Complications of Liver Surgery

  • Oliver P. F. Panzer


Over the years improvements in the understanding of the functional anatomy of the liver, patient selection and surgical technique have greatly reduced the rate of complications of hepatic surgery. Consequently, the number of liver resections has greatly increased over the last decade. Nonetheless, intraoperative complications continue to exist. This chapter will discuss the most common complications associated with non-transplant liver surgery and evaluate the potential treatment options available. We will focus on methods to reduce intraoperative blood loss, ischemia reperfusion injury after hepatic resections and lastly, discuss the issue of low residual hepatic mass as a consequence of excessive liver resection.

Assessment of the surgical risk of patients undergoing elective liver surgery must include the preoperative state of the patient, the degree of cirrhosis, steatosis, fibrosis (Child-Pugh classification or the MELD score), the extent of liver dysfunction and...


Hemorrhage Antifibrinolytic Liver failure Small-for-size syndrome ALPPS procedure Minimal invasive resection 


  1. 1.
    Hendriks HGD, van der Meer J, de Wolf JTM, et al. Intraoperative blood transfusion requirement is the main determinant of early surgical re-intervention after orthotopic liver transplantation. Transpl Int. 2005;17:673–9.CrossRefGoogle Scholar
  2. 2.
    Cacciarelli TV, Keeffe EB, Moore DH, et al. Effect of intraoperative blood transfusion on patient outcome in hepatic transplantation. Arch Surg. 1999;134:25–9.CrossRefGoogle Scholar
  3. 3.
    Stainsby D, Williamson L, Jones H, Cohen H. 6 Years of shot reporting—its influence on UK blood safety. Transfus Apher Sci. 2004;31:123–31.CrossRefGoogle Scholar
  4. 4.
    de Boer MT, Molenaar IQ, Hendriks HGD, Slooff MJH, Porte RJ. Minimizing blood loss in liver transplantation: progress through research and evolution of techniques. Dig Surg. 2005;22:265–75.CrossRefGoogle Scholar
  5. 5.
    Ramos E, Dalmau A, Sabate A, et al. Intraoperative red blood cell transfusion in liver transplantation: influence on patient outcome, prediction of requirements, and measures to reduce them. Liver Transpl. 2003;9:1320–7.CrossRefGoogle Scholar
  6. 6.
    Porte RJ, Hendriks HGD, Slooff MJH. Blood conservation in liver transplantation: the role of aprotinin. J Cardiothorac Vasc Anesth. 2004;18:31S–7S.CrossRefGoogle Scholar
  7. 7.
    Foster JH, Berman MM. Solid liver tumors. Major Probl Clin Surg. 1977;22:1–342.PubMedGoogle Scholar
  8. 8.
    Jarnagin WR, Gonen M, Fong Y, et al. Improvement in perioperative outcome after hepatic resection: analysis of 1,803 consecutive cases over the past decade. Ann Surg. 2002;236:397–406; discussion 406–7.CrossRefGoogle Scholar
  9. 9.
    Helling TS, Blondeau B, Wittek BJ. Perioperative factors and outcome associated with massive blood loss during major liver resections. HPB (Oxford). 2004;6:181–5.CrossRefGoogle Scholar
  10. 10.
    Sirichindakul B, Chanwat R, Nonthasoot B, Suphapol J, Nivatvongs S. Risk factors associated with major intraoperative blood loss in hepatic resection for hepatobiliary tumor. J Med Assoc Thail. 2005;88(Suppl 4):S54–8.Google Scholar
  11. 11.
    Bergenzaun L, Gudmundsson P, Öhlin H, et al. Assessing left ventricular systolic function in shock: evaluation of echocardiographic parameters in intensive care. Crit Care. 2011;15:R200.CrossRefGoogle Scholar
  12. 12.
    Tripodi A, Salerno F, Chantarangkul V, et al. Evidence of normal thrombin generation in cirrhosis despite abnormal conventional coagulation tests. Hepatology. 2005;41:553–8.CrossRefGoogle Scholar
  13. 13.
    Lisman T, Leebeek FWG. Hemostatic alterations in liver disease: a review on pathophysiology, clinical consequences, and treatment. Dig Surg. 2007;24:250–8.CrossRefGoogle Scholar
  14. 14.
    Westerkamp AC, Lisman T, Porte RJ. How to minimize blood loss during liver surgery in patients with cirrhosis. HPB (Oxford). 2009;11:453–8.CrossRefGoogle Scholar
  15. 15.
    van Gulik TM, de Graaf W, Dinant S, Busch ORC, Gouma DJ. Vascular occlusion techniques during liver resection. Dig Surg. 2007;24:274–81.CrossRefGoogle Scholar
  16. 16.
    Yi B, Qiu Y-H, Liu C, et al. Hepatic blood inflow occlusion with/without hemihepatic artery control versus the Pringle maneuver in resection of hepatocellular carcinoma: a retrospective comparative analysis. Chin Med J. 2010;123:1413–6.PubMedGoogle Scholar
  17. 17.
    Alkozai EM, Lisman T, Porte RJ. Bleeding in liver surgery: prevention and treatment. Clin Liver Dis. 2009;13:145–54.CrossRefGoogle Scholar
  18. 18.
    Takayama T, Makuuchi M, Kubota K, et al. Randomized comparison of ultrasonic vs clamp transection of the liver. Arch Surg. 2001;136:922–8.CrossRefGoogle Scholar
  19. 19.
    Melendez JA, Arslan V, Fischer ME, et al. Perioperative outcomes of major hepatic resections under low central venous pressure anesthesia: blood loss, blood transfusion, and the risk of postoperative renal dysfunction. J Am Coll Surg. 1998;187:620–5.CrossRefGoogle Scholar
  20. 20.
    Jones RM, Moulton CE, Hardy KJ. Central venous pressure and its effect on blood loss during liver resection. Br J Surg. 1998;85:1058–60.CrossRefGoogle Scholar
  21. 21.
    Moug SJ, Smith D, Leen E, Angerson WJ, Horgan PG. Selective continuous vascular occlusion and perioperative fluid restriction in partial hepatectomy. Outcomes in 101 consecutive patients. Eur J Surg Oncol. 2007;33:1036–41.CrossRefGoogle Scholar
  22. 22.
    Chen H, Merchant NB, Didolkar MS. Hepatic resection using intermittent vascular inflow occlusion and low central venous pressure anesthesia improves morbidity and mortality. J Gastrointest Surg. 2000;4:162–7.CrossRefGoogle Scholar
  23. 23.
    Smyrniotis V, Kostopanagiotou G, Theodoraki K, Tsantoulas D, Contis JC. The role of central venous pressure and type of vascular control in blood loss during major liver resections. Am J Surg. 2004;187:398–402.CrossRefGoogle Scholar
  24. 24.
    Wang W-D, Liang L-J, Huang X-Q, Yin X-Y. Low central venous pressure reduces blood loss in hepatectomy. World J Gastroenterol. 2006;12:935–9.CrossRefGoogle Scholar
  25. 25.
    Eid EA, Sheta SA, Mansour E. Low central venous pressure anesthesia in major hepatic resection. Middle East J Anesthesiol. 2005;18:367–77.PubMedGoogle Scholar
  26. 26.
    Massicotte L, Lenis S, Thibeault L, Sassine M-P, Seal RF, Roy A. Effect of low central venous pressure and phlebotomy on blood product transfusion requirements during liver transplantations. Liver Transpl. 2006;12:117–23.CrossRefGoogle Scholar
  27. 27.
    Feng Z-Y, Xu X, Zhu S-M, Bein B, Zheng S-S. Effects of low central venous pressure during preanhepatic phase on blood loss and liver and renal function in liver transplantation. World J Surg. 2010;34:1864–73.CrossRefGoogle Scholar
  28. 28.
    Kumar A, Anel R, Bunnell E, et al. Pulmonary artery occlusion pressure and central venous pressure fail to predict ventricular filling volume, cardiac performance, or the response to volume infusion in normal subjects. Crit Care Med. 2004;32:691–9.CrossRefGoogle Scholar
  29. 29.
    Berrevoet F, de Hemptinne B. Use of topical hemostatic agents during liver resection. Dig Surg. 2007;24:288–93.CrossRefGoogle Scholar
  30. 30.
    Figueras J, Llado L, Miro M, et al. Application of fibrin glue sealant after hepatectomy does not seem justified: results of a randomized study in 300 patients. Ann Surg. 2007;245:536–42.CrossRefGoogle Scholar
  31. 31.
    Fergusson DA, Hebert PC, Mazer CD, et al. A comparison of aprotinin and lysine analogues in high-risk cardiac surgery. N Engl J Med. 2008;358:2319–31.CrossRefGoogle Scholar
  32. 32.
    Molenaar IQ, Warnaar N, Groen H, Tenvergert EM, Slooff MJH, Porte RJ. Efficacy and safety of antifibrinolytic drugs in liver transplantation: a systematic review and meta-analysis. Am J Transplant. 2007;7:185–94.CrossRefGoogle Scholar
  33. 33.
    Warnaar N, Polak WG, de Jong KP, et al. Long-term results of urgent revascularization for hepatic artery thrombosis after pediatric liver transplantation. Liver Transpl. 2010;16:847–55.CrossRefGoogle Scholar
  34. 34.
    Mangano DT, Tudor IC, Dietzel C. Multicenter Study of Perioperative Ischemia Research Group, Ischemia Research and Education Foundation. The risk associated with aprotinin in cardiac surgery. N Engl J Med. 2006;354:353–65.CrossRefGoogle Scholar
  35. 35.
    Lodge JPA, Jonas S, Oussoultzoglou E, et al. Recombinant coagulation factor VIIa in major liver resection: a randomized, placebo-controlled, double-blind clinical trial. Anesthesiology. 2005;102:269–75.CrossRefGoogle Scholar
  36. 36.
    Planinsic RM, van der Meer J, Testa G, et al. Safety and efficacy of a single bolus administration of recombinant factor VIIa in liver transplantation due to chronic liver disease. Liver Transpl. 2005;11:895–900.CrossRefGoogle Scholar
  37. 37.
    Hendriks HG, Meijer K, de Wolf JT, et al. Reduced transfusion requirements by recombinant factor VIIa in orthotopic liver transplantation: a pilot study. Transplantation. 2001;71:402–5.CrossRefGoogle Scholar
  38. 38.
    de Meijer VE, Kalish BT, Puder M, Ijzermans JNM. Systematic review and meta-analysis of steatosis as a risk factor in major hepatic resection. Br J Surg. 2010;97:1331–9.CrossRefGoogle Scholar
  39. 39.
    Simmonds PC, Primrose JN, Colquitt JL, Garden OJ, Poston GJ, Rees M. Surgical resection of hepatic metastases from colorectal cancer: a systematic review of published studies. Br J Cancer. 2006;94:982–99.CrossRefGoogle Scholar
  40. 40.
    Cucchetti A, Ercolani G, Vivarelli M, et al. Impact of model for end-stage liver disease (MELD) score on prognosis after hepatectomy for hepatocellular carcinoma on cirrhosis. Liver Transpl. 2006;12:966–71.CrossRefGoogle Scholar
  41. 41.
    Hartog A, Mills G. Anaesthesia for hepatic resection surgery. Continuing Educ Anaesth Critical Care Pain. 2009;9:1–5.CrossRefGoogle Scholar
  42. 42.
    Bahde R, Spiegel H-U. Hepatic ischaemia-reperfusion injury from bench to bedside. Br J Surg. 2010;97:1461–75.CrossRefGoogle Scholar
  43. 43.
    Gurusamy KS, Gonzalez HD, Davidson BR. Current protective strategies in liver surgery. World J Gastroenterol. 2010;16:6098–103.CrossRefGoogle Scholar
  44. 44.
    Esaki M, Shimada K, Nara S, et al. Left hepatic trisectionectomy for advanced perihilar cholangiocarcinoma. Br J Surg 2013;100:801–7.CrossRefGoogle Scholar
  45. 45.
    Belghiti J, Marty J, Farges O. Techniques, hemodynamic monitoring, and indications for vascular clamping during liver resections. J Hepatobiliary Pancreat Surg 1998;5:69–76.CrossRefGoogle Scholar
  46. 46.
    Gurusamy KS, Kumar Y, Pamecha V, Sharma D, Davidson BR. Ischaemic pre-conditioning for elective liver resections performed under vascular occlusion. Cochrane Database Syst Rev. 2009:CD007629.Google Scholar
  47. 47.
    Gurusamy KS, Kumar Y, Sharma D, Davidson BR. Methods of vascular occlusion for elective liver resections. Cochrane Database Syst Rev. 2007:CD006409.Google Scholar
  48. 48.
    Gurusamy KS, Sheth H, Kumar Y, Sharma D, Davidson BR. Methods of vascular occlusion for elective liver resections. Cochrane Database Syst Rev. 2009:CD007632.Google Scholar
  49. 49.
    Abu-Amara M, Gurusamy KS, Hori S, Glantzounis G, Fuller B, Davidson BR. Pharmacological interventions versus no pharmacological intervention for ischaemia reperfusion injury in liver resection surgery performed under vascular control. Cochrane Database Syst Rev. 2009:CD007472.Google Scholar
  50. 50.
    Sato N, Murakami K, Ishida K, Ikeda K, Saito K. Pulmonary hypertension and polymorphonuclear leukocyte elastase after esophageal cancer operations. Ann Thorac Surg. 1991;51:754–8.CrossRefGoogle Scholar
  51. 51.
    Tian Y, Jochum W, Georgiev P, Moritz W, Graf R, Clavien P-A. Kupffer cell-dependent TNF-alpha signaling mediates injury in the arterialized small-for-size liver transplantation in the mouse. Proc Natl Acad Sci U S A. 2006;103:4598–603.CrossRefGoogle Scholar
  52. 52.
    Weigand MA, Plachky J, Thies JC, et al. N-acetylcysteine attenuates the increase in alpha-glutathione S-transferase and circulating ICAM-1 and VCAM-1 after reperfusion in humans undergoing liver transplantation. Transplantation. 2001;72:694–8.CrossRefGoogle Scholar
  53. 53.
    Bucuvalas JC, Ryckman FC, Krug S, Alonso MH, Balistreri WF, Kotagal U. Effect of treatment with prostaglandin E1 and N-acetylcysteine on pediatric liver transplant recipients: a single-center study. Pediatr Transplant. 2001;5:274–8.CrossRefGoogle Scholar
  54. 54.
    Man K, Lee TK, Liang TB, et al. FK 409 ameliorates small-for-size liver graft injury by attenuation of portal hypertension and down-regulation of Egr-1 pathway. Ann Surg. 2004;240:159–68.CrossRefGoogle Scholar
  55. 55.
    Bustos M, Beraza N, Lasarte J-J, et al. Protection against liver damage by cardiotrophin-1: a hepatocyte survival factor up-regulated in the regenerating liver in rats. Gastroenterology. 2003;125:192–201.CrossRefGoogle Scholar
  56. 56.
    Xu X, Man K, Zheng S-S, et al. Attenuation of acute phase shear stress by somatostatin improves small-for-size liver graft survival. Liver Transpl. 2006;12:621–7.CrossRefGoogle Scholar
  57. 57.
    Beck-Schimmer B, Breitenstein S, Urech S, et al. A randomized controlled trial on pharmacological preconditioning in liver surgery using a volatile anesthetic. Ann Surg. 2008;248:909–18.CrossRefGoogle Scholar
  58. 58.
    Beck C, Schwartges I, Picker O. Perioperative liver protection. Curr Opin Crit Care. 2010;16:142–7.CrossRefGoogle Scholar
  59. 59.
    Dahm F, Georgiev P, Clavien P-A. Small-for-size syndrome after partial liver transplantation: definition, mechanisms of disease and clinical implications. Am J Transplant. 2005;5:2605–10.CrossRefGoogle Scholar
  60. 60.
    Kam I, Lynch S, Svanas G, et al. Evidence that host size determines liver size: studies in dogs receiving orthotopic liver transplants. Hepatology. 1987;7:362–6.CrossRefGoogle Scholar
  61. 61.
    Man K, Su M, Ng KT, et al. Rapamycin attenuates liver graft injury in cirrhotic recipient--the significance of down-regulation of Rho-ROCK-VEGF pathway. Am J Transplant. 2006;6:697–704.Google Scholar
  62. 62.
    Kelly DM, Bennett R, Brown N, et al. Predicting the discharge status after liver transplantation at a single center: a new approach for a new era. Liver Transpl. 2012;18:796–802.CrossRefGoogle Scholar
  63. 63.
    Boillot O, Delafosse B, Méchet I, Boucaud C, Pouyet M. Small-for-size partial liver graft in an adult recipient; a new transplant technique. Lancet. 2002;359:406–7.CrossRefGoogle Scholar
  64. 64.
    Shoup M, Gonen M, D'Angelica M, et al. Volumetric analysis predicts hepatic dysfunction in patients undergoing major liver resection. J Gastrointest Surg. 2003;7:325–30.CrossRefGoogle Scholar
  65. 65.
    Tucker ON, Heaton N. The ‘small for size’ liver syndrome. Curr Opin Crit Care. 2005;11:150–5.Google Scholar
  66. 66.
    Uesaka K, Nimura Y, Nagino M. Changes in hepatic lobar function after right portal vein embolization. An appraisal by biliary indocyanine green excretion. Ann Surg. 1996;223:77–83.CrossRefGoogle Scholar
  67. 67.
    Baumgart J, Lang S, Lang H. A new method for induction of liver hypertrophy prior to right trisectionectomy: a report of three cases. HPB (Oxford). 2011;13:71–2.Google Scholar
  68. 68.
    de Santibañes E, Clavien PA. Playing Play-Doh to prevent postoperative liver failure: the ‘ALPPS’ approach. Ann Surg. 2012;255:415–7.Google Scholar
  69. 69.
    Fahrner R, Patsenker E, de Gottardi A, et al. Elevated liver regeneration in response to pharmacological reduction of elevated portal venous pressure by terlipressin after partial hepatectomy. Transplantation. 2014;97:892–900.CrossRefGoogle Scholar
  70. 70.
    Ren Z, Xu Y, Zhu S. The effect of terlipressin on hepatic hemodynamics in small-for-size livers. Hepato-Gastroenterology. 2012;59:208–11.Google Scholar
  71. 71.
    Suehiro T, Shimada M, Kishikawa K, et al. Effect of intraportal infusion to improve small for size graft injury in living donor adult liver transplantation. Transpl Int. 2005;18:923–8.CrossRefGoogle Scholar
  72. 72.
    Jia C, Dai C, Bu X, et al. Co-administration of prostaglandin E1 with somatostatin attenuates acute liver damage after massive hepatectomy in rats via inhibition of inflammatory responses, apoptosis and endoplasmic reticulum stress. Int J Mol Med. 2013;31:416–22.CrossRefGoogle Scholar
  73. 73.
    Busani S, Marconi G, Schiavon L, et al. Living donor liver transplantation and management of portal venous pressure. Transplant Proc. 2006;38:1074–5.CrossRefGoogle Scholar
  74. 74.
    Abu Hilal M, Underwood T, Taylor MG, Hamdan K, Elberm H, Pearce NW. Bleeding and hemostasis in laparoscopic liver surgery. Surg Endosc. 2010;24:572–7.CrossRefGoogle Scholar
  75. 75.
    Sandadi S, Johannigman JA, Wong VL, Blebea J, Altose MD, Hurd WW. Recognition and management of major vessel injury during laparoscopy. J Minim Invasive Gynecol. 2010;17:692–702.CrossRefGoogle Scholar

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© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of AnesthesiologyColumbia University Medical CenterNew YorkUSA

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