Transection of the proper hepatic artery or one of its main branches
- Consequences are unpredictable and can range up to lobe necrosis.
- For a larger artery with poor blood backflow from the liver-proximal stump, reanastomosis should be attempted.
- In the case of transection of the main artery, reconstruction is mandatory, possibly as a saphenous vein interposition.
Arterial Bleeding
- Can occur during dissection of the hepatic hilum, generally well manageable.
- Due to the risk of injury to bile duct structures and further vascular injuries, bleeding in the hepatic hilum should not be blindly punctured; instead, successive dissection 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 embolism or massive bleeding!
- Tangential clamping with oversewing
- In severe cases, manual compression and temporary occlusion of the vena cava caudal and possibly also cranial to the liver after opening the diaphragm (suprahepatic clamping).
Bleeding from the liver resection surface
- Targeted sutures, no deep mass sutures, as they lead to necrosis of the surrounding parenchyma and can result in injury to adjacent vessels, e.g., thin-walled hepatic veins.
- In the case of massive diffuse bleeding from the resection surface (usually due to coagulation disorders), temporary packing with abdominal towels may be necessary.
Prophylaxis of Intraoperative Bleeding
- Adequate access with sufficient exposure
- Generous mobilization of the liver
- Preliminary encircling of the hepatoduodenal ligament
- Intraoperative ultrasound with visualization of vascular structures in the resection area
- Controlled parenchymal dissection
- Avoidance of overfilling the venous system (low CVP)
Air Embolism
- Facilitated by low or even negative CVPs.
- Avoid further air entry by detecting, clamping, or oversewing the entry site, immediate PEEP ventilation
Pneumothorax
- → intraoperative thoracic drainage.
Hollow Organ Injuries
- In previously operated patients, especially after cholecystectomy or previous gastric procedures, adhesiolysis is necessary. Hollow organs may be injured and must be appropriately managed/oversewn.