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  • Metastasis (colon, breast, neuroendocrine).
  • Hepatocellular carcinoma.
  • Cholangiocarcinoma.
  • Hepatoblastoma.
  • Gallbladder carcinoma.
  • Hepatic sarcoma.
  • Adenoma.
  • Biliary cystadenoma.
  • Symptomatic hemangioma or focal nodular hyperplasia.
  • Hepatic tumor of unknown etiology.

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  • Distant metastatic disease for primary liver tumors.
  • Presence of extrahepatic metastases for metastatic lesions (relative).
  • Severe medical comorbidity.
  • Inability to achieve negative margins.
  • Insufficient estimated liver remnant following resection.
  • Significant cirrhosis or portal hypertension.

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  • The patient should be supine with arms extended.

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  • Adequacy of resuscitation should be monitored closely, and any concern for bleeding should be promptly evaluated.
  • Assessment of liver function should be followed closely in the postoperative period (neurologic status, coagulation factors, liver function tests).
  • Benzodiazepines and hepatotoxic medications should be avoided in the early postoperative period.
  • Deep vein thrombosis prophylaxis should be provided.
  • Oral diet can be advanced as tolerated; if not tolerated, other forms of enteral nutrition should be initiated.
  • Close monitoring for possible complications is required (see later).

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  • Bleeding.
  • Bile leak.
    • Manifested by bile staining in drains or evidence of cholestasis on liver function tests.
    • Symptoms may involve increased abdominal pain, ileus, fever, or tachycardia.
    • Many bile leaks are self limited and can be treated with percutaneous drainage alone.
    • More severe bile leaks will require endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and biliary stent placement, or placement of a percutaneous transhepatic cholangiocatheter (PTC) in situations where ERCP is not technically possible.
  • Abscess or infection.
  • Hepatic dysfunction, which can be manifested by the following:
    • Acidosis.
    • Impaired mental status.
    • Hypoglycemia.
    • Coagulopathy.
    • Hyperbilirubinemia.
    • Transaminitis.
    • Renal failure.
    • Predisposition to infection.
    • Care is primarily supportive, but evaluation should be performed to exclude major biliary or vascular complications.
  • Tumor recurrence.
  • Embolism (usually intraoperative).
    • Can be diagnosed using intraoperative transesophageal echocardiography if necessary.
    • Prevented by optimizing CVP during parenchymal dissection.

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