Major liver resection without clamping: a prospective reappraisal in the era of modern surgical tools

Hemorrhage and transfusions remain the main causes of mortality and morbidity from liver resection. In cases of extended resection, especially performed on diseased liver, ischemia-reperfusion injury related to pedicle clamping may be a significant risk factor of postoperative liver dysfunction. The ideal alternative would be to perform major hepatectomy without clamping and without significant bleeding.

This prospective study aimed to reconsider the risk of major hepatectomy performed without pedicle clamping and under low venous pressure in the light of modern surgical tools. Inclusion criteria were adults requiring a resection of more than three segments on healthy or pathologic livers but not on preoperative documented cirrhosis.

Fifty patients, with a mean age of 53 +/- 15 years were included. Twenty-two patients had underlying liver disease. The main indications were colorectal metastases, primary liver tumors, and living donation. Twenty-six right hepatectomies, 17 extended right hepatectomies, and 7 extended left hepatectomies were performed. Unclamping method was successful in 96% of patients on an intention-to-treat basis. Seventy-four percent of patients were not transfused and no patients died. Surgical complication rate was 16% but no complication led to reoperation. Medical complication rate was 20%, including three transient liver dysfunctions.

Major hepatectomy without clamping can be performed safely. The low rate of postoperative liver dysfunction, especially in cases of underlying liver disease, suggests good preservation of the small and diseased remnant liver.