Perioperative management - Right hemihepatectomy

Malignant tumors:

• Liver metastasis
• Hepatocellular carcinoma (HCC)
• Cholangiocellular carcinoma (CCC)

Benign tumors:

• Adenoma
• Focal nodular hyperplasia (FNH)

• Impaired liver function with insufficient residual functionality, e.g., cirrhosis, particularly Child-Pugh-Turcotte B + C
• Systemic infection
• Diffuse metastasis also in left lobe
• Invasion of the diaphragm or hepatoduodenal ligament
• Invasion of the vena cava or hepatocaval confluence
• Other distant metastasis
• Uncontrolled primary

• Confirmation/localization of tumor Abdominal US, multiphase CT study, upper quadrant CT-angiography, possibly: MRI, contrast enhanced US, ERCP with cytology, FNA (US or CT guided); intraoperative US
• Ruling out (additional) distant metastasis CT-chest, intraoperative US
• Lab panel: RBC, albumin, bilirubin, gamma-GT, AP, ALT, AST, coagulation, creatinine, electrolytes, blood group, antibody screening test, tumor markers
• ECG, possibly other cardiopulmonary function studies

• Order 6 packed red cells
• Check if ICU bed is available
• Preoperative single-shot 2nd generation cephalosporin half an hour before skin incision

Recurrence, seroma, (secondary) bleeding, hematoma, need for blood transfusion with corresponding risks, necrosis of hepatic parenchyma, biliary fistula, bilioma, biliary peritonitis, bile duct stenosis, hemobilia, liver failure with coma, arrhythmias, cardiovascular disorders, thromboembolic complications, positioning injuries, electrosurgery injuries, injury of adjacent organs, pleural effusion requiring drainage, abscess, secondary wound healing, abdominal wound dehiscence, incisional hernia, adhesions, revision surgery, death

• General anesthesia
• Thoracic epidural catheter
• Normothermia (keep patient warm)
• Keep CVP low

Supine, right arm adducted, left arm abducted, slight hyperflexion at thoracolumbar junction

• Surgeon on right side of patient
• First assistant facing surgeon
• Second assistant left of surgeon on right side of patient
• Scrub nurse on left side of patient, caudad of first assistant

• Retractor system
• Mercedes retractor (Aesculap)
• Gallbladder tray + vascular tray or LTX tray
• Multiple clip applier
• CUSA

Postoperative analgesia: Adequate pain management; in case of severe pain complement epidural catheter with systemic analgesics, taking into account the potential liver toxicity; follow the link to PROSPECT (Procedures Specific Postoperative Pain Management) or this link to the International Guideline Library.

Postoperative care: Remove abdominal drain on postoperative day 1 - 5, depending on the quality and volume of the secretions; remove skin sutures/staples around postoperative day 12.

Deep venous thrombosis prophylaxis: Unless contraindicated, the high risk of thromboembolism calls for prophylactic physical measures and low-molecular-weight heparin, adapted to weight or dispositional risk, for at least 2 weeks, possibly up to 6 weeks. Note: Renal function, HIT II (history, platelet check). This link will take you to the International Guideline Library.

Ambulation: Immediate ambulation, phased return to full physical activity.

Physical and respiratory therapy

Diet: In absence of atony, nausea or vomiting liquids on day of surgery If tolerated, rapid return to unrestricted diet.

Bowel movement: Laxatives may have to be started on postoperative day 2

Work disability: Depending on patient occupation between 3 and 6 weeks