The vascular control in liver resection: revisitation of a controversial issue

Limiting intraoperative blood loss and the consequent need for whole blood transfusion is a widely accepted goal in liver resection. To achieve this goal, liver resection carried out under warm ischemia seems adequate. Methods used for this purpose can be categorized as follows: those with only an inflow control and the one that consists of total vascular exclusion. Liver resections under inflow vascular control are safer than those performed without. Furthermore, up to now the ischemia-reperfusion liver damage does not seem to affect the patients' course. The clinical evidence shows that intermittent warm ischemia seems to be safer than the continuous clamping and guarantees an effective control of the intraoperative bleeding. Conversely, total vascular exclusion is an invasive technique with not negligible morbidity; then its real indications should be restricted to exceptional cases, such as those with infiltration of the inferior vena cava which demands substitution of the involved vessel. In conclusion, up to now intermittent warm ischemia is the most appropriate approach to carry out safe liver resections.