Peri-operative care of patients with hepatocellular carcinoma is critical for the survival of cirrhotic patients undergoing major hepatectomy. Peri-operative nutritional support in the form of branched-chain amino-acid-enriched solution, medium chain triglyceride, inorganic phosphate and multivitamins may be beneficial in sustaining liver function after hepatectomy. Intra-operatively, anaesthetic agents which are potentially harmful to the liver should be avoided, and haemodynamic monitoring to ensure adequate volume replacement should be made to maintain hepatic blood flow. The surgeon has to prevent unnecessary liver injury and excessive bleeding, and to exercise the technique meticulously avoiding bile leakage, haematoma and excessive rotation of the liver which may result in twisting of inflow and outflow vascular pedicles. Postoperatively, prolonged monitoring of haemodynamics is essential; the use of mechanical ventilation enables adequate administration of intravenous analgesics without respiratory depression and provides appropriate oxygenation of the liver and prevents pleural effusion. In the immediate postoperative period, continuation of parenteral nutrition would be beneficial to maintain a higher level of short half-life carrier proteins, decrease the requirement of diuretics to control ascites, induce less weight loss and reduce septic morbidity. Early resumption of enteral feeding may positively affect hepatic function and regeneration, and should be instituted as soon as the bowel function returns.
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