Complications - Left lateral liver resection, laparoscopic

Collar incision in marked cutaneous emphysema

1.1 Position induced complications

In order to improve organ exposure in laparoscopic surgery, patients are often brought into extreme positions which may compromise long superficial nerves. Nerves particularly at risk include:

• Peroneal nerve
• Femoral nerve
• Ulnar nerve
• Brachial plexus

Prophylaxis

• Padded shoulder supports if Trendelenburg position is expected
• In lithotomy position the stirrups at the level of the head of the fibula should be padded with additional gel cushions
• When the arms are adducted, the elbow areas should be positioned on additional padding and loosely secured to the body pronated.
• Abducted arms should always be positioned on a padded support and never abducted beyond 90°

1.2 Trocar insertion complications

Insertion of the trocars and, particularly the first trocar, may injure hollow viscera and vessels; in many cases safe assessment and management of the injury will require speedy conversion to laparotomy. Laparoscopic assessment of retroperitoneal vascular injuries is almost impossible. Even if accidental intestinal injury could be managed laparoscopically, the possibility must be considered that there might be additional intra-abdominal injuries not evident at first glance.

1.3 Pneumoperitoneum-induced complications

Pneumoperitoneum may trigger a variety of pathologic changes in hemodynamics and the lungs, kidneys and endocrine organs. Depending on the intra-abdominal pressure, type of anesthesia, ventilation technique used, and the underlying disease, inadequate management of anesthesia may result in severe complications.

1.3.1 Cardiovascular complications

• Arrhythmia
• Cardiac arrest
• Pneumopericardium
• Hypotension/hypertension

1.3.2 Pulmonary complications

• Pulmonary edema
• Atelectases
• Air embolism
• Barotrauma
• Hypoxemia
• Pneumothorax/pneumomediastinum

Emergency procedure

• Deflate the pneumoperitoneum
• If the anesthesiologist cannot manage the complication, consider conversion to open surgery or terminate the operation

Special case: Extreme subcutaneous emphysema

Up to 3% of all laparoscopies are complicated by collar skin emphysema; if left untreated it may threaten compression of the airways with secondary pneumothorax and pneumomediastinum and require CO2 deflation via a collar incision.As long as CO2 pneumothorax does not result in ventilation problems, watchful waiting is one possible option because the CO2 within the chest is rapidly absorbed. In case of ventilation problems or extensive pneumothorax a chest tube is indicated. Due to their flaccid tissue elderly patients are particularly at risk.

1.4. Organ specific complications

The complications specific to laparoscopic liver resection resemble those of open surgery. If they cannot be managed laparoscopically, conversion to laparotomy should not be delayed. Depending on the complication, proceed as described below:

1.4.1 Bleeding

Arterial bleeding

• May occur during dissection of the hepatic hilum but usually is easily managed
• Due to the risk of injury to bile duct structures and other vessels, bleeding in the hepatic hilum should not be blindly suture ligated, but better managed by successive dissection and specific measures under direct view.
• Arterial leakage: Direct suture with Prolene® 5-0 or 6-0 or clip
• In accidental transection of a major artery its reconstruction is mandatory, possibly reanastomose with a saphenous vein graft.

Venous bleeding

• e.g., from the portal vein, is much more difficult to manage: Under local control first attempt to gain overview, then clamp the vein close to its trunk and possibly suture it.
• Bleeding from the inferior vena cava is sometimes hard to control
• In retroperitoneal bleeding, which may spring up while freeing the liver, the inferior vena cava usually has not yet been freed enough to clamp it tangentially. In this case, the inferior vena cava must be grasped and compressed, best with forceps, after which the lesion is exposed and sutured; in this situation it is helpful if the inferior vena cava below the liver had been looped beforehand.
• When the inferior vena cava is bleeding at the level of its confluence with the hepatic veins, often the only management possible is by manual compression.
• In difficult situations it may become necessary to temporarily clamp the inferior vena cava cephalad and caudad of the liver. This may even require opening up the diaphragm at the caval foramen.
• Caution: There is the risk of air embolism!

Bleeding from the hepatic resection area

• Targeted suture ligation
• No deep bulk suture ligations because they result in necrosis of the surrounding parenchyma and may lead to injury of adjacent vessels, e.g. thin-walled hepatic veins.
• In diffuse bleeding: Coagulation, e.g., with an argon beamer
• Massive diffuse bleeding from the resection area (most often due to coagulopathy) may require temporary packing with towels.

Preventing intraoperative bleeding

• Adequate access with sufficient exposure
• Generous freeing of the liver
• Preliminary hilar ligatures in anatomical lobectomies
• Intraoperative ultrasonography with visualization of the vascular structures at the area of resection
• Controlled dissection of the parenchyma
• Avoiding venous system overload (low CVP)
• Careful management of the area of resection

Compromised arterial blood supply

• As a matter of principle, when dissecting the hilum care must be taken to prevent accidental injury to and ligature of the wrong artery. This would result in a significant complication.

1.4.2 Bile leakage

• With gallbladder present: Occlude the common bile duct and manually compress the gallbladder while simultaneously inspecting the resection area of the liver; possibly targeted suture ligation
• With the gallbladder already removed: Check with methylene blue or Lipovenös® (lipid emulsion) via the cystic stump: After methylene blue or Lipovenös® has been pressure injected into the bile duct system, bile leakage will be easily visible as discharge of blue solution /white lipid.

1.4.3 Air embolism

• Air embolism (in laparoscopic procedures: CO2 embolism) may occur through accidental or unnoticed openings in small hepatic veins; the symptoms include sudden tachycardia, hypotension, arterial hypoxemia, arrhythmia and elevated CVP. Low and even negative CVP encourages air embolism.
• Prevent further entry of air by detecting, clamping or suturing the point of entry, and immediately start PEEP ventilation.

1.4.4 Pneumothorax

• May occur in tumors close to or infiltrating the diaphragm → intraoperative chest tube

1.4.5 Transection of the common bile duct

• If after accidental transection of the common bile duct both stumps display good blood supply, they may be anastomosed directly, possibly T-tube drainage
• In case of possibly compromised blood supply hepaticojejunostomy is indicated

1.4.6 Injuries to hollow viscera

• Many patients with previous surgery, particularly after cholecystectomy or gastric procedures, require adhesiolysis. This may result in injury to hollow viscera.

2.1 Secondary bleeding

Secondary bleeding after liver surgery may be due to insufficient intraoperative hemostasis or coagulation/fibrinolysis disorders.

Purely venous secondary bleeding most often will cease spontaneously. Secondary arterial and portal venous bleeding will not stop spontaneously and must be managed surgically. This may be performed laparoscopically. However, in many cases it takes too long to obtain adequate view, in which case standard open access is recommended.

Perihepatic hematoma

• Ultrasound/CT-controlled drainage, depending on the extent; possibly relaparotomy
• Formation of subphrenic and subhepatic abscesses possible

Subcapsular hematoma

• Usually, the body will absorb small hematomas while larger ones may rupture
• In case of revision surgery manage the hematoma area of the parenchyma with the argon beamer

Central liver hematoma

• Central arterial bleeding within the hepatic parenchyma may result in the formation of pseudoaneurysms which may undergo secondary rupture due to pressure and necrosis in the immediate vicinity; in this case rapid revision may be indicated
• Diagnostic work-up with ultrasonography and CT, possibly selective arterial embolization

2.2 Biliary fistula

• Patient stable without signs of peritonitis: Leave target drainage in place, monitor drainage volume; will often cease spontaneously.
• Specific diagnostic work-up if drainage volume >100 mL/day; attempt ERCP with stenting to lower the pressure within the biliary tree.
• Only very few cases will require revision surgery.

2.3 Liver abscess

• Usually as sequela of biliary fistulas; managed by interventional CT-guided drainage, only very few cases will require revision surgery.

2.4 Pleural effusion

• Concomitant pleural effusion is sometimes seen after right hemihepatectomy, less frequently on the left side
• Depending on the extent, it may require drainage

2.5 Pneumonia

• Postoperative pulmonary infection is not uncommon, particularly whenever patients do not comply with the required postoperative respiratory exercises
• Continuous administration of oxygen via nose cannula or mask is not always helpful because this may result in shallow breathing
• Prevention: Rapid postoperative ambulation, Bird ventilator, TriFlo inspiratory exerciser, CPAP mask, physiotherapy/respiratory exercises

2.6 Secondary perforation of hollow viscera

• Emergency relaparotomy

2.7 Liver failure

While postoperative liver failure is rather rare, it is the most important parameter of perioperative mortality after liver resections. Since the therapeutic options in postoperative (residual) liver failure are very limited, pre-operative risk assessment is most essential. It allows careful selection of patients possibly eligible for liver resection.

In healthy livers resection of segment II/III should not pose a problem; only cirrhosis of the liver and a rather large left lateral hepatic lobe may result in postoperative liver failure. If there is fulminant liver failure nevertheless, liver transplantation is the only available option.

For preoperative planning in liver resection the functional reserve capacity of the liver after resection (Partial Hepatic Resection Rate, PHRR) may be estimated according to the following equation:

PHRR = (resected liver volume - tumor volume) / 
/total liver volume - tumor volume)

By now, the residual hepatic volume after resection may be calculated by two-dimensional CT (2D-CT) and magnetic resonance imaging (2D-MRI). However, this still does not allow precise assessment if the blood supply will suffice for the remaining tissue. Software systems reconstructing all intrahepatic blood vessels and bile duct structures and the corresponding parenchyma in three dimensions can help visualize and quantify the liver situation. Considering the patient's own hepatic anatomy, they allow simulations by virtual resection.