Hepatic vascular occlusion: which technique?

Each vascular occlusion technique has a place in major and minor hepatic resectional surgery, based on the tumor location, presence of associated underlying liver disease, patient cardiovascular status, and experience of the operating surgeon. Understanding of the potential application of different techniques, anticipation of the expected and potential hemodynamic responses, and knowledge of the limitations of each technique are fundamental to appropriate surgical planning adapted to each patient. Experience with the various clamping methods enables an aggressive but safe approach to surgical treatment of hepatobiliary diseases, with acceptable blood loss and transfusion requirements. In all cases, surgical strategy should be defined with the anesthesiologist, particularly in regard to hemodynamic monitoring, in order to optimize perioperative patient management and to minimize the risk for complications such as bleeding and air embolism. Importantly, randomized study has shown that the added dissection, operative, and postoperative risks associated with HVE are not balanced by decreased blood loss compared with hepatic pedicle clamping, except in exceptional cases when tumors involve the major hepatic veins or vena cava. In addition, dissection in preparation for clamping may be used as safe approach techniques to tumors in difficult locations, even when eventual clamping is not performed. Similarly, the liver-hanging maneuver enables resection without mobilization, compression, and manipulation of large tumors. In the future, renewed interest in the impact of hepatic ischemia and reperfusion may reveal that some clamping methods, in particular inflow occlusion, act as a means of preconditioning before a period of prolonged hepatic ischemia, for complex hepatic resection or for graft harvest from a living donor. Finally, the addition of infrahepatic caval clamping may add a new, simple, effective technique to the armamentarium of the liver surgeon, particularly as more routine hepatic surgery moves from the specialized center to the community.