1.1a Bleeding
Arterial Bleedings
- can occur during dissection of the hepatic hilum, are usually well manageable
- Due to the risk of injury to bile duct structures and further vascular injuries, bleedings in the hepatic hilum should not be blindly stabbed, instead successive exposure and targeted management
- Arterial vessel leaks: direct suture with Prolene® 5-0 or 6-0
- In case of accidental transection of a main artery, reconstruction is mandatory, reanastomosis, if necessary using a saphenous vein interposition
Venous Bleedings
- e.g. from the portal vein, are much more difficult to control: under local control of the bleeding, an overview should first be obtained, then clamped proximally and possibly the vessel oversewn.
Bleedings from the Vena Cava
- may be difficult to control
- In retrohepatic localized bleedings, which can occur during mobilization of the liver, the vena cava is usually not yet sufficiently exposed to clamp it tangentially; here, only grasping and narrowing the vena cava helps, best with forceps; then expose the lesion and oversew; in this situation, it is helpful if the vena cava was previously looped infrahepatically
- In bleedings from the vena cava at the level of the hepatic vein ostia, bleeding control is often only possible by manual compression
- In difficult situations, it may be necessary to temporarily occlude the vena cava below and above the liver; for this, opening the diaphragm at the level of the caval passage may be required
- Caution: there is a risk of air embolism!
Bleedings from the Resection Surface of the Liver
- Targeted mattress sutures
- No deep mass mattress sutures, they lead to necroses of the surrounding parenchyma and can result in injuries to adjacent vessels, e.g. thin-walled hepatic veins
- In diffuse bleedings: coagulation e.g. with an argon beamer
- In massive diffuse bleeding from the resection surface (usually due to coagulation disorders), temporary packing with abdominal towels may also be necessary
Prophylaxis of Intraoperative Bleedings
- Adequate access with sufficient exposure
- Generous mobilization of the liver
- Preliminary hilar ligations in anatomical lobectomies
- Intraoperative sonography with visualization of vascular structures in the resection area
- Controlled parenchyma dissection
- Avoidance of overfilling of the venous system (low CVP)
- Careful management of the resection surface
1.1.b Compromise of Arterial Blood Supply
- In principle, caution is advised during preparation of the hilum to avoid accidentally injuring or ligating the wrong artery. This would represent a significant complication.
1.2 Bile Leaks
- If the gallbladder is still present: occlusion of the common bile duct and manual compression of the gallbladder with simultaneous inspection of the liver resection surface; if necessary, targeted mattress suture
- If the gallbladder has already been removed: perform a methylene blue or Lipovenös test via the cystic duct stump. Lipovenös or methylene blue is injected under pressure into the biliary system, so that bile leaks can be well visualized by the exit of white fat emulsion or the blue solution.
1.3 Air Embolism
- Air embolisms (in laparoscopic procedures: CO2 embolisms) can arise from unintended or unnoticed opening of small hepatic veins, which manifests as sudden tachycardia, hypotension, arterial hypoxemia, arrhythmias, and an increase in CVP. The embolisms are favored by low or even negative CVPs.
- Avoid further entry of air by detecting, clamping or oversewing the entry site, immediate PEEP ventilation
1.4 Pneumothorax
- Can occur in tumors close to the diaphragm or infiltrating → intraoperative chest drainage
1.5 Transection of the D. Choledochus
- After accidental transection of the D. choledochus, if there is good perfusion of both stumps, a direct anastomosis can be performed, if necessary insertion of a T-drain
- In uncertain perfusion conditions, creation of a hepaticojejunostomy is indicated
1.6 Hollow Organ Injuries
- In pre-operated patients, especially after cholecystectomy or previous interventions on the stomach, adhesiolysis must be performed. Hollow organs can be injured in the process.