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

2. 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.

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

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

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

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

7. ANAESTHESIA PLAN ETGA + Thoracic Epidural Anesthesia

8. 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

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

10. 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

11. 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

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

13. 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.

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

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

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

17. 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.

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

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

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

29. THANK YOU