Complications - Right hemihepatectomy

Severing of the A. hepatica propria or one of its main branches

• Consequences are unpredictable and can range up to lobe necrosis.
• Therefore, reconstruction of the main artery is mandatory, if necessary as a V. saphena interposition.

 Arterial bleedings

• Can occur during dissection of the hepatic hilum, are usually well controllable.
• Due to the risk of injury to bile duct structures and further vascular injuries, bleedings in the hepatic hilum should not be blindly stitched, instead successive free preparation 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 bleedings!
• Tangential clamping with oversewing
• In severe cases, manual compression and temporary occlusion of the V. cava caudal and possibly also cranial to the liver after opening the diaphragm (suprahepatic clamping).

Bleedings from the resection surface of the liver

• PRINGLE maneuver, therefore prior looping of the Lig. hepatoduodenale.
• Targeted understitching, no deep mass understitching, they lead to necroses of the surrounding parenchyma and can result in injuries to adjacent vessels, e.g., thin-walled hepatic veins.
• In case of massive diffuse bleeding from the resection surface (usually due to coagulation disorders), temporary packing with abdominal cloths may also be necessary.

Prophylaxis of intraoperative bleedings

• Adequate access with sufficient exposure
• Generous mobilization of the liver
• Preliminary looping of the Lig. hepatoduodenale
• Intraoperative sonography with depiction of the vascular structures in the resection area
• Controlled parenchyma dissection
• Avoidance of overfilling of the venous system (low CVP)

Severing / Injury of the CHD

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

Air embolism

• Is favored by low or even negative CVPs.
• Avoid further entry of air by detection, clamping or oversewing of the entry site, immediate PEEP ventilation

Pneumothorax

• Can occur in tumors close to the diaphragm → intraoperative thoracic drainage.

 Hollow organ injuries

• In pre-operated patients, especially after cholecystectomy or previous interventions on the stomach, adhesiolysis must be performed. In the process, hollow organs can be injured, which must be managed/sutured accordingly.

Postoperative Bleeding

• Postoperative bleeding in liver procedures can be caused by inadequate intraoperative hemostasis, but in not a few cases it is attributable to disorders of the coagulation and fibrinolysis system, which must be considered when indicating operative revision.
• Detection of the cause using angio-CT, if necessary 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 then, if necessary, must be surgically managed in case of circulatory instability.

Biliary Fistula

• Stable patient without signs of peritonitis: Leave target drainage in place, monitor output volume, often spontaneous cessation.
• ERCP with stent insertion to reduce pressure in the biliary system.

Portal Vein Thrombosis

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

Pleural Effusion

• Respiratory insufficiency.
• Chest X-ray, ultrasound.
• First negative balance, depending on extent if necessary thoracic drainage system

Pneumonia

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

Posthepatectomy Liver Failure

Postoperative liver failure is defined as a postoperatively acquired impairment of the liver's synthesis, excretory, and detoxification functions. Laboratory findings show an elevated INR and hyperbilirubinemia on the 5th postoperative day. Liver failure can manifest in varying degrees from moderate liver function impairment to hepatically induced multiorgan failure. It 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 nonetheless, rescue is only possible through transplantation.