Complications - Right hemihepatectomy

1. Bleeding:

• Arterial bleeding
  • May occur during dissection of the hepatic hilum; it is usually well controllable.
  • Because of the risk of injury to biliary structures and further vascular injuries, bleeding in the hepatic hilum should not be suture-ligated indiscriminately; instead, successive exposure and targeted management.
  • Arterial vascular leaks: direct suture with non-absorbable monofilament suture 5-0 or 6-0 or clip
  • In accidental transection of a main artery, reconstruction is obligatory, re-anastomosis if necessary using a saphenous vein interposition graft.
• Venous bleeding
  • May arise from 3 sources:
    • Portal vein during hilar dissection
    • Vena cava or retrohepatic veins during retrohepatic mobilisation
    • Hepatic vein confluence during dissection of the hepatic veins or their transection
  • Venous bleeding is considerably more difficult to control than arterial bleeding.
  • In principle, the strategy consists of localisation, grasping for temporary bleeding control, gaining an overview, in order then to be able to place a clip, an oversuture, or, in the case of the hepatic veins, a stapler in a targeted manner.
  • Blind oversewing should be avoided.
  • Tightening the Pringle tourniquet (see below) can be helpful in reducing bleeding.
  • Bleeding from the vena cava may be difficult to control.
  • In bleeding from the vena cava at the level of the hepatic vein confluence, bleeding control is often only possible by means of manual compression.
  • In difficult situations it may be necessary to temporarily occlude the vena cava below and above the liver. For this, opening of the diaphragm at the level of the caval passage may be required.
  • Caution: When the hepatic veins or the vena cava are opened, there is a risk of air embolism, which can become a life-threatening emergency.
• Bleeding from the resection surface of the liver
  • Targeted grasping and clipping, suture ligation if necessary
  • Caution: Mass suture ligations should be avoided. They lead to necrosis of the surrounding parenchyma and can result in injury to adjacent vessels, e.g. thin-walled hepatic veins.
  • In diffuse bleeding: fulguration with eschar formation, e.g. with an argon beamer
  • In massive diffuse bleeding from the resection surface (usually due to coagulation disorders), temporary packing with abdominal swabs may also become necessary.
  • If required, the application of haemostatic fleece with subsequent compression may be helpful.
• Prophylaxis of intraoperative bleeding
  • Inflow control:
    • Placement of a tourniquet around the hepatoduodenal ligament before beginning parenchymal dissection.
    • For this purpose, a tourniquet is placed around the hepatoduodenal ligament.
    • If necessary, this can be closed, thereby sufficiently interrupting blood inflow into the liver (Pringle manoeuvre).
    • Vascular defects can be addressed within 15-minute Pringle intervals, after which the Pringle manoeuvre can be released again.
  • Outflow control:
    • Blood outflow from the liver occurs via the three hepatic veins.
    • The venous star, i.e. the suprahepatic vena cava with the confluences of the hepatic veins, should be exposed in larger liver resections, so that in the event of bleeding the affected vein can be grasped centrally and subsequently reconstructed.
    • The left and often also the middle hepatic vein can usually be exposed and separately encircled in left-sided liver resections. In many cases the middle and left hepatic veins have a common opening into the vena cava, which facilitates encircling.
    • With the right hepatic vein in the context of right hemihepatectomy, this is rather rarely achieved. However, in resections of the posterior segments the right hepatic vein should at least be exposed in order to be able to control it in case of problems.
• Controlled parenchymal dissection:
  • By means of a controlled parenchymal dissection, intrahepatic vessels should be identified before injury and securely addressed prior to transection.
  • The method of parenchymal dissection should be determined according to the structural quality of the liver. Fundamentally available are: Ultracision, ultrasonic or water-jet dissector, and dissection using monopolar scissors and bipolar forceps.
  • Tip: In pronounced fibrosis and cirrhosis, Ultracision is well suited, whereas dissection with monopolar scissors and forceps is rather to be discouraged. Bleeding within the liver may nevertheless occur during parenchymal dissection.
  • Activation of the Pringle manoeuvre reduces bleeding through inflow control.
  • Most minor bleeding can be stopped with bipolar coagulation. Lesions of larger blood vessels must be closed either with a clip or with suture ligation.
  • If the source of intraparenchymal bleeding cannot be identified, compression for 5–10 minutes is often helpful.
• Subtle demonstration of the structures with adequate exposure
• Intraoperative sonography with visualisation of the vascular structures in the resection area
• Preliminary hilar ligatures in anatomical lobectomies
• Avoidance of overfilling of the venous system (low CVP)
• Careful management of the resection surface

2. Compromise of the arterial blood supply

• In principle, caution is warranted during dissection of the hilum so as not to inadvertently injure or ligate the wrong artery. This would constitute a considerable complication and would usually necessitate vascular reconstruction.

3. Bile leaks

• A bile leak overlooked and not addressed intraoperatively carries a high risk of a postoperative biloma.
• Similar to intrahepatic blood vessels, bile ducts are also addressed during parenchymal transection. After identification, these are likewise closed intrahepatically with clips or sutures. Coagulation, by contrast, has not proven effective here.
• Before completing the operation, a careful inspection of the resection surface must be carried out.
• If a stapler is used for parenchymal transection, higher rates of postoperative bile fistulae are seen here compared with other parenchymal dissection techniques.

4. Gas embolism

• Air emboli can occur with inadvertent or unnoticed opening of hepatic veins, which becomes apparent through sudden tachycardia, hypotension, arterial hypoxaemia, arrhythmias and an increase in CVP. The emboli are generally favoured rather by low or even negative CVPs.
• Prevention of further entry of air by detection, clamping or oversewing of the entry site, immediate PEEP ventilation.

5. Pneumothorax

• in tumours close to the diaphragm or infiltrating it → intraoperative chest drain

6. Transection of the ductus choledochus

• After accidental transection of the ductus choledochus, a direct anastomosis can be performed if both stumps are well perfused, if necessary with placement of a T-drain.
• In cases of uncertain perfusion conditions and larger defects, creation of a hepaticojejunostomy is indicated.

7. Hollow organ injuries

• In previously operated patients, particularly after cholecystectomy or prior procedures on the stomach, adhesiolysis must be performed. In the process, hollow organs may be injured.