# Total Intravenous Anaesthesia and an Opioid-Sparing Strategy for an Extended Left Hemihepatectomy with Total Caudate Resection, Total Hepatic Vascular Exclusion, and Venovenous Bypass: An Integrative Anaesthesia Approach

## TL;DR

This paper describes a complex liver surgery case using advanced anesthesia techniques to reduce opioid use and protect cognitive function.

## Contribution

The paper introduces an integrative anesthesia approach combining TIVA, EEG monitoring, and opioid-sparing strategies in high-complexity liver surgery.

## Key findings

- Intrathecal opioids and TIVA reduced opioid use during surgery.
- EEG-guided anesthesia monitoring was used to protect neurocognition.
- Venovenous bypass and cold perfusion enabled safe tumor resection.

## Abstract

We present a case of a 72-year-old man who underwent an open extended left hemihepatectomy and total caudate lobe resection with total hepatic vascular exclusion (THVE) for a large hepatocellular carcinoma (HCC). Anaesthetic management included the use of intrathecal opioids and total intravenous anaesthesia (TIVA) with propofol and remifentanil. Due to tumour adherence to the right hepatic vein-inferior vena cava junction, venovenous (VV) bypass and cold in situ perfusion were required. This case illustrates neurocognitive protection principles, electroencephalogram (EEG)-guided depth of anaesthesia monitoring, multimodal opioid-sparing analgesic strategies, enhanced recovery principles, and sustainable, low-emission TIVA anaesthetic maintenance, exemplifying an integrative approach in high-complexity liver surgery.