[The hepaticocaval intersection: current anatomosurgical aspects. Apropos of 32 dissections]

Segmental occlusive phlebography of IVC coupled with a slit in its posterior wall, injection of corrosive substances into portal and hepaticocaval network, biometry of the retrohepatic IVC and serial sections of injected livers from 32 fresh subjects has allowed definition of the hepaticocaval intersection which constitutes one of the rare current stumbling-blocks to hepatic surgery. Emergency surgery for hepaticocaval injuries exposes patients to the risk of gas embolus and massive haemorrhage. Using a median sternolaparotomy approach they require previous temporary hemostasis by quadruple clamping or intracaval shunt: in more than half of cases the length of the subhepatic, suprarenal IVC of less than 1 cm does not permit application of a clamp and necessitates introduction of an intracaval shunt by the atrial route. Cold surgery for certain hepatic tumors close to the intersection can benefit from vascular exclusion of liver but the right middle capsular and inferior phrenic veins must be clamped: clamping of the suprahepatic IVC is dependent on the site of the intersection in relation to diaphragm. The principal right hepatic vein, lacking collateral over 1 cm external to liver in 1 of 2 cases, can be controlled extraparenchymatously after mobilization of right liver, but caution is needed because of the predominance of "accessory" hepatic veins in 25% of cases. Control of hepatic veins external to liver on left side is dangerous since a common trunk is frequent (87.5%), collateral branches numerous and often vulnerable. Relations between intersection, diaphragm and right atrium also define modalities of treatment of hepatic lesions in membranes of terminal IVC and in Budd Chiari's syndrome.