory exercises.

2.5 Secondary perforation of hollow viscera

• Emergency relaparotomy

2.6 Liver failure

While postoperative liver failure is rather rare, it is the most important parameter of perioperative mortality after liver resections. Since the therapeutic options in postoperative (residual) liver failure are very limited, preoperative risk assessment is most essential.

It allows careful selection of patients possibly eligible for liver resection.

In healthy livers resection of segment II/III should not pose a problem; only cirrhosis of the liver and a rather large left lateral hepatic lobe may result in postoperative liver failure.

If there is fulminant liver failure nevertheless, liver transplantation is the only available option.

For preoperative planning in liver resection the functional reserve capacity of the liver after resection (Partial Hepatic Resection Rate, PHRR) may be estimated according to the following equation:

PHRR = (resected liver volume - tumor volume) / 
/total liver volume - tumor volume)

By now, the residual hepatic volume after resection may be calculated by two-dimensional CT (2D-CT) and magnetic resonance imaging (2D-MRI). However, this still does not allow precise assessment if the blood supply will suffice for the remaining tissue. Software systems reconstructing all intrahepatic blood vessels and bile duct structures and the corresponding parenchyma in three dimensions can help visualize and quantify the liver situation. Considering the patient's own hepatic anatomy, they allow simulations by virtual resection.