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Page 4 of 12 Kumar et al. Mini-invasive Surg 2018;2:41 I http://dx.doi.org/10.20517/2574-1225.2018.49

[20]
of body fat and protein stores . Given that postoperative insulin resistance has been associated with poor
pain control, increased morbidity, and increased length of hospital stay after surgery, several studies have
[2]
examined the impact of preoperative carbohydrate drink on patient well-being . A review of 17 RCTs
including 1445 patients concluded that patients receiving carbohydrates have reduced LOS, less periopera-
[22]
[21]
tive insulin resistance and experience less fever, hunger, thirst, nausea and anxiety . Hausel et al. inves-
tigated the impact of carbohydrate loading on postoperative nausea and vomiting (PONV) in 172 patients
undergoing elective laparoscopic cholecystectomy. Within the first 24 h after surgery, the carbohydrate fed
group experienced significantly lower incidence of PONV. Yet, other studies have not reported such ben-
[23]
[24]
eficial effects . Mathur et al. conducted a double-blind placebo RCT in 2009 to study the effect of pre-
operative carbohydrate drink on clinical outcomes after colorectal surgery and liver resection. The study
however, did not observe any beneficial effects in LOS, oral intake or postoperative infections. Despite
some controversy, carbohydrate loading has a solid physiologic foundation which is supported by several
[5]
studies . Thus, incorporation of such strategies helps in patient’s enhanced recovery, more so in the light
of the fact that insulin resistance affects liver regeneration and might therefore have the potential of further
[2]
delaying the recovery . Overall, although preoperative fasting does not need to exceed 6 h for solids, a ju-
dicious recommendation for patients being operated at first time on the morning is to allow a normal meal
the night before and continue carbohydrate liquids up to 2 h before induction of anesthesia.

Antimicrobial prophylaxis
Surgical site infection (SSI) is the most common postoperative complication after high-risk surgery, which
[25]
increases both hospital stay and treatment costs . Incidence of SSI after liver resection ranges between
2% and 15%, and has significant impact on LOS, morbidity and mortality [26,27] . Even though liver surgery is
considered a clean contaminated surgery, it is categorized as contaminated surgery when combined with
extrahepatic bile duct resection due to the possibility of biliary or enteric spillage during surgery. In such
[28]
scenarios, bile is almost always (up to 75%) contaminated due to preoperative biliary drainage . In addi-
tion, invasive nature of major hepatic resection and inevitable surgical field contamination has lead to the
empirical use of prolonged antibiotic prophylaxis among surgeons. This practice, however, ends up increas-
ing bacterial resistance and prolongs patient recovery. To date, three RCTs on postoperative antibiotic pro-
phylaxis in patients undergoing hepatectomy without extrahepatic bile duct resection have been reported.
Although only one of these RCTs has supported prolonged prophylaxis based on significant difference in
the incidence of signs of infections or systemic inflammatory response syndrome, the incidence of infec-
[32]
tion did not differ among all RCTs [29-31] . In a more recent RCT by Sugawara et al. , it was found thattwo-

day administration of antibiotic prophylaxis is sufficient for patients undergoing complicated major hepa-
tectomies with extrahepatic bile duct resection. Various other methods to reduce infectious complications
[33]
have been attempted, including the use of pre- and pro-biotics, with no strong evidence of their efficacy .
In summary, it is recommended to administer a single dose of intravenous antibiotics before skin incision,
of the type recommended by a local infectious committee. Postoperative “prophylactic” antibiotics are not
recommended, with the exception of simultaneous bile duct resection in patients with a biliary drainage,
where prophylaxis should be selected on the basis of preoperative surveillance bile cultures and discontin-
ued on postoperative day (POD) 3, unless evidence to the contrary is shown.

Antithrombotic prophylaxis
Despite the common belief that liver resection impairs coagulation, increasing the risk of bleeding and
[34]
protecting patient from thromboembolism, hypocoagulability is rare after liver resections . A study done
in living donor hepatectomy showed that pulmonary embolism is not rare despite prophylaxis with low
[35]
molecular weight heparin (LMWH) . These clinical findings have been supported by thromboelasto-
gram monitoring which shows a hypercoagulable state after liver resection due to imbalance in coagula-
tion proteins [36,37] . Furthermore, major hepatectomy has been identified as an independent risk factor for
[38]
pulmonary embolism . A cohort study of 419 patients showed lower symptomatic postoperative venous
[39]
thromboembolism if prophylaxis is initiated from day 1 after major hepatectomy . One meta-analysis