Anesthesia for Hepatic resection

Eshetu. T

1 anesthesia for hepatobiliary surgery 03/12/2023

 Introduction
The liver can regenerate functionally active parenchyma after tissue loss.

Indication
Colorectal hepatic metastases

The management of benign and malignant primary hepato-biliary tumours

Donation for transplantation

Hepatic trauma

2 anesthesia for hepatobiliary surgery 03/12/2023

 Introduction
Surgical technique
The surgical aim

Excise the diseased part of the liver with adequate oncological clearance

Minimal blood loss

Leaving enough healthy liver to avoid liver failure

Allow regeneration.

3 anesthesia for hepatobiliary surgery 03/12/2023

 Introduction
There are three phases to the operation with differing anesthesia goals:

1. Initial phase:
 Mobilization of the liver

 Localization of the lesions with confirmation of resectability,

 If confirmed, followed by cholecystectomy and dissection of the porta

hepatis.

2. Resection phase.

4
3. Hemostasis and closure.
anesthesia for hepatobiliary surgery 03/12/2023
 PREOPERATIVE MANAGEMENT
Patient Selection
This involves the assessment
Patient factors
Age, cardiopulmonary function impact of comorbid diseases and recovery chemotherapy
Tumor factors: prognostic information
Anatomic factors:
Resectable
location of the lesions
the resectable margin (ideally >1 cm)
FLR (functional liver remnant

5 anesthesia for hepatobiliary surgery 03/12/2023

 PREOPERATIVE MANAGEMENT
Assessment of Cardiopulmonary Function

Cardiopulmonary exercise testing (CPET

Assessment of Liver Function

Child–Pugh A and Child–Pugh B cases with an FLR greater than 40% can be

considered.

6 anesthesia for hepatobiliary surgery 03/12/2023

 Anesthetic management
Anesthesia for hepatic resection surgery focused on strategies to

Limit blood loss during the resection

Minimizing reperfusion injury to the liver

Reduce the risk of postoperative liver failure.

7 anesthesia for hepatobiliary surgery 03/12/2023

 Anesthetic management
Avoid halothane due to hepatotoxicity

Atracurium/cisatracurium preferred

Intravenous fluid administration is limited until the posttransection phase

vasopressor infusions are titrated to maintain optimal perfusion pressure

Ensure normothermia throughout for optimal coagulation

intravenous fluid warmers, forced air warming blankets, or warming gel mats

8 anesthesia for hepatobiliary surgery 03/12/2023

 Anesthetic management
Monitoring Recommendations
Large bore venous access
Optional placement of a pulmonary artery catheter with central venous catheter
(CVC) could be considered for large complex resections
Aid rapid volume loading if necessary and for easy venesection if performing
normovolemic hemodilution
Availability of a rapid infusion system
Arterial line ( regular blood sugar and lactate monitoring)
CVC – allows CVP targeting and norepinephrine infusion
Minimally invasive CO monitoring using esophageal Doppler
Goal-directed fluid therapy during the postresection phase of surgery

9 anesthesia for hepatobiliary surgery 03/12/2023

 Analgesia
NSAIDS should be avoided wherever possible
This group of patients is at risk of renal impairment and coagulation defects,
Opiates that are metabolized in the liver and excreted renally
Potential disadvantage of accumulation with cerebral depressant effects
Opioid-sparing (gabapentinoids and low dose ketamine (eg, 0.5 mg/kg)
Use of epidural techniques have been the preferred postoperative analgesic
option
Given the proposed benefits on postoperative recovery after major surgery
Use of large surgical incisions during hepatic surgery.
Concern is the associated prolongation of PT

10 anesthesia for hepatobiliary surgery 03/12/2023

 Strategies for Minimizing BloodLoss
Blood loss of 10 litre has been reported after liver resection

Large transfusions are a risk factor for major postoperative complications

and liver failure.

Intraoperative blood loss during liver resection increased risk of morbidity

and mortality

11 anesthesia for hepatobiliary surgery 03/12/2023

 Strategies for Minimizing BloodLoss
Patients with cirrhosis, steatosis, and after chemotherapy are at especially
increased risk of coagulopathy and bleeding.
Preoperative factors associated with increased risk of transfusion.
Preoperative anemia
The need for an extrahepatic procedure
The need for caval exposure
Major hepatectomy (>3 segments)
Tumor size
Thrombocytopenia
Cirrhosis
Reoperation.

12 anesthesia for hepatobiliary surgery 03/12/2023

 Strategies for Minimizing BloodLoss
The features of the coagulopathy seen in hepatic disease

Reduced synthesis of coagulation factors and inhibitors,

Quantitative and qualitative platelet defects and hyperfibrinolysis.

Coagulopathy induced or exacerbated by

Acidosis, hypothermia, and hypocalcaemia

All of which should be monitored and treated.

13 anesthesia for hepatobiliary surgery 03/12/2023

 Strategies for Minimizing BloodLoss
Multi-modal perioperative techniques have been used to decreased blood lose
Techniques such as

Acute normovolemic hemodilution

Intraoperative cell salvage

The use of temporary hepatic vascular occlusion

The intraoperative maintenance of low central venous pressure (CVP).

Tranexamic acid

14 anesthesia for hepatobiliary surgery 03/12/2023

 Strategies for Minimizing BloodLoss
Low CVP
Maintaining a CVP < 5 mm Hg
Reduced blood loss, length of stay, morbidity, and mortality.
Achieve low CVP targets:
Reverse Trendelenburg 15 degree
Fluid restriction to 1 mL/kg/h
TEA or intrathecal analgesia
GTN infusion at 5 to 15 mcg/min
Minimization of PEEP/reduced ventilation
Mannitol 0.5 g/kg and furosemide 10 mg

15 anesthesia for hepatobiliary surgery 03/12/2023

 Strategies for Minimizing BloodLoss
Hepatic vascular occlusion
Isolate the hepatic circulation from the systemic circulation
Temporary hepatic inflow occlusion (Pringle maneuver)
Total vascular exclusion (TVE).
The Pringle maneuver
Continuously or intermittently with a limit of an hour or less.
It results in a 10% decrease in cardiac output
40% increase in SVR, 40% increase in MAP.
There is growing evidence for a reduction in blood loss, transfusion risk
Associated reperfusion injury
postoperative liver failure

16 anesthesia for hepatobiliary surgery 03/12/2023

 Strategies for Minimizing BloodLoss

17 anesthesia for hepatobiliary surgery 03/12/2023

 Postoperative management
Underlying liver dysfunction/large resections have greater risks of
postoperative complications
Bile leak, ascites, liver failure, pulmonary complications, thrombotic
complications, systemic sepsis, and intra-abdominal infection
Ascites due to increased fluid shifts and complicating fluid and electrolyte
management.
Hypophosphatemia is common and occasionally sodium and water
retention with edema formation secondary to hyperaldosteronism.

18 anesthesia for hepatobiliary surgery 03/12/2023

 Postoperative management
A transient early increase in serum hepatic transaminase and AP levels as a
result of hepatocellular damage is common
Persisting elevation suggests ongoing hepatic ischaemia.
A low serum urea on the first postoperative day is an early sign of liver
dysfunction.
Liver failure which may be complicated by:
Hypoglycemia - requiring glucose infusion.
Encephalopathy - supported by lactulose and minimizing opiates.
Coagulopathy is usually corrected with FFP as required
 larger volume blood loss may require targeted blood product
 tranexamic acid administration

19 anesthesia for hepatobiliary surgery 03/12/2023

 Postoperative Liver Failure
Postoperative liver failure show symptoms and signs around 72 h
Will develop Jaundice, encephalopathy, and coagulopathy.
Overall, postoperative hepatic insufficiency occurs around 3%
Pre-existing cirrhosis or biliary tract obstruction incidence of fatal liver
failure up to 32%.
Risk factors is usually multi-factorial
Low-volume liver remnant
Hepatic ischaemia
Blood loss

20 anesthesia for hepatobiliary surgery 03/12/2023

 Postoperative Liver Failure
Intraoperative Strategies to Minimize PLF
Avoiding the administration of any hepatotoxic drugs perioperatively

Minimizing intraoperative bleeding and Consequent blood transfusion

Minimizing vascular occlusion times

Reducing reperfusion injury to the liver

 Ischaemic pre-conditioning

 intermittent clamping technique

Maintaining an optimal hemodynamic balance

21 anesthesia for hepatobiliary surgery 03/12/2023

 Anesthesia for laparoscopic surgery in adults

Eshetu. T

22 anesthesia for hepatobiliary surgery 03/12/2023

 INTRODUCTION
The laparoscopic approach has become a standard of care for many
abdominal surgical procedures.
Compared with laparotomy
Laparoscopy can reduce postoperative pain,
 Result in shorter recovery time
 Allow smaller incisions
 Reduce the postoperative stress response.

Laparoscopy requires insufflation of intraperitoneal or extraperitoneal gas,

usually carbon dioxide (CO ), to create space for visualization and
surgical maneuvers.

23 anesthesia for hepatobiliary surgery 03/12/2023

 INTRODUCTION
Anesthetic concerns for patients undergoing laparoscopic differ from those

for patients undergoing open abdominal surgery.

They include the physiologic effects of the

Pneumoperitoneum,

Absorption of CO2

positioning required for surgery.

24 anesthesia for hepatobiliary surgery 03/12/2023

 Common laparoscopic procedures
 GIT- colonic, gastric, hepatic, appendectomy, splenectomy,

cholecystectom, hernia repair.

 Urologic – nephrectomy, prostatectomy

 Gynecologic – hysterectomy, opheroctomy, infertility

 Vascular – aortic procedures

 Adrenal surgeries

25 anesthesia for hepatobiliary surgery 03/12/2023

 Advantages
 Reduced tissue trauma, wound size, post operative pain and analgesic consuption.

 Improved postoperative respiratory function.

 Good hemostasis

 Reduced postoperative ileus

 Minimize infection risk

 Earlier mobilization

 Shorter hospital stay

 Improved cosmetic result

26 anesthesia for hepatobiliary surgery 03/12/2023

 SURGICAL TECHNIQUES
 Insufflations of CO2 in to the peritoneal cavity creates pneumo-

peritonium.
 CO2 : non-combustible, high blood solubility.

 CO2 is insufflated at a rate of 4-6Lt/min to a pressure of 10-20cmH2O .

 Inert gases can be alternatives for CO2.

 Gas-less approaches

27 anesthesia for hepatobiliary surgery 03/12/2023

 SURGICAL TECHNIQUES
Laparoscopy requires creation of a pneumoperitoneum by insufflation of gas(CO2)
To open space in the abdomen for visualization and allow surgical manipulation.
CO insufflation can be performed blindly using a Veress needle or by placement of a
port under direct vision through a small subumbilical incision.
The gas source is connected to the needle or port
Intraabdominal pressure (IAP) is monitored as gas is insufflated
Pressure ≤15 mmHg to minimize physiologic effects.
For laparoscopic prostatectomy, which is performed in steep Trendelenburg position,
the European Association for Endoscopic Surgery recommends IAP below 12 mmHg

28 anesthesia for hepatobiliary surgery 03/12/2023

 SURGICAL TECHNIQUES
After insufflation, a port is placed, and the laparoscope is inserted.

Under direct intraabdominal vision, further instrument ports are placed.

The surgeon uses a video monitor connected to the laparoscope to see

intraabdominal contents and perform the procedure.

29 anesthesia for hepatobiliary surgery 03/12/2023

 PREOPERATIVE EVALUATION
A medical history and anesthesia­directed physical examination

Medical conditions that may affect the response to physiologic changes

associated with laparoscopy and the surgical procedure.

30 anesthesia for hepatobiliary surgery 03/12/2023

 PHYSIOLOGIC EFFECTS OF LAPAROSCOPY
Cardiovascular changes
CV changes are variable and dynamic


Well tolerated by healthy patients.



Significant intraoperative cardiac dysfunction can occur in older patients and



cardiopulmonary disease
Congestive heart failure, pulmonary hypertension, valvular heart disease


Increase in MAP, SVR, and CVP, decreases in CO and SV during peritoneal insufflation.


Patients with CPD may require more pharmacologic interventions and more intensive


monitoring
31 anesthesia for hepatobiliary surgery 03/12/2023
 PHYSIOLOGIC EFFECTS
Cardiovascular changes during laparoscopy relate to the

Increase in intraabdominal pressure (IAP)

Carbon dioxide (CO2) insufflation,

Effects of positioning

Absorption of CO2,

32 anesthesia for hepatobiliary surgery 03/12/2023

 PHYSIOLOGIC EFFECTS
Effects of pneumoperitoneum –
Neuroendocrine and mechanical effects on cardiovascular physiology.
Neuroendocrine effects
Increase in IAP results in
 catecholamine release
 activation of the renin–angiotensin system with vasopressin release
This increases MAP in most patients
Increases in SVR and PVR
Vagal stimulation, from insertion of the Veress needle or peritoneal stretch with gas
insufflation, can result in bradyarrhythmias.
Bradycardia is common
Atrioventricular dissociation, nodal rhythm, and asystole have been reported
33 anesthesia for hepatobiliary surgery 03/12/2023
 PHYSIOLOGIC EFFECTS
Mechanical effects
Mechanical aspects of laparoscopy are dynamic, depend on the patient’s
preexisting volume status, insufflation pressure, and position.
Compression of arterial vasculature with pneumoperitoneum
Increases SVR and PVR,
Variable effects on CO and blood pressure (BP).
Hypercarbia caused by CO absorption may also increase SVR and PVR
Minute ventilation is increased to prevent hypercarbia.
Cardiovascular effects tend to resolve quickly as pneumoperitoneum is
maintained.

34 anesthesia for hepatobiliary surgery 03/12/2023

 PHYSIOLOGIC EFFECTS
Effects of positioning
Head­up (eg, for cholecystectomy) or head­down (eg, pelvic surgery) positions to
allow the intraabdominal organs to fall away from the surgical field.
Extremes of position can affect cardiovascular function.
The head­up position (ie, reverse Trendelenburg) leads to
Venous pooling, tends to reduce venous return to the heart and may result in
hypotension, especially in patients who are hypovolemic.
The­head down position (ie, Trendelenburg) position increases venous return and
cardiac filling pressures.
CVP, mean pulmonary artery pressure, and pulmonary capillary

35 anesthesia for hepatobiliary surgery 03/12/2023

 PHYSIOLOGIC EFFECTS
Effects of hypercarbia
Absorption of CO2 during laparoscopy have direct and indirect CV

effects.
The direct effects of hypercarbia and associated acidosis

Decreased cardiac contractility, sensitization to arrhythmias, and systemic

vasodilation.

Indirect effects are the result of sympathetic stimulation

Tachycardia and vasoconstriction, which may counteract vasodilation

36 anesthesia for hepatobiliary surgery 03/12/2023
 PHYSIOLOGIC EFFECTS
Pulmonary changes
Pneumoperitoneum with CO2 and surgical positioning are associated with changes in

pulmonary function and gas exchange.

These changes can result from increased IAP with pneumoperitoneum and from

absorption of CO2.
Increased Minute ventilation to compensate for absorption of CO2.
Hyperventilation may be difficult for patients
COPD, asthma, and in morbidly obesity, and in Trendelenburg position
 Arterial blood gases may be required to monitor ventilation.

37 anesthesia for hepatobiliary surgery 03/12/2023

 PHYSIOLOGIC EFFECTS

Changes in pulmonary mechanics

• Pneumoperitoneum
• Cephalad displacement of the diaphragm and mediastinal structures
• Reduces functional residual capacity (FRC) and pulmonary
compliance
• Resulting in atelectasis and increased peak airway pressures.
• Exacerbated with steep Trendelenburg positioning
• Reduced with reverse Trendelenburg positioning
• The changes in pulmonary compliance may be less with
retroperitoneal insufflation
38 anesthesia for hepatobiliary surgery 03/12/2023
 PHYSIOLOGIC EFFECTS
CO2 absorption
CO2 is highly soluble and is rapidly absorbed into the circulation

CO2 absorption increases quickly and reaches a plateau at 60 minutes of

insufflation
Ventilation must be increased to maintain normal EtCO2 and PaCO2

Surgical technique may influence the degree of CO2 absorption.

Subcutaneous emphysema increased absorption of CO2.

Subcutaneous emphysema common during retroperitoneal insufflation of CO2

39 anesthesia for hepatobiliary surgery 03/12/2023
 PHYSIOLOGIC EFFECTS
Ventilation/perfusion matching
The reduction in FRC and atelectasis associated with laparoscopy
leads to shunting and ventilation/perfusion mismatch
Endotracheal tube
Pneumoperitoneum and Trendelenburg positioning
Cephalad movement of the carina
Result in mainstem endobronchial migration of the endotracheal tube
hypoxia, and high inspiratory pressure
Endotracheal tube cuff pressure increases in some patients

40 anesthesia for hepatobiliary surgery 03/12/2023

 Regional circulatory changes
Splanchnic blood flow
The mechanical and neuroendocrine effects of pneumoperitoneum

Decrease splanchnic circulation

 Reduced total hepatic blood flow and bowel perfusion.

Hypercapnia can cause direct splanchnic vasodilatation.

Thus, the overall effects on splanchnic circulation are not clinically

significant

41 anesthesia for hepatobiliary surgery 03/12/2023

 Regional circulatory changes
Renal blood flow
Pneumoperitoneum results in

Reduction in renal perfusion and urine output

Associated with renal parenchymal compression, reduced renal vein flow, and

increased levels of vasopressin.

When IAP is kept under 15 mmHg, renal function and urine output

generally normalize soon after pneumoperitoneum deflation

42 anesthesia for hepatobiliary surgery 03/12/2023

 Regional circulatory changes
Cerebral blood flow
Increased intraabdominal and intrathoracic pressures, hypercarbia, and

Trendelenburg positioning
All increase CBF and ICP

In patients with intracranial mass lesions or significant cerebrovascular disorders

(eg, carotid atherosclerosis and cerebral aneurysm),

The increase in ICP may have clinical consequences.

Normocapnia should be maintained

43 anesthesia for hepatobiliary surgery 03/12/2023

 Regional circulatory changes
Intraocular pressure (IOP)
IOP increases with pneumoperitoneum

Increases further when the patient is positioned in Trendelenburg

IOP increased by an average of 13 mmHg from baseline at the end of the

procedure
Increased IOP may results postoperative visual loss in patients with prolonged

cases

44 anesthesia for hepatobiliary surgery 03/12/2023

 ANESTHETIC MANAGEMENT
Choice of anesthetic
For procedures performed in Trendelenburg position, GA with ETT
Allows optimal ventilatory control and support.
Spinal or epidural anesthesia for short procedures in the supine or head­up position
A sensory level of T4 to T6 is required for adequate neuraxial anesthesia.

Monitoring and intravenous access

Standard American Society of Anesthesiologists (ASA) monitors

Continuous intraarterial pressure should be added as required by

The patient’s medical condition, the expected blood loss, and the duration of surgery.
45 anesthesia for hepatobiliary surgery 03/12/2023
 ANESTHETIC MANAGEMENT
Induction of anesthesia
A variety of medications and techniques can be used for induction of

anesthesia
For most adults, intravenous (IV) induction is performed.

An orogastric tube should be placed and suctioned to decompress the stomach

prior to needle or trochar insertion and to minimize stomach injury

46 anesthesia for hepatobiliary surgery 03/12/2023

 ANESTHETIC MANAGEMENT
Maintenance of anesthesia
Various inhalation and IV anesthetics can be used for maintenance of GA

NO for maintenance during laparoscopy is controversial.

Concerns regarding the use of NO

Increase in PONV and bowel distention

47 anesthesia for hepatobiliary surgery 03/12/2023

 ANESTHETIC MANAGEMENT
Mechanical ventilation
The dynamic changes in pulmonary function during laparoscopy
Require intraoperative adjustment of mechanical ventilation.
Modes of ventilation
Lung­protective intraoperative ventilatory strategy,
using a tidal volume of 6 to 8 mL/kg
5 to 10 cmH O PEEP.
Which may reduce postoperative pulmonary complications
Improve oxygenation during laparoscopy
Increase RR rather than the TV, to increase MV
Compensate for CO absorption while avoiding barotrauma
48 anesthesia for hepatobiliary surgery 03/12/2023
 ANESTHETIC MANAGEMENT
Mild hypercapnia approximately 40 mmHg) if necessary to maintain peak
airway pressures under 50 cmHO2 in order to avoid barotrauma.
Mild hypercarbia can improve tissue oxygenation by increasing cardiac
output (CO) and vasodilation
Increasing the inspiratory to expiratory (I:E) ratio may be beneficial in
steep Trendelenburg position during laparoscopy.
Peak pressures over 50 mmHg
Ventilate with pressure control with volume guarantee.
If peak pressure remains over 50 mmHg, set the I:E ratio at 1:1.

49 anesthesia for hepatobiliary surgery 03/12/2023

 ANESTHETIC MANAGEMENT
Hypoxia
Auscultate to rule out bronchospasm and endobronchial intubation.

Increase the FiO2 and perform a recruitment maneuver

If oxygenation improves increase PEEP and periodic recruitment maneuvers

If hypoxemia and high PAP persist, for patients in Trendelenburg position,

Reduce the degree of tilt and/or reduce the insufflation pressure

If ETCO2 >50 mmHg despite hyperventilation, examine for signs of subcutaneous emphysema.

If hypercarbia and/or hypoxia persists discuss conversion to open surgery

50 anesthesia for hepatobiliary surgery 03/12/2023

 ANESTHETIC MANAGEMENT
Fluid management
Perioperative fluid therapy affect postoperative outcomes after abdominal
surgery.
Restrictive fluid therapy improves outcome with avoidance of bowel
edema and interstitial fluid accumulation
Prolonged steep head­down position, excessive fluid administration may
result in facial, pharyngeal, and laryngeal edema.
In this setting, restrictive or goal­directed fluid therapy is essential.

51 anesthesia for hepatobiliary surgery 03/12/2023

 ANESTHETIC MANAGEMENT
Traditional indicators used to guide fluid therapy (eg, heart rate [HR],

ABP, central venous pressures [CVPs], and urine output) are unreliable.
Dynamic indicators such as SV or systolic pressure variation are preferred.

Achieved by administration of small fluid boluses as necessary.

52 anesthesia for hepatobiliary surgery 03/12/2023

 ANESTHETIC MANAGEMENT
Nausea and vomiting prophylaxis
Laparoscopy has been identified as a risk factor for PONV.
Routine prophylactic multimodal antiemetic therapy should be utilized
The number of antiemetic combinations can be based on the patient’s level of risk.
Approach to antiemetic prophylaxis
All patients
Dexamethasone (4 to 8 mg IV after induction)
5­HT antagonists (eg, ondansetron 4 mg at the end of surgical procedure).
High­risk patients
Additional antiemetic therapy with preoperative transdermal scopolamine
In addition use total IV anesthesia (TIVA) with propofol.
Rescue therapy
Low­dose promethazine (6.25 mg IV, slowly) or dimenhydrinate (1 mg/kg IV)

53 anesthesia for hepatobiliary surgery 03/12/2023

 Plan for postoperative pain management
The origins of pain after laparoscopic

Somatic (ie, from port­site incisions)

Visceral (ie, from peritoneal stretch and manipulation of abdominal tissues).

The degree of pain usually low to moderate

Multimodal approach \to minimize postoperative administration of opioids.

Acetaminophen, NSAIDs, COX ­specific inhibitors, and dexamethasone

Local infiltrate the incisions with local anesthetic (LA)

Intraperitoneal instillation of LA

54 anesthesia for hepatobiliary surgery 03/12/2023

 INTRAOPERATIVE COMPLICATIONS
 Complications during laparoscopy include

Physiologic effects of the laparoscopic approach

hemodynamic compromise, respiratory decompensation,

Surgical maneuvers

Access­related injury; vascular, solid organ, or bowel injury;

Carbon dioxide spread to subcutaneous and intrathoracic spaces; gas embolism)

Patient positioning

55 anesthesia for hepatobiliary surgery 03/12/2023

 INTRAOPERATIVE COMPLICATIONS
Hemodynamic complications

Hypotension, hypertension, and arrhythmias

During insufflation

Surgical injury during abdominal access

 gas embolism, vascular or solid organ injury with hemorrhage) can cause rapid cardiovascular decompensation.

Hypervigilance with regard to blood pressure (BP), heart rate (HR), peak inspiratory pressures,

end tidal CO (ETCO ), and oxygen saturation.

Changes in vital signs should be immediately discussed with the surgeon

 Reevaluation of the position of the needle or port and possible release of the pneumoperitoneum.

56 anesthesia for hepatobiliary surgery 03/12/2023

 INTRAOPERATIVE COMPLICATIONS
Treatment of hemodynamic dysfunction
Confirmation that intraabdominal pressure (IAP) is within acceptable limits;
Exclusion of treatable causes;
Supportive therapy including reduction in anesthetics,
Fluid administration
Pharmacologic interventions.
If supportive therapy is ineffective, deflation of the abdomen may be necessary.
After cardiopulmonary stabilization, cautious, slow reinsufflation may then be
attempted using lower IAP.
Persistent signs of significant cardiopulmonary impairment, convert to an open
procedure

57 anesthesia for hepatobiliary surgery 03/12/2023

 INTRAOPERATIVE COMPLICATIONS
During surgery
During surgery, hemodynamic instability can occur for a variety of reasons and may

be more likely in patients with cardiac comorbidities

Hemorrhage

Hyperventilation

Positioning

 Head­up positioning

 Venous pooling and reduced venous return to the heart.

 Vasopressor administration (eg, phenylephrine) and/or fluid administration may be required.

58 anesthesia for hepatobiliary surgery 03/12/2023

 INTRAOPERATIVE COMPLICATIONS
Pulmonary complications
 Including hypercarbia and hypoxemia, altered respiratory mechanics, CO absorption ventilation
perfusion mismatch or surgical injury (eg, diaphragm or lung injury).
 Hypercarbia – It may be necessary to increase ventilation during laparoscopy to compensate for
CO absorption
 When severe hypercarbia occurs during laparoscopy The patient should be examined for signs of
subcutaneous emphysema
crepitus over the abdomen, chest, clavicles and neck.
 When high ETCO persists despite aggressive hyperventilation
reduced insufflation pressure
conversion to open surgery may be required

59 anesthesia for hepatobiliary surgery 03/12/2023

 INTRAOPERATIVE COMPLICATIONS
Carbon dioxide insufflation
Subcutaneous emphysema
Capnothorax
Capnomediastinum and capnopericardium
Gas embolism

60 anesthesia for hepatobiliary surgery 03/12/2023

 INTRAOPERATIVE COMPLICATIONS
Subcutaneous emphysema
CO2 is insufflated into subcutaneous tissues.
Improperly placed Veress needle or trocar,
Gas can track into the thorax and mediastinum
Resulting in capnothorax, capnomediastinum, and capnopericardium.
Risk factors for subcutaneous emphysema during laparoscopy
Surgery lasting longer than 200 minutes
The use of six or more surgical ports
Patient age >65

61 anesthesia for hepatobiliary surgery 03/12/2023

 INTRAOPERATIVE COMPLICATIONS
Subcutaneous emphysema
Subcutaneous emphysema resolves after the abdomen is deflated
When crepitus or swelling occurs in the head, neck, or upper chest, the
potential for airway
compromise after extubation is increased
In most cases, subcutaneous CO2 is superficial and does not compromise
the airway lumen.
When external swelling is severe
Absorption of CO from subcutaneous emphysema may continue for up to
several hours after surgery.

62 anesthesia for hepatobiliary surgery 03/12/2023

 INTRAOPERATIVE COMPLICATIONS
Subcutaneous emphysema
Healthy patients are able to increase ventilation to eliminate CO
Chronic lung disease or with opioid­induced respiratory depression can
remain hypercarbic and acidotic Somnolence, hypertension, and
tachycardia may occur.
For symptomatic patients with subcutaneous emphysema of the head and
neck region
Postoperative chest radiograph should be performed to rule out capnothorax.
Patients with significant subcutaneous emphysema should be observed in
the post­anesthesia care unit (PACU) for several hours
Until swelling begins to subside and vital signs are normal.

63 anesthesia for hepatobiliary surgery 03/12/2023

 Thank you

64 anesthesia for hepatobiliary surgery 03/12/2023