of hepatic vascular exclusion for extensive liver resection. The American Jourt.l of Surgery; 163: 602-605. Hepatic vascular exclusion, which includes clamping of the portal pedicle along with the inferior vena cava below and above the liver, may be a useful procedure for resection of liver tumors close to the hepatic veins or the vena cava that are usually considered unresectable by conventional techniques. Since complete caval exclusion is the key to good hemodynamic tolerance and a bloodless transection of the liver parenchyma, several technical aspects of the procedure must be accomplished and are detailed. PAPER DISCUSSION KEY WORDS" Liver resection, liver vascular isolation. Whereas blood loss can be minimised at an early stage in classical anatomical hepatic resections due to the ready access of the portal venous and arterial branches at the hilus of the liver, adequate control of the hepatic veins may not always be achieved in those cases in which the lesion is situated close to or involves these veins and the vena cava. These difficulties can be overcome by total vascular exclusion of the liver which was first described by Heaney and his colleagues in 19661 and has been championed in the last decade by Huguet2-4. The present article describes in some detail the technical operative details of the procedure although one has to go to the previous literature to assess the precise role and results of the operation2'3'5-7. The key manoeuvres of the operation are the preliminary mobilisation of the liver and freeing of its peritoneal attachments, mass clamping of the portal vessels and clamping of the infra-and supra-hepatic vena cava. In their description, the authors stress the importance of the preparation and careful monitoring of the patient and the identification of vascular anomalies. Their approach to venous collaterals around the vena cava is at variance with other workers 5,a who prefer to ligate and/or divide the right adrenal vein and ignore the potential bleeding which Huguet and his colleagues would attempt to control with careful positioning of the caval clamps. The haemodynamic consequences of total vascular exclusion should not be underestimated and readers are referred to the earlier publications by the same group and in which peroperative monitoring and resuscitation of the patient are detailed4. Despite the increased familiarity with hepatic mobilisation and vascular isolation which has arisen from experience with hepatic transplantation, liver surgeons have HPB INTERNATIONAL 333 been slow to employ total vascular exclusion of the liver. In the original paper from the Monaco group, there was an associated mortality of 29 3. Subsequent publications have indicated a much lower mortality but in a recent report 2 of the 14 patients managed in this way died during surgery or in the immediate postoperative perioda. Morbidity and mortality may be reduced by the reduction in operative haemorrhage but blood loss of up to 7 litres was reported in one patient in the recent report from Emre and his col...