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INVESTIGATIONS

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

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INVESTIGATIONS

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  1. CASE REPORT – RIGHT HEPATECTOMYDr.M.MuthuShenbagam,MD(Anes),DA.Asst.ProfessorDept.ofAnaesthesia,KanyakumariGovt.Medical College Hospital.

  2. 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. INVESTIGATIONS Hb - 10 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 – 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.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 IVScoline 75mg IVINTUBATION : 8.0 ID Endo tracheal tube & BAE checked

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

  13. 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- uneventfulSurgery 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 + GlycopyrolateExtubated awake.Postop period – Vitals – StableShifted 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

  21. THANK YOU

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