Pain after liver resection can be difficult to manage. Epidural anesthesia (EA) isaneffective technique inpain control inthis surgery. However, postoperative coagulopathy and hypotension due to autonomic nervous system block in high-risk patients, may result that the EA is an inadequate analgesic technique in according to enhanced recovery after surgery (ERAS) recommendations for liver surgery. Regional block techniques have been recommended for liver surgery in ERAS guidelines. Erector spinae plane (ESP) block is a recent block described for thoracic and abdominal surgeries and provides both somatic and visceral analgesia. We describe a high-risk patient with cardiac dysfunction and Parkinson’s disease who underwent laparoscopic right liver resection for hepatocellular carcinoma. Satisfactory intra and postoperative analgesia was achieved by a combined continuous ESP block, transversus abdominis plane (TAP), and oblique subcostal TAP blocks. Surgery and postoperative period was uneventful. No opioids were administered during hospitalization. A combined of thoracic and abdominal wall blocks can be an effective approach for intra and postoperative analgesia in highrisk patients undergoing laparoscopic liver resection. Further clinical research is recommended to establish the effectiveness of the ESP block as an analgesic technique in this surgery.

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Liver transplantation (LT) is a serious hemostatic challenge in patients with portal vein thrombosis (PVT). Advances in monitoring systems have improved surgery in this setting. We report the successful application of a point-of-care (POC) rotational viscoelastic thromboelastometry-guided (TEM) testing system (ROTEM) which allowed management of coagulation during LT in a 64-year-old cirrhotic patient with a model for end-stage liver disease (MELD) score of 16. Perioperatively, the patient showed complete PVT, hepatomegaly, splenomegaly, recanalization of the umbilical vein, and portosystemic shunt. Macroscopic liver and spleen adherences with collateral circulation were evident. Coagulation factors and fibrinolysis were assessed preoperatively and at graft reperfusion to evaluate the need of hemostatic therapy. Based on ROTEM findings, the patient received 16 g of human fibrinogen concentrate, half preoperatively (with prothrombin complex concentrate 2000 IU, tranexamic acid 1 g, and platelets 2 IU), and two doses of 4 g before and after graft reperfusion; we achieved normalization of all monitored parameters. No ischemia-reperfusion syndrome was present. Postoperatively portal vein flux at Color-Doppler ultrasonography was normal. After a 3-day ICU stay, the patient was moved to the Department of Surgery and discharged on day 14. The postoperative course was uneventful and did not require any further haemostatic therapy.

Whilst some guidelines for hemorrhage management during major abdominal surgery have been written, evaluation of the patient’s basal condition remains the headmost factor. Firstly, an assessment to predict perioperative bleeding should be performed, although its prognostic ability is limited as it relies on the patient’s anamnesis and on standardized tests that can have a low predictive accuracy. Upon hemorrhage, monitoring the therapeutic window between hypovolemia and hypervolemia is of crucial importance. According to the guidelines, both a prompt stabilization of cardiac preload and goal-directed fluid therapy (with either colloids or crystalloids) are advised in case of both hypovolemia and hypervolemia. Plasma transfusion, instead, is discouraged for treatment of elevated (mild to moderate) International normalized ratio (INR), as it was shown to have minimal effects and increase the risk of infection. In summary, to define the weak link in the coagulation cascade and the etiopathogenesis of postoperative bleeding is necessary to rely on all available methodologies, such as standardized tests, Point-of-care tests and goal-directed therapies. This review gives an overview of the many factors that are to be monitored during surgical hemorrhage and a summary of the approaches to manage coagulopathy.