Surgical complications - part 5 ppt

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384 P. B. Boulos & A. O’Bichere
be revised by local exploration. Necrosis below the fascia and therefore intra-
peritoneally requires immediate exploratory laparotomy. If there is concern
about recurrent necrosis because of tension or body wall thickness, a loop-
end stoma or divided-end-loop stoma should be constructed in order to avoid
skeletonisation of the bowel.
Retraction
Tension on the stoma, improper construction or siting and ischaemia are
responsible factors. An abdominal opening that is wider than the bowel lumen
causes tension on the mucocutaneous sutures which break and the stoma
separates from the skin. This is more likely to occur when forming a colostomy
than an ileostomy, and is an emergency if the colostomy recedes into the
peritoneal cavity. Otherwise colostomy retraction is not as clinically significant
as retraction of an ileostomy as with flush stoma the appliance adheres poorly
and the skin is damaged by intestinal effluent. Stoma retraction may occur as
a late complication if a patients gains excessive weight.
Local revision involves measures to secure the ileostomy spout eversion
and these include bidirectional seromyotomies to induce fibrosis, sutures to
include the bowel edge, serosa at skin level and the skin edge, sutures between
the serosa and fascia around the stoma, stapling the everted stoma with a
bladeless linear cutting stapling instrument.
Colostomy refashioning may demand mobilisation of the splenic flexure
of the colon or even division of the inferior mesenteric artery at its origin in
the obese patient to prevent tension on the colostomy.
Obstruction
This is commonly due to food bolus obstructing an oedematous newly
fashioned ileostomy. Stenosis complicating ischaemia is a common cause of
colostomy and ileostomy obstruction. The obstruction resolves spontaneously
or by saline irrigation of the ileostomy through a Foley catheter and a careful
dilatation with the finger or graduated dilators can be attempted in a stenosed

stoma. Only if these measures fail to relieve obstruction, refashioning the stoma
is considered and this will probably require re-exploration as at this early stage
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Complications of Colorectal Surgery 385
local revision can be technically difficult and not safe because of inflammation
and odema at the site of the stoma.
Late Complications
Prolapse
Ileostomy prolapse is rare and is usually associated with parastomal hernia,
and is more common in obese patients. Repair requires refashioning of the
ileostomy with local repair of the parastomal hernia which is rarely successful
in the long term.
Colostomy prolapse is also not common and is associated with parastomal
hernia, but is seen more frequently in paraplegic patients who had a stoma
for constipation, rectal prolapse, incontinence and in right sided or transverse
colostomies. The prolapse which is an intussusception of the proximal bowel is
easily reducible and patients learn how to reduce their own prolapse. Elective
treatment is to excise the redundant colon with local repair of the parastomal
hernia if present and if the prolapse recurs, resiting the stoma or colectomy
with ileostomy might be required.
Hernia
Parastomalherniais the commonest complicationamongpatientswith stomas.
Obesity, chronic respiratory disease, and a predilection to other abdominal
hernias are predisposing factors. There is no evidence that a stoma through
the rectus muscle reduces the risk of a parastomal hernia.
A parastomal hernia is repaired if it is causing psychological stress, interfer-
ing with the adherence of the appliance, causing pain from intestinal incarcer-
ation or obstruction, associated with prolapse or is cosmetically unacceptable.
Local repair may involve suture approximation of the defect with or without
mesh reinforcement and if this fails, resiting of the stoma might be necessary.

Stenosis
This is commonly due to ischaemic superficial necrosis at the time the stoma
was formed. Stenosis andfistulation can be a manifestation ofrecurrent Crohn’s
disease. Obstructive symptoms and difficulty with the appliance are the main
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386 P. B. Boulos & A. O’Bichere
reasons for revision of the stoma. Local revision is feasible at least 3 months
after the initial procedure as fibrosis becomes established and the tissue planes
are better defined to allow exteriorisation of a fresh segment of the bowel
for fashioning a new stoma. However in Crohn’s disease the extent of the
disease should be defined with a barium study as a laparotomy might be more
appropriate.
Fistulation
This usually follows subcutaneous infection which can be avoided by keeping
the size of the abdominal wall opening to the size of the bowel and preserv-
ing the subcutaneous fat, in order not to create a potential dead space for
haematoma and infection, and by not suturing the serosa to the fascia espe-
cially in Crohn’s disease. Recurrent Crohn’s disease in the efferent limb to a
stoma can fistulate through the stoma.
Pain around the stoma, discharge, poor adherence of the appliance and
skin irritation are reasons for local revision of a stoma that might involve
proximal bowel resection in Crohn’s disease or resiting of the stoma if the skin
and subcutaneous tissues are inflamed.
Complications of Stoma Closure
The closure of a stoma has its morbidity and should not be delegated to
an inexperienced surgeon. The main complications are intestinal leak and
intestinal obstruction.
A leak is either from the suture line or unrecognised inadvertent intra-
peritoneal damage to the bowel from traction or sharp injury while freeing the
stoma through a narrow abdominal aperture. It is therefore safer to extend

the incision or convert to a standard laparotomy if the stoma is densely
adherent. A leak often manifests as an enterocutaneous fistula than with
peritonitis.
Intestinal obstruction is due to oedema or stenosis at the anastomosis
and is more common with ileostomy than colostomy closure because of the
narrower lumen of the bowel.When the intestinal ends are judged to be narrow,
side-to-side anastomosis is easily performed with a linear stapler and provides
a wider lumen than an end-to-end anstomosis.
In either complication, conservative management is adopted before
surgical intervention is considered.
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Complications of Colorectal Surgery 387
SEPSIS
In abdominal operations signs of sepsis in the postoperative period after rul-
ing out extra-abdominal causes are either due to wound or intra-abdominal
infection.
Wound infections
Wound infection depends on the size and virulence of the bacterial inoculum,
local wound environment and the host organism defenses. Risk factors for
wound infection are operations on the abdomen, operations lasting more
than 2 hours, and a clean or dirty operation. Therefore the patient’s general
condition is optimised, tissue damage is avoided and contamination prevented
by mechanical bowel preparation and prophylactic systemic antibiotics.
Wounds at high risk of infection should be left open and packed until
delayed primary closure is carried out once the wound has filled with healthy
granulation tissue and there is minimal exudate and no pathogenic organisms
are isolated on wound culture. Otherwise the wound is left to heal by secondary
intention.
A closed wound that shows erythema, tenderness or exudates, is managed
by removing the sutures or staples, and any purulent material is drained and

the wound dressed appropriately. If there is fascial dehiscence the wound is
debrided and closed with retention sutures with the option to limit the closure
to the abdominal wall leaving the skin and fat layers open for local dressings.
Antibiotics are prescribed according to bacteriological analysis.
The most serious wound infections are the necrotising soft tissue infec-
tions because of associated mortality and should be suspected, in the case of
unusually severe pain in the incision, spreading erythema, oedema or crepi-
tus when a clinical microbiologist should be involved. This is an emergency
that requires prompt debridement with the excision of all necrotic tissue to the
margins of viable tissues. Initial broad spectrum antibiotic therapy is with peni-
cillin, aminoglycoside or clindamycin until tissue cultures are available. These
patients usually require repeated debridements, prolonged intensive wound
care and subsequently skin grafting.
Perineal wound infection
This is associated with closure rather than with open packing of the per-
ineal wound especially when excision of the rectum is complicated by faecal
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388 P. B. Boulos & A. O’Bichere
contamination. Treatment is by opening the wound and local care. However
the wound might not heal and if it remains unhealed for more than six months
it is then defined as a perineal sinus. Although soft tissue excision is more exten-
sive for cancer than for inflammatory bowel disease where the levators and the
external anal sphincters are preserved by performing intersphincteric excision,
persistent perineal sinuses are more common with inflammatory bowel disease
or when rectal excision is performed after radiation therapy.
With pelvic floor and sphincter muscle repair, the reconstituted anal canal
creates tension on the perineal incision that is responsible for skin ischaemia
and necrosis, wound disruption and infection. It is safer to carry out partial
closure of the wound and rely on healing by secondary intention for complete
healing.

Intra-abdominal infection
This should be suspected if the patient exhibits fever, prolonged ileus, abdom-
inal pain or leucocytosis. Abdominal examination for tenderness or an intra-
abdominal mass is limited by the abdominal incision. Ultrasonography in
the postoperative period is hampered by the wound, dressings and drainage
tubes and is unhelpful in surveying the abdomen and pelvis for fluid or gas
collections especially if there is intestinal gas distension from ileus.
Abdominal and pelvic CT is the investigation of choice and it allows
the placement of a percutaneous catheter for the drainage of abdominal or
pelvic abscesses avoiding the morbidity of surgical drainage, although it might
not be as successful in complex abscesses. The organisms usually isolated
include facultative gram negative bacilli, aerobic gram negative bacilli, obli-
gate and aerobic organisms and enterococci or other faecal streptococci. A
combination of an antianaerobe plus aminoglycoside or a third generation
cephalosporin is recommended, but it may have to be modified according
to culture results. The effectiveness of treatment is determined by the res-
olution of the signs of sepsis within 48 hours and diminution in the size
of the abscess on repeated CT scans. Otherwise re-exploration should be
considered.
Abscesses and enteric fistulas associated with anastomotic dehiscence are
managed as described already. Dehiscence of the rectal stump after Hartmann’s
or subtotal colectomy for acute fulminating colitis can be the cause of pelvic
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Complications of Colorectal Surgery 389
sepsis unless the rectal stump had been exteriorised as mucus fistula, although
a mucus fistula can be the source of infection if it retracts into the pelvis.
Instillation of contrast material into the rectum may confirm extravasation
from the apex of the rectal stump, which can be successfully managed by
percutaneous drainage of the abscess and catheter irrigation of the rectal stump
to evacuate residual faecal material. It is prudent that the rectal stump is always

washed out at the time of the primary operation.
ABDOMINAL COMPARTMENT SYNDROME
Abdominal compartment syndrome (ACS) is a potentially fatal consequence
of increased intra-abdominal pressure related to the prolonged exposure of
the bowel and massive intravenous fluid replacement associated with condi-
tions that colorectal surgeons frequently encounter namely intra-abdominal
haemorrhage, pelvic fractures, intestinal obstruction and colonic cancer. Pro-
longed unrelieved elevation of intra-abdominal pressure can cause pulmonary
compromise, renal impairment, cardiac failure, shock and death.
Pathophysiology
Oliguria is often the first evidence of excessive intra-abdominal pressure
attributed to renovascular rather than ureteric compression from occlusive
pressure on the inferior vena cava and renal veins, and to a lesser extent direct
pressure on the renal arteries as well as direct extrinsic pressure on the kidneys.
Ventilation is impeded from compromised inspiration because the lungs
are compressed. Progressive increase in the peak inspiratory pressure is required
to maintain tidal volume. Hypercarbia and potentially fatal respiratory acidosis
may develop. Elevated pCO2 and rising peak inspiratory pressures are signs
of significant abdominal pressure.
Pressure on the inferior vena cava reduces cardiac return while the heart
pumps against increased aortic and peripheral vascular resistance. Cardiac
output is diminished, and cardiovascular failure and shock are terminal events.
Compression on the inferior vena cava leads to peripheral venous stasis
causing severe oedema of the lower extremities and potential for thrombosis
and pulmonary embolism.
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390 P. B. Boulos & A. O’Bichere
Diagnosis and Treatment
Postoperative ACS develops within the first 24 hours. Oliguria manifests
within 12 hours after surgery. Renal scan, renogram and excretory urograms

are likely to be normal. Intravesical pressure measurement is the most useful
and it corresponds with the intra-abdominal pressure when the patient is in
the supine position, but is less accurate when the patient is in the Trendelen-
burg or reversed Trendelenburg position. In most critically ill patients a Foley
catheter is already in place, which can be connected to a water manometer via a
three-way stopcock. A pressure above 25 mmHg should cause concern because
when prolonged the risk of renal failure is considerable especially in patients
with compromised renal function. Hypovolaemic and seriously ill patients are
at risk of ACS at even lower pressure when other clinical parameters should
also be considered. Re-opening the abdomen to release the mounting pressure
in the abdominal cavity before irreversible damage occurs is life-saving.
It is preferable that ACS is anticipated and prevented. During a protracted
surgical procedure intravesical and/or ventilatory pressures are helpful mea-
surements and if wound closure is difficult, the wound is left open. A variety of
materials are used for temporary cover of the bowel, including sterilised plastic
material fashioned from intravenous or irrigation fluid bags termed “Bogota
bag.” A staged abdominal repair is deferred until the patient has recovered.
CONCLUSION
This account is not by any means comprehensive, but it provides an overall
insight into common postoperative complications associated with colorectal
surgery and highlights preventive measures that rely on sensible judgement in
decision-making, caution and technical skill. Complications due to functional
disturbance are related to the nature of the procedure; they are not within the
theme of this chapter and should be taken into account when considering the
overall morbidity.
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Chapter 12
COMPLICATIONS OF MAJOR
HEPATOBILIARY SURGERY
David J. Reich, Hoonbae Jeon,

Jorge A. Ortiz and Cosme Manzarbeitia
In this chapter, the authors seek to describe the various complications that
may occur during or after major hepatobiliary surgery, to provide treatment
options, and to discuss perioperative steps that minimise the risk of these prob-
lems. The authors try to provide a broad coverage of what has been learned
by leading hepatobiliary surgeons, and also to share our personal experience
in this field. The topics covered include complications related to procedures
routinely performed by hepatobiliary surgeons, including hepatic resection,
biliary resection for malignancy and radiofrequency ablation (RFA). Compli-
cations of cholecystectomy, common bile duct exploration and other biliary
procedures for benign disease, the domain of the general surgeon, are not
covered in this chapter.
Several developments in the 1990s have led to a significant improvement
in results after major hepatobiliary surgery. Perhaps most importantly, there
are a growing number of hepatobiliary surgeons, many of whom work as
391
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392 D. J. Reich et al.
part of experienced liver transplant and hepatobiliary surgical teams. There is
increasing communication and collaboration among these groups, even at a
global level, that facilitates learning. Patients benefit from hepatobiliary sur-
geons’ increased focus on liver anatomy and physiology. For example, the
better understanding of these disciplines gleaned from living donor and other
reduced size liver transplant procedures has been applied to non-transplant
resectional techniques. As more cutting edge hepatobiliary surgery is per-
formed, more effective equipment for imaging, resection and ablation con-
tinues to be invented, including magnetic resonance imaging (MRI) vascular
studies and cholangiography, laparoscopic ultrasonography, the cavitron ultra-
sonic surgical aspirator (CUSA), the harmonic scalpel, more versatile stapling
devices, RFA, and so on. Paralleling these surgical advances, has been a finer

understanding of coagulation and the development of a wide array of haemo-
static agents that have led to reduced morbidity from hepatobiliary surgery.
Complementing all these advances are further improvement in the fields of
anaesthesia and critical care. The aforementioned progress has greatly facil-
itated the safer performance of increasingly aggressive hepatobiliary surgery
and has made it possible to offer valuable surgical therapy to more patients
afflicted with diseases of the liver and bile ducts.
COMPLICATIONS OF HEPATIC RESECTION
The general approach to major hepatobiliary resection used by groups in the
United States, Europe and Asia is similar, and includes careful selection of
patients, care by a highly experienced and skilled surgical team, preoperative
radiological evaluation, and an attempt at minimal blood transfusion. A recent
nationwide study in the United States demonstrated that procedure volume
is an important predictor of mortality after major hepatobiliary resection.
1
Strict adherence to operative principles is the most important strategy for the
prevention of complications. Local complications such as bleeding, necrosis,
biliary fistula and sepsis can be prevented to alarge degree by precise application
of modern techniques of liver surgery.
Results of Hepatic Resection
As a result of the aforementioned advances, the current mortality rate after
major hepatobiliary resection even in cirrhotic patients is less than 1% at
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Complications of Major Hepatobiliary Surgery 393
Fig. 1. Depiction of various factors that either increase or decrease the risk of complications
following hepatobiliary resection.
some large centres.
2–8
Prior to the 1990s, this mortality rate was reported as
being 3% to 8%.

2,9
Interpreting mortality rates for hepatobiliary resection is
not straightforward because there are multiple variables that can potentially
effect patient outcomes, including the nature of the resection (i.e. the amount
of resected hepatic parenchyma, the surface area of the transection plane, and
proximity of the lesion to major vasculature); the underlying condition of the
hepatic parenchyma (i.e. the presence of steatosis, hepatitis, cirrhosis, and/or
obstructive jaundice); and technical aspects of the surgery (i.e. the amount of
intra-operative blood loss and transfusion, the duration of vascular occlusion,
and the skill and experience of the surgeon). The distribution of these factors
varies among case series from different centres. Thus, reports of morbidity
and mortality rates after major hepatobiliary resection should be cautiously
interpreted. Figure 1 depicts various factors that either increase or decrease the
risk of complications following hepatobiliary resection.
Anatomic and Technical Principles of Hepatic Resection
A surgeon’s knowledge of liver anatomy is critical in ensuring good outcomes
after hepatobiliary surgery (Fig. 2). The liver has segmental subdivisions in its
Jan. 23, 2007 10:8 SPI-B404 Surgical Complications ch12
394 D. J. Reich et al.
Fig. 2. Appreciation of the hepatic anatomy is critical for the safe conduct of hepatobiliary
resection. The liver can be divided into four sectors and eight segments (as numbered), which
are each supplied by separate branches of the portal vein (darker blue). These sectors are each
separated by an hepatic vein (lighter blue). Cantlie’s line (red) marks the plane in which the
middle hepatic vein runs, and defines the resection margin for right and left hepatic lobectomies.
internal architecture and a variety of anatomical variations in the vasculature
and biliary system exist from individual to individual.Therefore, it is advisable
to obtain a detailed road map of the patient’s hepatic vascular anatomy via com-
puted tomography (CT) scan or MRI prior to major resection. At present, liver
resection is based on precise knowledge of the natural lines of division of the
liver.

10
One can gain an appreciation for the segmental anatomy of the liver by
studying the corrosion cast model of the liver created by injecting resin into the
portal vein, hepatic arteries and bile ducts. The liver can be divided into four
sectors and eight segments, which are each supplied by separate branches of
the portal vein. These sectors are each separated by an hepatic vein.
11
Cantlie’s
line marks the plane in which the middle hepatic vein runs. Intraoperative
ultrasonography is an integral tool for navigating the internal landmarks of
hepatic segmental anatomy in modern hepatic surgery.
12
Theoretically, resec-
tion of any of the eight segments or any combination of segments is possible,
13
under ultrasonographic guidance
14
or via the extra-glissonian approach.
15
During the infancy of modern hepatobiliary surgery, the thoracoabdom-
inal incision was almost exclusively used in order to maximise exposure of
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Complications of Major Hepatobiliary Surgery 395
the operative field. However, since the introduction of costal arch retractors
that are fixable to the operating table, most cases are done via the abdom-
inal approach, which is associated with less postoperative morbidity. Strong
costal arch retractors such as Stieber or Thompson retractors allow for ade-
quate exposure of the suprahepatic or retrohepatic vena cava, which is the most
difficult area to expose. A bilateral subcostal incision with a midline extension
toward the sternum (“Mercedes incision”) is the standard incision for most

major hepatobiliary procedures. Some surgeons still use variants of the thora-
coabdominal incision, which provide an easier approach to the dome of the
liver and less mobilisation of the right side of the liver.
16
Special attention is required during the transverse (or oblique) stage of the
Mercedes incision to open the abdominal wall all the way to the posterior axil-
lary line, aiming at the tip of the 10th rib, so that the rib cage can be elevated
enough to visualise the hepatic dome and suprahepatic vena cava.Typically, it is
wise to expose the suprahapatic vena cava and hepatic veins after division of the
coronary ligament, prior to resection. Maximal exposure with stable retraction
of the rib cage, full mobilisation of the liver from its ligamentous attachments
to the diaphragm and retroperitoneum, and identification of inflow and out-
flow vascular structures are essential to safely perform major hepatobiliary
resection.
Vascular Occlusion Techniques for Hepatic Resection
In 1902, Pringle wrote that blood loss from the injured liver could be arrested
by occlusion of the portal triad.
17
Continuous or intermittent inflow occlu-
sion can be performed safely up to one hour in the normothermic patient.
Intermittent clamping has been shown to be better tolerated by the hep-
atic parenchyma than continuous clamping in animal models and human
subjects.
18–20
Fifteen minutes of inflow occlusion and five minutes of reperfu-
sion resulted in less ischaemia-reperfusion injury during the period of ischemic
preconditioning.
19–21
With inflow occlusion, the hepatic parenchyma is per-
fused by less oxygenised blood from the hepatic veins, which ameliorates

ischaemia-reperfusion injury secondary to clamping.
22
The Pringle manoeuvre
is generally recommended for major hepatic resections.
23
However, severely
fibrotic or steatotic parenchyma does not tolerate the ischaemic insult of inflow
occlusion. Resection of such liver tissue may be performed without the Pringle
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396 D. J. Reich et al.
manoeuvre, using an assortment of technologically advanced haemostatic
dissecting instruments, including ultrasonic and hydrojet dissectors. Inflow
occlusion is also avoided with graft hepatectomy for living-donor liver trans-
plantation, in which case it is necessary to protect both the liver graft and the
donor’s liver remnant from ischaemia during the parenchymal transection. In
summary, the Pringle manoeuvre is easy, quick and effective for the reduction
of blood loss and the maintenance of haemodynamic stability, and it avoids
injury to the hepatic parenchyma.
In the case of massive hepatic resection for a large tumour or a tumour
in close proximity to the confluence of hepatic veins or the vena cava, total
vascular isolation (TVI), which arrests inflow and outflow, may be neces-
sary to prevent excessive bleeding or air embolism.
24
To decrease excessive
venous pooling in the lower body that results from cross-clamping of the vena
cava, the supraceliac aorta may be clamped at the same time or a venovenous
bypass may be instituted. Even with the significant changes in cardiac output
and systemic vascular resistance, adequate systemic blood pressure and pul-
monary artery wedge pressure can be maintained in the absence of severe
acidosis.

25
Theoretically, the surgical field should be completely bloodless
with this manoeuvre. However, back bleeding from the adrenal vein or other
retroperitoneal collateral vessels is possible. To achieve complete haemostasis,
it is necessary to mobilise the caudate lobe of the vena cava. Aggressive fluid
resuscitation and invasive haemodynamic monitoring are required because of
the decreased venous return from caval clamping. Anaesthetic management
and the management of postoperative morbidity can be difficult.
26
For these
reasons, TVI is restricted to selected cases.
27,28
To avoid the shortcomings of
TVI, a technical modification of the procedure that does not occlude the vena
cava, but achieves haemostasis of hepatic venous tributaries, is also feasible.
29
Division of the Hepatic Parenchyma
The most essential component of dividing the hepatic parenchyma is the selec-
tive destruction of hepatocytes, while initially preserving the fibre-rich blood
vessels and bile ductules. After being exposed, the blood vessels and bile duc-
tules can be ligated or cauterised in the plane of resection. Several techniques
and devices have been used to divide the hepatic parenchyma, but there is no
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Complications of Major Hepatobiliary Surgery 397
consensus on which method is superior. The traditional method, the so-called
finger fracture technique, is seldom used in the current era except in the case of
traumatic laceration of the liver.
30
Finger fracture involves significant haem-
orrhage, which in turn makes it difficult to locate the correct anatomical plane

of dissection. The clamp crushing technique, which is a refined version of the
finger fracture technique, is widely used, safe and effective. The surgeon uses
a haemostatic clamp to selectively crush the soft hepatic parenchyma, while
avoiding the tubular blood vessels and bile ductules within. These are then dis-
cretely clipped or ligated. Ligation of tiny blood vessels and bile ductules is not
only time consuming, it is also ineffective, resulting in incompletely controlled
structures that may become a source of postoperative bleeding or bile leakage.
Therefore, the surgeon must be flexible in making decisions about when to use
titanium clips, suture ligation or electrocautery, depending on the situation.
The CUSA, Harmonic Scalpel and Hydro Jet are technologically advanced
dissecting instruments that can facilitate haemostatic liver resection. Vibra-
tion of the piezoelectric unit at the tip of the CUSA destroys tissue, while
irrigating and aspirating debris from the operative field.
31
The CUSA hand-
piece may be armed with monopolar electrocautery to facilitate haemostatic
dissection.
32
The Harmonic Scalpel uses ultrasonically activated shears for
haemostatic tissue dissection. The hydro jet dissector (Jet Cutter) uses a high-
pressure water stream to selectively destroy hepatic parenchyma.
33,34
When
using these devices it is important to minimise transmission of energy to the
same spot for a prolonged period of time in order to avoid vascular injury. The
tip of the device should be kept in continuous oscillatory motion, perpen-
dicular to the resection plane when using the CUSA and Harmonic Scalpel,
and parallel to the resection plane when using the water jet. By using the
CUSA, Harmonic Scalpel or Hydro Jet, inflow occlusion can be avoided, thus
minimising hepatic ischaemia. They provided haemostatic cutting and are not

associated with increased risk of postoperative bleeding, bile leak, or abscess
formation at the cut margins. Use of a vascular stapler for hepatic resection can
also aid in minimising blood loss and reducing the need for inflow occlusion.
Regardless of which resection techniques and devices are used, it is important
to minimise the amount of tissue ischaemia along the resection plane. Mat-
tress suturing of the resection margin is no longer recommended because of
the resultant tissue necrosis.
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398 D. J. Reich et al.
Haemorrhage from Hepatic Resection
Table 1 lists the various complications that can occur after hepatobiliary resec-
tion. In earlier years, liver resection was associated with a high risk of significant
haemorrhage. This limited the performance of safe surgery. More recently,
a better understanding of the hepatic surgical anatomy, improved vascular
imaging techniques, refined anesthetic management, and the development of
technologically advanced dissecting equipment have significantly improved
the ability to perform hepatobiliary surgery haemostatically. Certainly, hepa-
tobiliary surgical patients require adequate correction of any underlying coag-
ulopathy and/or thrombocytopenia, with the infusion of fresh frozen plasma,
cryoprecipitate, and/or platelets.
Intraoperative bleeding
Intraoperative haemorrhage is one of the most significant risk factors for
postoperative complications. Therefore, the following methods of reducing
intraoperative blood loss deserve close attention. During routine right hep-
atic resection, complete mobilization of the liver is necessary before beginning
the parenchymal transection. When the right hepatic lobe is rotated medially,
control of the right hepatic vein outside of the liver is possible, which helps to
reduce the amount of intraoperative blood loss.
35,36
Introduction of this con-

trolled hepatectomy technique in the 1950s
37
and its revival in the 1980s
38
has
significantly contributed to reduced blood loss and decreased morbidity from
major hepatobiliary resection. By combining this approach with the Pringle
Table 1. Complications of Hepatobiliary Resection
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Complications of Major Hepatobiliary Surgery 399
manoeuvre, the surgeon can eliminate bleeding from the transected hepatic
parenchyma, except for back bleeding from hepatic venous tributaries.
Traditionally, patients were prepared for hepatobiliary resection by inten-
tional volume overloading in anticipation of intraoperative blood loss. How-
ever, maintaining a low (<8cmH
2
O) intraoperative central venous pressure
(CVP) has proven to be a simple way to reduce bleeding during parenchymal
transection without TVI.
39,40
Simply lifting the mobilised liver a few centime-
tres can help to reduce back bleeding from hepatic venous tributaries. Again,
it is important to mobilise the liver so that the surgeon can easily visualise
and manipulate the transection plane with the left hand. Use of manoeuvres
such as the reverse Trendelenberg position to elevate the liver above the right
atrium, or partial banding of the infrahepatic vena cava to decrease venous
return have been tried by several groups to decrease blood loss from hepatic
veins. However, a recent study failed to demonstrate that the use of either of
these manoeuvres decreased the pressure gradient between the hepatic veins
and superior vena cava.

41
One should also note that manipulating a CVP too
low can lead to the development of an air embolism.
Venous bleeders from the transected plane should be temporarily con-
trolled with light finger pressure before being permanently controlled with fine
sutures. The natural response of placing a suction tip against venous bleeders
should be avoided as it results in further blood loss. The author’s preference
is to locate small venous bleeders on the transected plane by intermittently
flushing the surgical field with saline and placing the suction cannula in the
dependent portion of the operating field. Until reasonable haemostasis has
been achieved, the pace of the transection should be slowed or even stopped.
Detachment of the hepatic ligamentous structures and rotation of the liver
can be impossible in the setting of a large tumour on the right side. Since intra-
operative iatrogenic rupture of an hepatocellular carcinoma is associated with
increased intraoperative blood loss and intraperitoneal extrahepatic recurrence,
extreme care should be taken during right lobe mobilisation in the presence of
a large tumour.
42
In this situation, an alternative may be parenchymal tran-
section without hepatic mobilisation. This technique is known as the anterior
approach or retrograde hepatectomy.
43
By minimising manipulation of the
liver parenchyma and rotation of the hepatoduodenal ligament, this approach
minimises compromised blood flow to the liver, thus preserving remnant liver
function.
44
A drawback of the anterior approach is the risk of massive back
Jan. 23, 2007 10:8 SPI-B404 Surgical Complications ch12
400 D. J. Reich et al.

bleeding from the deeper plane of parenchymal transection; without prior
mobilisation of the right lobe of the liver and the tumour, the hepatic lobe
cannot be lifted up and compressed manually.
Postoperative bleeding
The most common cause of postoperative bleeding is the dislodgement of a
ligature or clip from a divided venous tributary or hepatic arterial branch.
Whenever a large-calibre vein such as the portal vein or an hepatic vein is
divided, the stump should be ligated with a trans-fixed suture or over-sewn
with vascular suture because the thin wall and short stump of these veins do
not securely hold suture. When cauterising a resected plane with monopolar
cautery or an argon beam coagulator, one should be careful to avoid burn-
ing the ligatures. Coating the raw surface of the resection plane with topical
haemostatic agents may decrease postoperative bleeding and bile leakage. Fib-
rin sealants represent an improvement over conventional topical agents because
they contain components that actively form clots.
45,46
Even after the achievement of a completely dry hepatic resection sur-
face, it is not uncommon to encounter postoperative bleeding in the patient
with cirrhosis, portal hypertension and hypersplenism. Minimal postoperative
bleeding in a haemodynamically stable patient can be observed and treated
with the transfusion of fresh frosen plasma and platelets. However, the sur-
geon must maintain a low threshold for surgical re-exploration, otherwise clot
induced fibrinolysis and consumptive coagulopathy will develop and exacer-
bate haemorrhage. Even if re-exploration fails to identify a focus of significant
haemorrhage, lavage of the clots reverses the fibrinolytic cascade and is often
in and of itself effective at stopping the bleeding.
Even if there is no ongoing haemorrhage, the patient with a large
haematoma after hepatic resection should usually be taken to the operating
room for haematoma evacuation and peritoneal lavage. Haematomas not only
harbour bacteria and lead to the development of intra-abdominal abscess, but

also become a source of bilirubin overload in the remnant liver. Imaging stud-
ies are indicated in the face of prolonged unconjugated hyperbilirubinemia
after hepatobiliary resection to exclude a collection of blood in the abdominal
cavity.
Haemorrhage from an arterial pseudo-aneurysm is an unusual compli-
cation that can occur in the setting of intra-abdominal abscess or leakage
Jan. 23, 2007 10:8 SPI-B404 Surgical Complications ch12
Complications of Major Hepatobiliary Surgery 401
from the biliary anastomosis. Bleeding from a pseudo-aneurysm can occur
abruptly and is often fatal. Nonetheless, vigilant monitoring for this com-
plication is warranted because the gross rupture of a pseudo-aneurysm often
follows prodromal signs and symptoms such as increased abdominal or back
pain, fever, leukocytosis, and/or haemobilia from a herald bleed.
47
Surgery
should be reserved for patients in whom transarterial embolisation or stenting
fails or is not feasible.
48,49
Even after successful haemostasis with an interven-
tional radiologic procedure, hepatic failure and sepsis can develop as a result
of ischaemic damage to the liver. The absence of collateral arterial vessels is a
relative contraindication to transarterial embolisation.
48
Bile Leakage and Fistula Formation after Hepatic Resection
Unlike bleeding, bile leakage at the time of surgery is not easily detected
without vigilant visual inspection of the operative field. The principal source
of bile leakage is the transected liver surface, although major biliary injury
or insufficiency of a biliary anastomosis are other possible sources. Leakage
of bile from the transected surface is important to detect intraoperatively,
otherwise it has a high likelihood of leading to intra-abdominal abscess. The

most important way to prevent postoperative bile leakage is to meticulously
manage the transected liver surface. Even when bile leakage is minimal it
can still be detected intraoperatively by searching for bile staining on a fresh
sponge compressed against the transected surface. Although a prospective,
randomised trial showed no benefit from trying to decrease bile leakage by
injecting a solution through the cystic duct and then closing leaking areas, this
technique can sometimes be helpful.
50
The routine placement of drains after
elective hepatic resection continues to be a source of debate.
51,52
Proponents of
drain placement argue that it is safe and lessens the risk of septic complications
after a bile leak. Opponents cite the risks of ascending infection and patient
discomfort. For patients with chronic parenchymal disease, it is probably best
to avoid drain placement after hepatic resection, considering the risk of ascites
accumulation and infection.
53
Patients with a bile leak typically present with signs and symptoms
of an intra-abdominal abscess and may be jaundiced. Ultrasound or CT
scan of the abdomen localises the biloma. Most biliary leakage after hep-
atic resection can be managed non-surgically by percutaneous drainage of
Jan. 23, 2007 10:8 SPI-B404 Surgical Complications ch12
402 D. J. Reich et al.
the extrahepatic collection and the administration of antibiotics empirically
and then appropriately guided by culture results. An hepatobiliary (99m)Tc-
iminodiacetic acid (HIDA) scan may help to qualify the magnitude of a leak.
Endoscopic retrograde cholangiopancreatogram (ERCP) confirms integrity of
the major bile ducts, and sphincterotomy decompresses the biliary tree and
facilitates leak closure. Operative intervention is more likely to be required if a

leak emanates from a major duct injury, such as a severed accessory or aberrant
duct, or from an anastomosis.
54,55
Ducts smaller than 4 cm can usually be
ligated or clipped. Larger ones require biliaryenteric bypass.
Hepatic Decompensation and Liver Failure after
Hepatic Resection
Even though the maximum extent of liver resection that is compatible with
good postoperative outcome remains unclear, it is generally believed that as
much as 70% (three of four sectors) of the liver can be safely resected if there
is no parenchymal disease. The total liver volume can be calculated based on
the patient’s body surface area.
56,57
However, the relative contribution of each
segment to the total liver volume is variable.
58
Therefore, for precise anatomic
planning for massive hepatic resection a CT scan or MRI is necessary.
59
The liver with underlying damage from cirrhosis or obstructive jaundice
has a diminished capacity for regeneration. In these situations, meticulous
evaluation of baseline liver function as well as anatomical planning of the resec-
tion is critical. The indocyanine green (ICG) clearance test is the most widely
accepted test for the preoperative evaluation of functional hepatic reserve.
60–63
ICG clearance is used to determine the optimal extent of resection in patients
with chronic liver disease.
64
Although hepatic resection has been considered the gold standard for the
treatment of primary hepatic tumours, in the era of liver transplantation this

approach should be reserved for patients without decompensated cirrhosis.
The evolution of techniques of segmental liver resection has led to the ability
to achieve better tumour clearance while preserving function of the remnant
liver, particularly relevant to patients with compensated cirrhosis.
65
The width
of the resection margin does not appear to influence the rate of postoperative
recurrence of hepatocellular carcinoma.
66
When resecting hepatocellular carci-
noma from the cirrhotic liver, preserving hepatic parenchyma and minimising
Jan. 23, 2007 10:8 SPI-B404 Surgical Complications ch12
Complications of Major Hepatobiliary Surgery 403
manipulation of the remnant liver are more important than achieving wider
resection margins.
Preoperative portal vein embolisation (PVE) has been used to induce com-
pensatory hypertrophy of the liver remnant after resection. PVE has been suc-
cessfully used prior to elective hepatic resection for hepatocellular carcinoma in
the cirrhotic liver, cholangiocarcinoma in the jaundiced liver, and metastatic
carcinoma in the normal liver.
67–74
A recent prospective randomised trial
demonstrated that PVE is only beneficial for hepatic resection in patients with
chronic liver disease.
75
This procedure is still recommended as a preoperative
adjunct, even for resection of a normal liver when the anticipated remnant liver
volume will be smaller than 30% of the original volume.
76
An advantage is

that portal venous pressure can be measured during PVE, which is important
because a significant elevation of portal venous pressure is associated with an
increased risk of decompensation of liver function after hepatic resection.
77
Although acute hepatic failure can occur, most patients experiencing hep-
atic dysfunction following liver resection will manifest subacute hepatic insuffi-
ciency with only mild, transient hyperbilirubinemia and possibly ascites and/or
encephalopathy, lasting up to a few weeks. Some will suffer variceal haemor-
rhage. Ascites is particularly common in the face of malnutrition or extensive
lymphatic dissection. When the more acute hepatic failure occurs, signs are
rarely evident in the intraoperative period. Typically, a relatively “normal” first
48–72 postoperative hours, in which the patient is often extubated and seems
to be faring well, is followed by progressive elevation of liver enzymes, pro-
thrombin time (PT), and bilirubin, and the development of encephalopathy. If
untreated, this condition can progress to frank coma, uncorrectable coagulopa-
thy, hepatorenal syndrome with oliguria, multisystem organ failure, and even-
tual death. Early recognition of liver failure is essential, so that monitoring of
liver enzymes, lactate and clotting parameters should be done frequently after
major liver resection. Ultrasonography and/or reoperation to ensure patency
of the hepatic vasculature and to exclude torquing of the remnant liver may be
life-saving. Replacement of blood products should be done with care so as not
to overtransfuse, which can lead to portal vein or hepatic artery thrombosis.
Early, aggressive therapy of oliguria with fluid and colloid replacement should
be guided by the monitoring of haemodynamic parameters with a pulmonary
artery (PA) catheter. Volume overload will aggravate oedema in the remnant
liver and decrease the chance of recovery. Management of encephalopathy may
Jan. 23, 2007 10:8 SPI-B404 Surgical Complications ch12
404 D. J. Reich et al.
require reintubation for airway protection. Salvage liver transplantation may
be appropriate in rare instances of liver failure after major resection, but only

if there was no prohibitive tumour burden.
COMPLICATIONS OF RESECTION FOR BILIARY
MALIGNANCY
Considering that the majority of patients undergoing major hepatobiliary
resection for biliary malignancy are in the seventh or eighth decades of their
lives and therefore have a higher incidence of medical comorbidity, the risk
of hepatic resection and the best type of resection for each individual patient
needs to be weighed against the survival benefit. Figure 1 and Table 1 relate
to resection for biliary malignancy, just as they do to hepatic resection.
Preoperative Planning
A histologically negative resection margin is the most favourable prognostic
variable for bile duct carcinoma.
78
To achieve this goal with proximal bile duct
or gall bladder carcinomas, concomitant hepatic resection may be necessary in
addition to resection of the extrahepatic bile duct with regional lymphadenec-
tomy. The necessity of preoperative biliary decompression in patients with
malignant obstructive jaundice remains controversial and is not uniformly
recommended.
79,80
However, for bile duct carcinoma in the hepatic hilum
that requires major hepatic resection, preoperative decompression of the bil-
iary tree decreases infectious complications from underlying cholangitis and
improves the regenerative capacity of the liver parenchyma.
81,82
Due to the proximity of the portal vein and hepatic artery to malig-
nant lesions, detailed preoperative imaging is extremely important for staging.
An arteriogram and portal venogram as well as a cholangiogram are essen-
tial to plan for resection of hilar cholangiocarcinoma.
83

MRI cholangiogram
and MRI angiogram may be adequate instead of conventional ERCP and
angiogram. The nature and extent of tumour invasion should be evaluated
in detail when planning the resection. Portal venous inflow and bile flow are
important for the maintenance of liver cell size and mass.
84,85
Segmental or
lobar atrophy may result from portal venous occlusion or biliary obstruction.
86
Jan. 23, 2007 10:8 SPI-B404 Surgical Complications ch12
Complications of Major Hepatobiliary Surgery 405
Appreciation of the anatomical distortions on preoperative imaging is impor-
tant to individualise the treatment strategy.
87
Preoperative imaging predicts
non-resectability based on local extension, but is not useful for assessing nodal
or peritoneal metastases. The role of laparoscopy and of endoscopic ultra-
sonography for staging bile duct carcinoma has yet to be defined; however,
they are increasingly performed prior to laparotomy.
88
Biliary Tree Resection and Lymphadenectomy
At the initial phase of exploratory laparotomy, precise assessment of tumour
extension often necessitates a biopsy with frozen section of any suspicious
lesion or lymph node. Evidence of a multicentric hepatic lesion, distant metas-
tasis, or para-aortic lymph node metastasis precludes resection. Lymphatic
spread is common with bile duct and gall bladder carcinoma and often involves
pericholedochal lymph nodes. Regional lymph node dissection that includes
the hepatoduodenal ligament is part of resection with curative intent.
In addition to complete hepatoduodenal lymphadenectomy with skele-
tonisation of the portal vein and hepatic artery, the entire portion of the extra-

hepatic, suprapancreatic bile duct should be removed. Lymphadenectomy of
the hepatic hilum without bile duct resection results in incomplete lymph
node clearance at best, and may cause stricture or necrosis of the bile duct.
Some groups have insisted on using para-aortic lymphadenectomy; however,
this procedure is associated with increased morbidity and does not appear
to offer any survival benefit. Aortic lymph node samplings can be helpful in
the initial phase of surgery to identify advanced cases and avoid proceeding
with major hepatobiliary resection in the patient with minimal predicted sur-
vival benefit. For complete removal of these nodes, pancreatoduodenectomy
in addition to hepatic and biliary resection has been performed by several
Japanese groups. However, this procedure cannot be routinely justified, con-
sidering the associated high mortality and morbidity in the absence of proven
survival benefit.
89,90
After bile duct resection and skeletonisation of the hepatic artery and
portal vein, maintenance of arterial flow is crucial to maintain integrity of the
biliaryenteric anastomosis. The hepatic artery must be handled with extreme
care to avoid intimal dissection. An accidentally divided hepatic artery must
be immediately reconstructed, preferably via microvascular technique.
Jan. 23, 2007 10:8 SPI-B404 Surgical Complications ch12
406 D. J. Reich et al.
Biliary Reconstruction
Biliaryenteric continuity is re-established with a hepaticojejunostomy to a
Roux-en-Y loop. The Roux-en-Y loop is prepared and brought cephalid,
usually in retrocolic fashion. For a very high biliary anastomosis in a deep
abdominal cavity, retrogastric placement of the jejunal loop may provide bet-
ter exposure and angle for manipulation. Mucosa-to-mucosa approximation is
mandatory for the hepaticojejunostomy. The authors’ preference is to perform
the end-to-side anastomosis with a single layer of 5-0 or 6-0 PDS interrupted
sutures. Additional layers of suture do not provide extra security. It is preferable

to place and tie sutures so that the knots are extraluminal because intralumi-
nal knots can act as niduses for bile stone formation.
91
The use of absorbable
monofilament suture also decreases the chance of bile stone formation. Anas-
tomotic stenting with a silastic tube, 5 Fr to 8 Fr in calibre, may ease the
biliary reconstruction and facilitate early postoperative patency, particularly
with small-calibre ducts. A closed suction drain should be placed adjacent to
the anastomosis.
After removal of the tumour, multiple segmental ducts may be exposed.
Each orifice should be probed to determine which hepatic segments it
drains. Adjacent duct openings may be incorporated to create a situation
where there are no more than three separate orifices to be anastomosed to
the Roux-en-Y loop. High anastomoses to multiple orifices of bile ducts
should not be performed sequentially; rather, the entire posterior row of
stitches to all exposed orifices should be placed first, then the jejunal loop
brought up, then the posterior row of stitches tied, and then the anterior row
completed.
Management of Biliaryenteric Leak
In the first few postoperative days, scant biliary leakage from either the bil-
iaryenteric anastomosis or liver margin may be noted from the drain. This is
usually self-limited, provided that hepatic arterial flow is intact and the anasto-
mosis was performed properly. Massive leaks during these few days necessitate
expeditious anastomotic revision. Most often, biliary leakage is first noted
after the first few postoperative days. Patients present with signs and symp-
toms of an intra-abdominal abscess. There is predominantly pain and fever,
Jan. 23, 2007 10:8 SPI-B404 Surgical Complications ch12
Complications of Major Hepatobiliary Surgery 407
and there may be bilious drainage from the incision site and/or jaundice.
Ultrasound or CT of the abdomen localises the biloma. The first priority is to

percutaneously drain the collection and start antibiotics. Subsequently, per-
cutaneous transhepatic cholangiography (PTC) delineates the site and extent
of the leak. Transhepatic stenting of the biliary tree, and of the anastomosis if
possible, diverts the biliary system, decreases pressure in the ducts, and helps to
seal the leak. Re-exploration and reanastomosis for biliary leakage is unlikely
to be successful in the face of infection, diffuse inflammation or malnutri-
tion, especially after resection of a very high lesion. Most biliaryenteric leaks
can be managed indefinitely without surgery by percutaneous drainage of the
extrahepatic collection and percutaneous transhepatic decompression of the
biliary tree. Although the presence of percutaneous catheters and the require-
ment that they be changed at least every few months are a serious nuisance for
patients, many leaks will eventually resolve after such long-term care. Cholan-
giograms and hepatobiliary (99m)Tc-iminodiacetic acid (HIDA) scans help
to qualify the magnitude of a leak and determine whether it is healing. Those
instances where a biliaryenteric anastomotic leak does not resolve may ben-
efit from eventual elective surgical revision, with some type of biliaryenteric
anastomosis.
Management of Biliaryenteric Stricture
Strictures may develop after biliaryenteric anastomosis. Most patients become
symptomatic months to years after surgery. The usual presentation is right
upper quadrant abdominal pain with jaundice. Some patients have cholangi-
tis at initial presentation. Liver function tests show elevated serum bilirubin
and alkaline phosphatase levels. Depending on the time of presentation after
surgery, patients may present with destruction of liver parenchyma and cir-
rhosis due to increased pressure in the biliary system. Ultrasound, CT or
MRI confirms the presence of a dilated intrahepatic ductal system. PTC helps
localise the site of stricture in the biliary tree. Brush samplings at the site of
stricture may be taken if recurrent malignancy is a concern. Strictures can
be managed by temporary percutaneous transhepatic dilatation and/or stent
placement. Fewer than half of patients require lifelong stenting or eventual

surgical revision of the hepaticojejunostomy.
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408 D. J. Reich et al.
COMPLICATIONS OF RADIOFREQUENCY ABLATION
FOR HEPATIC LESIONS
Ablation is increasingly used in the management of liver tumours as either pal-
liative or curative treatment for primary, metastatic, or some benign tumours,
or as a “bridge” to liver transplantation for patients with unresectable hepato-
cellular carcinoma. Ablation is used when adequate resection of tumour/s is not
possible because of proximity to vascular or biliary structures, multicentricity,
or inadequate hepatic functional reserve. Ablation may be performed as RFA,
cryoablation, ethanol injection, or hepatic arterial ligation or embolisation.
In general, ethanol injection and arterial embolisation are not considered the
domain of the surgeon and hepatic arterial ligation is rarely performed today,
since embolisation is easily achievable with interventional radiologic tech-
niques. Cryoablation, compared to RFA, is associated with longer Intensive
Care Unit and hospital lengths of stay, greater blood loss and higher over-
all morbidity.
92
Additionally, the performance of cryoablation is considered
by many to be more cumbersome, making RFA the preferred ablative tech-
nique by many hepatobiliary surgeons. Therefore, this discussion focuses on
complications related to RFA.
The passage of radiofrequency current through saline rich tissue causes
focal ionic agitation, heat and coagulation necrosis. RFA can be performed
laparoscopically, percutaneously, or via laparotomy. Thus, complications from
RFA are related to thermal injury and to the particular surgical approach used
for the ablation. The percutaneous approach for ablation is the least invasive
and may benefit the patient with inadequate hepatic functional reserve, at
increased risk for general anaesthesia and laparotomy or laparoscopy. Open or

laparoscopic RFA is preferred for peripheral lesions because these approaches
make it possible to protect surrounding viscera by separating them from the
heated tissue. These approaches are also preferred to percutaneous RFA in
the case of large lesions because they allow for inflow occlusion (Pringle
manoeuvre) during the ablation, to avoid the heat sink effect of blood flow and
thus ensure more complete ablation.
93
Laparoscopic RFA is less invasive than
open RFA and therefore preferred to the open technique, provided laparo-
scopic ultrasonography equipment is available and the surgeon is versatile at
performing laparoscopic ultrasonography and RFA needle placement, both of
which are somewhat technically challenging.