Retrocaval liver lifting maneuver and modifications of total hepatic vascular exclusion for liver tumor resection

Abstract

AIM:To evaluate the efficacy of technical modifications of total hepatic vascular exclusion (THVE) for hepatectomy involving inferior vena cava (IVC). METHODS:Of 301 patients who underwent hepatectomy during the immediate previous 5-year period, 8 (2.7%) required THVE or modified methods of IVC cross-clamping for resection of liver tumors with massive involvement of the IVC. Seven of the patients had diagnosis of colorectal liver metastases and 1 had diagnosis of hepatocellular carcinoma. All tumors involved the IVC, and THVE was unavoidable for combined resection of the IVC in all 8 of the patients. Technical modifications of THVE were applied to minimize the extent and duration of vascular occlusion, thereby reducing the risk of damage. RESULTS:Broad dissection of the space behind the IVC coupled with lifting up of the liver from the retrocaval space was effective for controlling bleeding around the IVC before and during THVE. The procedures facilitate modification of the positioning of the cranial IVC cross-clamp. Switching the cranial IVC cross-clamp from supra-to retrohepatic IVC or to the confluence of hepatic vein decreased duration of the THVE while restoring hepatic blood flow or systemic circulation via the IVC. Oblique cranial IVC cross-clamping avoided ischemia of the remnant hemi-liver. With these technical Retrocaval liver lifting maneuver and modifications of total hepatic vascular exclusion for liver tumor resection Retrospective Study ORIGINAL ARTICLEmodifications, the mean duration of THVE was 13.4 ± 8.4 min, which was extremely shorter than that previously reported in the literature. Recovery of liver function was smooth and uneventful for all 8 patients. There was no case of mortality, re-operation, or severe complication (i.e. , Clavien-Dindo grade of Ⅲ or more). CONCLUSION:The retrocaval liver lifting maneuver and modifications of cranial cross-clamping were useful for minimizing duration of THVE.

Treatment of hepatocellular carcinoma with hepatic vein tumor thrombosis protruding into the inferior vena cava by conversion surgery following chemotherapy with regorafenib: a case report

“…This high mortality rate may be related to the use of THVE. Although THVE is needed for the resection of liver tumors involving IVC [11], it is technically complicated and may cause liver damage due to the prolonged ischemia and circulatory instability caused by the absence of venous return via the IVC [11]. These conditions cause congestion of the kidneys and intestine, which may explain why the damage and morbidity after THVE are much greater than under inflow occlusion alone [12].…”

Vascular Involvements in Cholangiocarcinoma: Tips and Tricks

“…A "trick" to reduce TVE time and liver ischaemia when reconstructing the IVC is to "slide down" clamps below the hepatocaval confluence as soon as possible (for instance, right after the supra-hepatic anastomosis is fashioned, before construction of the inferior anastomosis [17,30,44]). Other authors have described the possibility of switching from TVE to oblique clamping of the IVC after transection of the parenchyma if the reconstruction involves only part of the vena cava and can be performed with a patch, obtaining good results in minimising TVE time [45] (Figure 1C).…”

Current trends in vena cava reconstructive techniques with major liver resection: a systematic review

“…One article was omitted due to duplicate data [33]. This resulted in 14 articles included in the final qualitative synthesis [14,[34][35][36][37][38][39][40][41][42][43][44][45][46]. All 14 articles were case series and thus uncontrolled-observational trials.…”

“…IVC resection techniques varied between articles with details only described for 203 of 350 patients. About one-third of patients (32%) underwent a primary caval repair [35,36,39,[41][42][43]45]. Two studies described ligation without repair which was only 7% of described cases [36,44].…”

“…Forty percent of patients had synthetic graft replacement, typically with PTFE graft [14,34,35,42,43,45,46]. Autologous graft replacement was another described technique using either the saphenous vein or inferior mesenteric vein (IMV) for 17% of cases [36,43] .P a t c hc l o s u r ew a so n l yu s e di n 3% of cases with either synthetic PTFE patches or an autologous vein patch with the IMV [34,36,39,41,43]. Three studies did not provide any detail on IVC resection and reconstruction [37,38,40].…”