Anaesthesia for elective liver resection: some points should be revisited

Abstract

Improvement in surgical techniques, technology and perioperative assessment has dramatically simplified the anaesthetic care for elective liver resection. Patients with a non-tumorous healthy liver should only need the usual preoperative assessment. Patients with pre-existing parenchymal liver disease should be specifically assessed for gas exchange impairment, alcoholic or nutritional-associated cardiomyopathy, infection, cirrhosis decompensation, acute alcoholic hepatitis, and kidney impairment. The type of anaesthetic management does not influence the intra- and postoperative courses. Intermittent clamping of the portal vascular triad is better tolerated than prolonged continuous periods of ischaemia--especially in patients with abnormal liver parenchyma. Intraoperative antibiotic prophylaxis must be administered to prevent translocation of intestinal enterobacteria to the systemic circulation in patients with both healthy and diseased livers. Blood-salvage techniques have limited indications in liver resection. Systematic invasive haemodynamic monitoring is no longer warranted. An arterial cannula should only be considered in procedures of long duration and in selected situations likely to cause anticipated circulatory impairment: total liver vascular occlusion, repeat surgery, combined organ resection, and surgery conducted on tumours >10 cm in size or in connection with the vena cava. In a recent large series of liver resections, 60% of patients did not need a blood transfusion, only 2% of transfused patients received >10 units of blood and cirrhosis was not predictive of increased intraoperative bleeding. Postoperative ascites, which always develops at the expense of circulating fluid, is a frequent occurrence in patients with healthy or diseased livers. Intra- and postoperative fluid limitation does not prevent postoperative ascites. Volume expansion, diuretics and vasopressor therapy should be initiated early to prevent kidney failure.