CASE REPORT – RIGHT HEPATECTOMY Dr.M.MuthuShenbagam,MD(Anes),DA. Asst.Professor Dept.of Anaesthesia, Kanyakumari Govt.Medical College Hospital.

51yrs old Mr. Stephen from Nagercoil,admitted at KGMCH with C/o 51yrs old Mr. Stephen from Nagercoil,admitted at KGMCH with C/o. Abdominal pain > 6 months. Diagnosed by CT as Giant Hemangioma (Rt) lobe of liver.

Hb - 10 gms % LFT- WNL Coagulation profile - WNL INVESTIGATIONS Hb - 10 gms % LFT- WNL Coagulation profile - WNL

Planned for Rt Hepatectomy. Assessed Procedure & risk explained to the patients and relatives. Adequate blood reserved.

Patient was shifted to OT. Started IV lines 2 widebore 16G venflon – Patient was shifted to OT. Started IV lines 2 widebore 16G venflon – Rt&Lt arm. One 18G venflon in LL.

Monitors. - Pulse oximeter - NIBP - ECG - CVP -Urine output

ANAESTHESIA PLAN ETGA + Thoracic Epidural Anesthesia

Emergency drugs ,NTG, Dopamine infusion kept ready. Premed :. -Inj Emergency drugs ,NTG, Dopamine infusion kept ready. Premed : -Inj.Glycopyrolate 0.2mg IV - Midazolam 2mg IV - Pethidine 50mg IV

Under Asepsis Rt Internal jugular vein cannulated & Triple lumen CVP catheter inserted under seldinger technique & distal port used for CVP measurement.

Under asepsis, RT lat-position, 18G Epidural Catheter inserted in T10-T11space& 5cm kept inside& 10ml of 0.2% Ropivacaine + 25mcg Fentanyl given through Epidural Catheter

INDUCTION : Thiopentone 250mg IV. Scoline 75mg IV INTUBATION : 8 INDUCTION : Thiopentone 250mg IV Scoline 75mg IV INTUBATION : 8.0 ID Endo tracheal tube & BAE checked

MAINTENANCE – N2O/O2 - Fentanyl - Atracurium LA supplementation thro Epidural.

Fluid- Maintenance with Crystalloids& Colloids Fluid- Maintenance with Crystalloids& Colloids. CVP was kept in the range of 4-6 cm water. NTG infusion was used to minimize blood loss.

Vascular control was done with inflow clamping of Hepatic A / portal vein (Pringle maneuver)

Intra operatively, during resection phase, huge blood loss from middle hepatic veins. BP to 60/40mmHg

MANAGEMENT: - Mephentermine 12 mg Bolus - Colloids/Blood 2 units rushed - Dopamine drip - which was stopped after control BP to 100/70mmHg

Rest of the intraop period- uneventful Surgery lasted for 6 hrs Rest of the intraop period- uneventful Surgery lasted for 6 hrs. Blood loss – app. 2 to 3 lit. Intraoperativly 6 units of blood transfused & calcium supplement given.

At the end of procedure – reversal with Neostigmine + Glycopyrolate Extubated awake. Postop period – Vitals – Stable Shifted to ISCU.

Problems in Liver Resection Long operation time Fluid Shifts Sudden unexpected blood loss Coagulopathy Hypothermia

Low CVP Technique – controversial Aids surgery Minimise blood loss But, increased risk of Airembolism Potential for Hemodynamic instability if bleeding is sudden & significant

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