[Vascular clamping in hepatic surgery]

Outcome of hepatectomy procedures depends greatly on proper control of intraoperative bleeding. We detail here the different techniques for vascular clamping, discussing their different indications. Four parameters can be used to define clamping: the zone of application: separate control of arterial or glisson pedicles and portal veins (pedicles, selective hilar, suprahilar and intrahilar clamps), suprahepatic veins or vena cava; selectivity: partial or total clamp of hepatic blood supply; duration, continuous or intermittent; association measures to favor tolerance to ischemia (cooling, preservation fluid) or to limit downstream consequences (extracorporal circulation, derivation). The optimal clamp depends on the localization of the lesion and its relations with the great vessels, presence of liver disease, and the patient's general and cardiovascular status as well as the experience of the operator and the anesthesist. The goal is to use clamp as sparingly as possible, favoring selective clamps to avoid ischemia.