Retrospective Study
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Mar 18, 2016; 8(8): 411-420
Published online Mar 18, 2016. doi: 10.4254/wjh.v8.i8.411
Retrocaval liver lifting maneuver and modifications of total hepatic vascular exclusion for liver tumor resection
Saiho Ko, Yuuki Kirihataya, Yayoi Matsumoto, Tadataka Takagi, Masanori Matsusaka, Tomohide Mukogawa, Hirofumi Ishikawa, Akihiko Watanabe
Saiho Ko, Yayoi Matsumoto, Tadataka Takagi, Masanori Matsusaka, Tomohide Mukogawa, Hirofumi Ishikawa, Akihiko Watanabe, Yuuki Kirihatayfa, Department of Surgery, Nara Prefecture General Medical Center, Nara 631-0846, Japan
Author contributions: Ko S conceived and designed the study, and wrote the manuscript; Kirihataya Y, Matsumoto Y and Takagi T acquired the data; Ko S, Matsusaka M and Mukogawa T analyzed and interpreted the data; Ishikawa H contributed to drafting of the manuscript; Watanabe A contributed to critical revision of the manuscript.
Institutional review board statement: The Institutional Ethical Committee of Nara Prefecture General Medical Center approved this retrospective clinical study.
Informed consent statement: Written informed consent was obtained from all patients for use of clinical data in research. The analysis is a retrospective study and the clinical data were anonymous.
Conflict-of-interest statement: None of the authors has any conflict of interest related to the publication of this manuscript.
Data sharing statement: There are no additional data available for this manuscript.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Dr. Saiho Ko, Director, Department of Surgery, Nara Prefecture General Medical Center, 1-30-1 Nara, Nara 631-0846, Japan. saihoko@naramed-u.ac.jp
Telephone: +81-742-466001 Fax: +81-742-466011
Received: November 28, 2015
Peer-review started: November 29, 2015
First decision: January 4, 2016
Revised: January 13, 2016
Accepted: March 7, 2016
Article in press: March 9, 2016
Published online: March 18, 2016
Processing time: 107 Days and 18.6 Hours
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 modifications, 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.

Keywords: Total hepatic vascular exclusion; Retrocaval liver lifting maneuver; Oblique clamping; Switching the clamp; Hepatectomy

Core tip: Total hepatic vascular exclusion (THVE) is needed for resection of liver tumors involving inferior vena cava (IVC). Because THVE has a high risk of morbidity, compared to inflow occlusion alone, its duration should be shortened. The technical modifications reported here minimized the risk of damage of THVE. Specifically, the procedures include the retrocaval liver lifting maneuver, switching of the cranial IVC cross-clamp, and oblique IVC cross-clamping. For the 8 patients retrospectively assessed, the duration of THVE was 13.4 ± 8.4 min, which was remarkably shorter than that reported previously. Postoperative recovery was smooth for all patients, without severe complications.