Hemodynamic and Respiratory Management During Liver Resection

Perioperative outcomes after hepatic resection have markedly improved, largely due to the increased use of minimally invasive techniques and the concentration of care in high-volume centers with experienced hepatobiliary surgeons and anesthesiology teams. Despite these advances, the vascular nature of the liver continues to present major intraoperative challenges, especially with regard to hemorrhage control. A range of blood-sparing strategies, including vascular inflow occlusion (eg, the Pringle maneuver) and combined inflow-outflow vascular exclusion techniques, are essential to minimizing blood loss, but can precipitate episodes of hemodynamic instability. In addition, there is broad consensus on the need to minimize distension of the suprahepatic veins to reduce backflow bleeding. This target is commonly achieved through restrictive fluid administration combined with low tidal volume (VT) ventilation and low levels of positive end-expiratory pressure (PEEP). However, fluid restriction may exacerbate perioperative hemodynamic instability. Moreover, when applied in the setting of pneumoperitoneum, a low VT and low PEEP ventilatory strategy may promote atelectasis, potentially increasing the risk of postoperative pulmonary complications. Consequently, advanced hemodynamic and respiratory management is essential during hepatic resection to ensure hemodynamic stability, effective bleeding control, and lung protection. In addition, continuous communication between surgical and anesthesiology teams regarding surgical maneuvers and cardiopulmonary management is crucial for optimizing intraoperative outcomes. This review focuses on hemodynamic and respiratory management during liver resections, including perioperative considerations specific to living donor liver transplantation.