Complications - Right Hemihepatectomy, Robotically Assisted

The complications specific to robotic liver resection generally mirror those of open liver surgery. However, the limited tactile control and access in robotic surgery necessitate specific strategies for complication management.

Key Principle:

If an intraoperative complication cannot be managed robotically, convert to laparotomy without hesitation to ensure patient safety.

1. Bleeding

Bleeding is the most feared complication in minimally invasive liver surgery due to the inability to immediately control bleeding digitally, as in open surgery. Significant vascular injuries can lead to life-threatening blood loss.

a. Arterial Bleeding

• Common Sites:
  • During hilar dissection.
     
• Management Strategies:

1. Avoid indiscriminate suturing in the hepatic hilum to prevent injuries to bile ducts and adjacent vessels
2. Localized vascular leaks:
   • Repair with direct sutures (e.g., Prolene® 5-0 or 6-0) or apply clips
3. Major artery transection:
   • Mandatory reconstruction via reanastomosis
   • Use of a saphenous vein interposition graft if necessary

b. Venous Bleeding

• Potential Sources:

1. Portal vein: During hilar dissection.
2. Inferior vena cava (IVC) or retrohepatic veins: During retrohepatic mobilization.
3. Hepatic vein confluence (venous outflow tract): During vein preparation or transection.

• Management Strategies

Initial Control:

• Temporarily grasp the bleeding area to achieve hemostasis and visualize the defect
• Apply targeted clips, sutures, or staplers as needed

Diffuse Bleeding:

• Avoid indiscriminate suturing, which may worsen injuries or necrosis.
• Consider tightening the Pringle tourniquet to reduce venous inflow temporarily.

Challenging Venous Bleeding:

• IVC bleeding:
  • Control may require temporary occlusion of the IVC above and below the liver.
  • In severe cases, the diaphragm may need to be incised at the level of the IVC entry for exposure
  • Hepatic vein confluence: Often requires manual compression and may necessitate conversion to open surgery
• Air Embolism:
  • Risk during vena cava or hepatic vein injuries.
  • Requires urgent management, including increased PEEP (positive end-expiratory pressure) and aspiration of air from the heart if embolism occurs.

c. Bleeding from the Liver Resection Surface

Management Strategies:

• Targeted hemostasis:
  • Grasp bleeding points and apply clips or sutures.
  • Avoid mass suturing, which may cause necrosis of surrounding tissue and damage to adjacent veins.
     
• Diffuse bleeding:
  • Use an argon plasma coagulator (via the assistant trocar) to cauterize the bleeding surface.
  • Severe cases may require temporary packing with abdominal towels to control bleeding.
  • Apply hemostatic agents (e.g., sponges or topical hemostatic pads) with compression.

 Coagulation Disorders:

• Massive diffuse bleeding from the resection surface is often due to coagulation abnormalities. Early recognition and appropriate correction are critical.

Prophylaxis of Intraoperative Bleeding in Robotic Liver Resection

1. Inflow Control: Pringle Maneuver

• Tourniquet Placement:
  • A band is placed around the ligamentum hepatoduodenale before parenchymal dissection begins
  • The band is threaded through a 12 Ch thoracic drain and exteriorized via the 12 mm assistant trocar between robotic ports 1 and 2
  • The table assistant can tighten the band externally to occlude hepatic inflow, achieving effective vascular control
     
• Management:
  • Typically, vascular injuries can be addressed during 15-minute Pringle intervals
  • Once bleeding is controlled, the Pringle maneuver is released to restore normal perfusion

2. Outflow Control: Hepatic Venous Management

• Blood Outflow:
  • Blood exits the liver through the three hepatic veins (right, middle, and left)
  • Large resections require exposure of the venous outflow tract (hepatic veins and suprahepatic IVC)
     
• Right Hepatic Vein:
  • Challenging to isolate in right hemihepatectomy. However, visualization is crucial for posterior segment resections to facilitate bleeding control if required
     
• Technique:
  • If bleeding occurs, secure the vein with a vessel loop for control
  • A clip can be placed close to the vein or bleeding can be managed using a third robotic instrument
  • Tip: This strategy minimizes blood loss and reduces the risk of air embolism.

3. Controlled Parenchymal Dissection

Dissection Techniques:

• Select the dissection method based on liver tissue quality:
  • 1. Ultracision or Ultrasonic Dissector: Effective for fibrotic or cirrhotic livers
  • 2. Monopolar scissors and bipolar forceps: Suitable for softer, healthy parenchyma
  • 3. Water-jet dissector: Effective for tissue sparing and vascular preservation

 Hemostasis During Dissection:

• 1. Small vessel bleeding:
  • Use bipolar coagulation for control
• 2. Larger vessels or bile ducts:
  • Secure with clips or sutures before transection
• 3. Severe bleeding:
  • Activate the Pringle maneuver to reduce inflow and manage bleeding

 Tips for Specific Liver Conditions:

• Fibrotic/cirrhotic livers:
  • Prefer sutures (e.g., over clip application), which are more effective in dense tissue
• Healthy parenchyma:
  • Use Haemolock clips for secure closure due to their locking mechanism
• Unlocalized Bleeding:
  • Compress the site with gauze for 5–10 minutes, then reattempt localization and repair

4. Additional Preventative Strategies

i. High-Resolution Visualization:

• Ensure clear structure exposure with adequate lighting and suction

ii. Intraoperative Ultrasound:

• Use to map vascular structures and confirm safe dissection margins

iii. Preliminary Hilar Ligatures:

• Pre-ligate major hilar structures during lobectomies to minimize unexpected bleeding

iv. Central Venous Pressure (CVP) Management:

• Maintain low CVP to prevent venous system overfilling and reduce bleeding risk.

v. Resection Surface Care:

• Ensure meticulous hemostasis of the resection plane using:
  • Bipolar forceps for small bleeders
  • Topical hemostatic agents or argon beam coagulation for diffuse oozing
  • Avoid mass suturing, which can lead to necrosis or injury to adjacent vessels

Key Notes for Effective Hemostasis and Bleeding Prevention

1. Use Pringle maneuver proactively for inflow control during challenging dissection phases
2. Prioritize outflow vein visualization to prevent severe bleeding or air embolism
3. Tailor parenchymal dissection techniques to liver tissue quality
4. Leverage advanced imaging and preoperative planning to anticipate high-risk areas
5. Maintain low CVP and use precise, targeted hemostatic techniques for the resection surface

This structured approach minimizes bleeding risks and ensures safe, efficient robotic liver resections.

Management of Intraoperative Complications in Robotic Liver Resection

3. Bile Leaks

• Risk: Undetected bile leaks can lead to postoperative bilioma formation
•  Management During Parenchymal Transection:
  • Like blood vessels, bile ducts must be identified and securely ligated intrahepatically with clips or sutures
  • Caution: Coagulation is ineffective for bile duct sealing
• Inspection and Repair:
  • Before closing, inspect the resection surface thoroughly for bile leakage
• Seal leaks with:
  • Selective suturing or
  • Clipping (if the duct stump is long enough)

Note: Stapler usage during parenchymal transection has been associated with a higher incidence of postoperative bile fistulas.

4. Gas Embolism

• Cause: Accidental or unnoticed opening of hepatic veins can lead to CO2 embolism during robotic/laparoscopic procedures.
• Signs:
  • Sudden tachycardia, hypotension, hypoxemia, arrhythmias, and an increase in central venous pressure (CVP).
• Management:
• Prevent further air entry by identifying and sealing the entry site with clips or sutures
• Initiate PEEP (positive end-expiratory pressure) to reduce embolism severity
•  In severe cases, consider patient repositioning (e.g., Trendelenburg) and aspirate the embolism if necessary

5. Pneumothorax

• Cause: May occur with diaphragm-adjacent tumors or direct diaphragmatic infiltration.
• Management:
  • Place an intraoperative thoracic drain to manage the pneumothorax.

6. Accidental Transection of the Common Bile Duct (D. choledochus)

• Repair Options:
  • Good blood supply: Perform direct anastomosis between bile duct ends, possibly with a T-tube for drainage.
  • Poor blood supply or large defects: Perform a hepaticojejunostomy.

7. Hollow Organ Injury

• Risk Factors:
  • Adhesions from prior surgeries (e.g., cholecystectomy or gastric procedures)
• Management:
  • Address hollow organ injuries (e.g., bowel, stomach) immediately
  • Inspect thoroughly for additional injuries that may not be initially apparent

8. Trocar-Related Injuries

• Common Sites:
  • Hollow organs and vessels during initial trocar placement
• Management:
  • For vascular injuries, convert to laparotomy if necessary for adequate exposure and repair
  • Retroperitoneal vascular injuries are particularly challenging to assess minimally invasively
  • Inspect for secondary injuries (e.g., bowel perforations) even if primary trocar injuries appear resolved

Complications from Pneumoperitoneum

Cardiovascular:

• Arrhythmias, cardiac arrest, pneumopericardium, hypo-/hypertension

Pulmonary:

• Pulmonary edema, atelectasis, gas embolism, barotrauma, hypoxemia, pneumothorax/-mediastinum
• Immediate Measures:
  • 1. Reduce intra-abdominal pressure or release the pneumoperitoneum
  • 2. If the complication cannot be managed by anesthesia, convert to open surgery or terminate the procedure

Other Complications and Their Management in Robotic Liver Resection

Rare Complications

Subcutaneous Emphysema:

• Rare cases of collar subcutaneous emphysema may occur, potentially compressing the airways and increasing the risk of pneumothorax or pneumomediastinum
• Management:
  • If a CO2 pneumothorax does not cause ventilatory problems, observation is often sufficient since CO2 is rapidly absorbed in the thorax
  • For ventilatory issues or extensive capnothorax, place a thoracic drain
  • Older patients are particularly susceptible due to tissue fragility
  • Very rarely, a cervical incision may be required to manage severe cases

Positioning Injuries

Nerve Compression:

• Extreme positions during minimally invasive procedures to enhance organ exposure can compromise superficial nerves
• Commonly affected nerves:
  • N. peroneus
  • N. femoralis
  • N. ulnaris
  • Plexus brachialis
• Preventive Measures for Positioning Injuries:
  • Shoulder Supports: Use padded supports for expected Trendelenburg positioning
• Leg Supports:
  • When in lithotomy position, cushion the leg holders around the fibular head with gel pads
• Arms Adducted:
  • If arms are kept close to the body, pad the elbows and secure them gently in a pronated position
• Arms Abducted:
  • Place abducted arms on a padded arm board, ensuring the angle does not exceed 90° to prevent nerve stretching

Summary

• Subcutaneous Emphysema: Treat with observation or thoracic drainage based on severity.
• Positioning Injuries: Prevent by following proper padding techniques and maintaining safe positioning angles.
• Awareness of these rare but significant complications ensures improved safety during robotic liver resections