• Zahir F Soonawalla, Charalabos Stratopoulos, Mark Stoneham, Douglas Wilkinson, B Julian Britton, and Peter J Friend.
• Nuffield Department of Surgery, John Radcliffe Hospital, Oxford, UK.
• Langenbecks Arch Surg. 2008 Mar 1;393(2):195-8.

Background And AimsThe Trendelenberg position is recommended during liver resection, to decrease the risk of venous air embolism. However, this position raises the central venous pressure and may increase blood loss. We propose that the reverse-Trendelenberg position can be safely and effectively used to maintain a low central venous pressure during liver surgery.Materials And MethodsFifty consecutive patients underwent elective liver resection at a single centre during a 17-month period. Patients were positioned with a head-up tilt during division of the liver parenchyma.ResultsPatients had a mean central venous pressure of 9.2 mmHg when supine, despite fluid restriction. The central venous pressure fell consistently and rapidly when they were tilted head-up, to a mean of 1.7 mmHg. The resections were completed with a median operative blood loss of 600 mL. No patient developed a clinically apparent venous air embolism. Postoperative renal dysfunction that could be attributed to low central venous pressure anaesthesia occurred in only one case.ConclusionThe reverse-Trendelenberg position effectively lowers the CVP during liver surgery. It is easy to monitor, titrate and reverse, and avoids the need for complex pharmacological interventions. We recommend this position to liver surgeons and anaesthetists who have found it difficult to maintain a low CVP with the supine or Trendelenberg positions.

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