Description

After signing the informed consent patients will be randomized into 2 groups.This stratification is aimed to reduce a strong risk factor for intraoperative blood loss which is the difficulty of performed procedure. Applied classification is simple to use and contains blood loos as one of the three main classifiers to determine the difficulty (beside operative time and conversion rate). Stratified randomization will be conducted by investigators via drawing a sealed envelope with computer-generated intervention code at the Department just before patient transfer to the operating theatre. There will be two study arms with 1:1 fashion

For both trial arms additional routine elements of perioperative anesthesia care will be

defined

• low central vein pressure, aimed for 5 ± 2 mmHg with restrictive fluid therapy
• ventilation in a volume-controlled mode without intraoperative high positive end-expiratory pressure (PEEP)
• invasive arterial blood pressure monitoring with maintaining mean arterial pressure ≥ 60 mmHg
• maintaining hemoglobin concentration > 8g/dl
• maintaining normothermia and normoglycemia
• maintaining oxygenation >94%, in case of hypercapnia with respiratory acidosis, the respiratory rate and tidal volume will be stepwise increased

The surgeon will be blinded to the study arm and level of pneumoperitoneum pressure.

The blood loss during liver parenchyma transection and total procedure blood loss will be reported based on the amount of sucked outside intraperitoneal fluids after liver transection and after procedure without volume inserted for intraperitoneal irrigation. The estimated blood loss will be measured in milliliters.

During the procedure, the surgeon will be asked for rating the quality of operating space in accordance to the Leiden Surgical Rating Scale every 60 minutes. In case of inadequate operating space, pneumoperitoneum pressure may be increased by 2 mmHg (with maximum of 16 mmHg in arm 1. and 12 mmHg in arm 2.). Intraoperative adverse events will be assessed in accordance to ClassIntra classification. Quality of recovery (QoR) will be measured on postoperative day 1, 3 and 5 with patient reported QoR-40 questionnaire, 30-day postoperative complication rate will be assessed in accordance to Clavien-Dindo classification. Length of hospital stay will be counted from the date of surgery to the discharge day. All patients will be followed up by researchers who are blinded to the intraoperative grouping.