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

Figure 4 Oblique cranial cross-clamping, performed in case 4. A (illustration) and B (intraoperative image): The trunk of LHV + MHV was free from tumor involvement, while the right aspect of the IVC was involved extensively (red arrowhead). After completion of hepatic parenchymal transection, the cranial IVC cross-clamp (blue arrowhead) was applied obliquely between the tumor-involved IVC and the trunk of LHV + MHV preserving outflow of the LHV + MHV trunk, which was possible because the retrocaval space had been dissected sufficiently. Then, the involved IVC wall (white arrowhead in B) and the liver was resected en-bloc under modified THVE; C (intraoperative image): The involved IVC wall was cut away with scissors (arrow) between the oblique cranial (blue arrowhead) and caudal (purple arrowhead) cross-clamps; D (illustration) and E (intraoperative image): The large cut orifice of IVC was reconstructed with IMV patch graft (black arrowhead). See Figure 1D for tumor status. IMV: Inferior mesenteric vein; IVC: Inferior vena cava; LHV: Left hepatic vein; THVE: Total hepatic vascular exclusion.