Complications - Liver resection for recurrent liver metastasis

Transection of the proper hepatic artery or one of its main branches

• Consequences are unpredictable and can range up to lobe necrosis.
• Therefore, reconstruction of the main artery is mandatory, possibly as a saphenous vein interposition.

Arterial Bleeding

• Can occur during dissection of the liver hilum, generally well manageable.
• Due to the risk of injury to bile duct structures and further vascular injuries, bleeding in the liver hilum should not be blindly sutured, 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 embolisms or massive bleeding!
• Tangential clamping with oversewing
• In severe cases, manual compression and temporary occlusion of the inferior vena cava caudal and possibly also cranial to the liver after opening the diaphragm (suprahepatic clamping).

Bleeding from the liver resection surface

• PRINGLE maneuver, therefore prior encircling of the hepatoduodenal ligament.
• Targeted sutures, no deep mass sutures, as they lead to necrosis of the surrounding parenchyma and can cause injury to adjacent vessels, e.g., thin-walled hepatic veins.
• In cases of massive diffuse bleeding from the resection surface (usually due to coagulation disorders), temporary packing with abdominal towels may also 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)

Transection/Injury of the Common Bile Duct

• Direct anastomosis possibly over T-drainage or creation of a biliodigestive anastomosis

Air Embolism

• Facilitated by low or even negative CVPs.
• Prevent further air entry by detecting, clamping, or oversewing the entry site, immediate PEEP ventilation

Pneumothorax

• Can occur with tumors near the diaphragm → 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.

Bleeding

• Bleeding in liver procedures can be due to inadequate intraoperative hemostasis, but in many cases, it is attributed to coagulation and fibrinolysis system disorders, which must be considered when deciding on surgical revision.
• Detection of the cause using Angio-CT, possibly selective arterial embolization, depending on the extent and circulatory situation, indication for relaparotomy.
• Development of subphrenic or subhepatic abscesses possible

Subcapsular Hematoma

• Small hematomas are usually resorbed.
• Larger ones can rupture in two stages and may need surgical intervention if circulatory instability occurs.

Bile Fistula

• Stable patient without signs of peritonitis: leave target drainage in place, monitor output, spontaneous cessation is not uncommon.
• ERCP with stent placement to reduce pressure in the bile duct system.

Portal Vein Thrombosis

• Sudden postoperative increase in transaminases.
• Doppler ultrasound examination
• Anticoagulation

Pleural Effusion

• Respiratory insufficiency.
• Chest X-ray, ultrasound.
• Initially negative balance, depending on the extent, possibly thoracic drainage placement

Pneumonia

• Postoperative pulmonary infections are not uncommon, especially if postoperative breathing exercises are not performed with the required consistency.
• Prophylaxis: rapid postoperative mobilization, Bird ventilation, Triflow, CPAP masks, physiotherapy/breathing exercises

Liver Failure

Postoperative liver failure is rather rare but represents the most important cause of perioperative mortality after liver resection. Since therapeutic options for postoperative (residual) liver insufficiency are very limited, preoperative risk evaluation is of crucial importance.
If fulminant liver failure occurs, rescue is only possible through transplantation.