liver resection

Click here to load reader

Post on 16-Feb-2016

92 views

Category:

Documents

3 download

Embed Size (px)

DESCRIPTION

Liver Resection. Abdominal Surgery Curriculum Jen Basarab -Tung. Background. Indications: Primary tumors Hepatocellular carcinoma Cholangiocarcinoma Metastatic tumors Colorectal cancer Neuroendocrine tumors Benign disease Symptomatic giant hemangioma - PowerPoint PPT Presentation

TRANSCRIPT

Slide 1

Abdominal Surgery CurriculumJen Basarab-Tung

Liver Resection1BackgroundIndications:Primary tumorsHepatocellular carcinomaCholangiocarcinoma Metastatic tumorsColorectal cancer Neuroendocrine tumorsBenign diseaseSymptomatic giant hemangioma Hepatic adenoma (risk of rupture and malignant degeneration)Living donors for liver transplantsMost commonly left lateral for pediatric recipientR hepatectomy for adult-adult in some centers

2BackgroundIndication for resection may inform you about condition of underlying liverHCC almost exclusively arises in setting of cirrhosisCholangioCa often associated with cholestasisResectabilityDetermined by CT or MRIFunction of location, underlying parenchyma, and future remnant size Will the patient have enough functional liver left to survive?

Relevant AnatomyLiver gets 25% of cardiac outputBlood flow from the portal vein (75%) and hepatic artery (25%)Post-hepatectomy survival requires only 30% of functional liver remainingLiver can be divided into 4 lobes based on surface anatomy:RightLeftCaudateQuadrateBut liver resections refer to a more complicated system of classification

Relevant AnatomyNote the clockwise numberingNo surface markersCaudate: 1Left liver: 2, 3, 4Right liver: 5, 6, 7, 8The Couinaud classification divides liver into 8 segments, each with its own vascular supply and biliary drainage:Ligamentum Teres

Relevant AnatomyMajor hepatectomy: resection of 3 or more segmentsRight hepatectomy: 5, 6, 7, 8Right lobectomy or trisegmentectomy: 4, 5, 6, 7, 8Left lobectomy: 2, 3, 4Left trisegmentectomy: 2, 3, 4, 5, 8Non-anatomic resection (wedge resection or segmentectomy) possible for small tumorsSegment 1 has its own (variable) blood supply and can be resected with any other lobes/segments8 2

4 3

6 5or right lobectomyRighthepatectomyPreoperative ConsiderationsLiver functionSynthetic funtion (Tbili, albumin, coags)TransaminasesIf elevated in setting of viral hepatitis, may be marker of poorer regeneration post-hepatectomyCorrection of coagulopathyVitamin K and/or FFP infrequently required for elective resectionsTumor markers: AFP (HCC), CA-19-9 (cholangio) and CEA (colon CA)Assessment for resectability and metastasis (CT/MRI)

Incision

A: Bilateral subcostal incision, which may include excision of the xiphoid. B: J-shaped incision along 8th, 9th, or 10th intercostal space facilitates exposure of segment VII/VIII or tumor involving right diaphragm, and may be extended to the left or lower abdomen.

Anesthetic ConsiderationsConsider epidural for post-op pain controlCheck coags/platelets and discuss w/ surgeon firstPost-op coagulopathy related to extent of resectionEndotracheal intubationUse cisatracurium in cirrhoticsCarefully titrate hepatically cleared drugs to effectPositioning is usually supine with arms tucked, so place lines early and make sure they runAnticipate hemodynamic changesCirrhotics often have low SVR with compensatory increase in CO at baselineHave vasoactive meds readyMaintain normothermiaHypothermia can worsen coagulopathyMore on EpiduralsSee syllabus for detailed infoLarge upper abdominal incisionand high risk for post-up pulmcomplications suggest epiduralanalgesia would be helpfulAt Stanford, epidurals for liver resections are controversial due to concern for post-op coagulopathyThis is NOT the case at most other institutionsAs always, discuss plan for neuraxial anesthesia with your attending and the surgical team

Fluid and Blood ManagementAnticipate significant blood loss in major resections300-500 ml in healthy livers, 400-800 ml in cirrhosisHigh risk of tearing vessels during mobilization of liverUnable to use cell salvage in cancer patientsT&C 2 units PRBC (95% of resections at Stanford use