Liver Resection

A man with cholangiocarcinoma - cancer of the gallbladder - presents for a large resection of the liver. The liver is divided into eight segments based on its anatomy and our goal was to remove two-thirds of it. This was going to be a large, potentially bloody surgery because the tumor was fairly close to the inferior vena cava. We planned accordingly, placing an introducer sheath into one of the large neck veins and setting up a rapid transfuser. The surgeons worked carefully; I could see the concentration in their movements as they delicately dissected the cancer from the largest vein in the body. We watched closely, as any errant move could cause massive blood loss requiring clamping of the inferior vena cava. But our surgeons' precise movements allowed them to peel the cancer away, an amazing technical feat of precision. The tension relaxed as the rest of the liver segments were resected, the hepatic vessels clipped, the bile duct system reconstructed, and the lymph nodes sampled. The patient never had problems with low blood pressure or excessive bleeding, we were quite satisfied as we finished the ten hour procedure, removed the breathing tube, and brought him to the recovery unit.

I began another anesthetic when the resident in the recovery unit called me. "I wanted to make sure he was never hypotensive," she said, "because he's dropping him blood pressure right now. The surgeons think he's dry and we're giving him some albumin and fluids." This was an appropriate initial response; we keep patients dehydrated for liver resections because liver congestion can cause a lot of problems, and most patients require rehydration after the operation. But when I checked in again, he was even more hypotensive, requiring pushes of vasopressors to keep his blood pressure in the normal range. His oxygen requirement went up and he was becoming more confused again.

I knew something was very wrong. When I got to the bedside, I called for blood and told the surgeons we needed to go back. There was unresolved bleeding somewhere, even though the drains were empty and the belly was soft. When I drew a blood gas, the blood didn't look like blood; it was too dilute. The only way to find and stop the source of bleeding was to go back in and find the bleeder. We crashed the patient back into the operating room, four anesthesiologists, working seemlessly as a team. We re-induced anesthesia, a tricky but necessary affair for a patient in hemorrhagic shock. We got a rapid transfuser set up and called a massive transfusion protocol, giving a total of eight units of blood, seven units of FFP, and some platelets. Such a resuscitation requires a lot of work, and we were occupied the entire time. But we managed to titrate the pressors off, improve the acidosis, replenish electrolytes, and stabilize the patient. The surgeons found a bleeding arterial vessel whose clip had been dislodged. If we had waited much longer, the patient would have had a cardiac arrest. But we managed to get him to the ICU in stable condition. The problem is that his liver, which has already suffered a large resection, had further injury during the period of low blood pressure. It will be slow to clear the acidosis, make clotting factors, clear waste products, and function again. But we hope that we can tide him through this critical period.

This case taught me that even if a field looks bloodless, an unexpected post-operative course must include unseen and unexpected hemorrhage. Sometimes a re-operation is necessary and sometimes the anesthesiologist who knows the patient's physiology best and identifies that something is direly wrong needs to speak up and make it happen. Access was central here, and the fact that we had an introducer to give blood as fast as a unit a minute saved this patient's life. The case taught me to prioritize and manage a rapidly changing clinical situation. This is what physician anesthesiologists train to do.