Major hepatic tumor resection using profound hypothermia and circulation arrest

In spite of recent reports of more aggressive investigation and treatment of malignant liver tumors in infants and children, there is still an alarming morbidity and mortality in the operative aspect of this tumor. Our operative approach to partial hepatectomy follows that laid down by many authors, but we seem to have the same intraoperative problems in removing the huge tumor confined to one liver lobe. The blood loss in such operations may equal or exceed the child's blood volume while intraoperative cardiac arrest is not unknown. The bleeding can be most acute in the course of the retrohepatic caval and hepatic veins dissection. Once bleeding becomes excessive, the dissection must continue in a hurried fashion leading to the above problems. Since 1977, six children have been admitted to our hospital with huge malignant liver tumors involving almost all of one liver lobe and part of the other. Each was explored through a long midline abdominal incision finding what was felt to be a resectable liver tumor. The incision was then carried upwards via a sternal split or a right thoracoabdominal incision and the liver mobilized. The patient was then put on cardiopulmonary bypass and cooled to a rectal temperature below 20 degrees C. Circulation arrest at this low temperature provided 1 hr or less of bloodless dissection, and an extended hepatic lobectomy was easily carried out. The patients were rewarmed on bypass and normal hemodynamics restored. Bleeding from the liver edge was controlled and the remainder of the operation completed. What was previously the most difficult aspect of a liver tumor operation has become the easiest part of the entire procedure. This operative approach is recommended in highly selected large tumor cases.