Intermittent complete vascular exclusion of the liver during hepatectomy: technique and indications

Complete intermittent vascular exclusion of the liver (IVEL) combines clamping of the hepatic pedicle with clamping of the hepatic veins without interruption of the caval flow. The major advantages of this technique are that patient preclamping fluid overload is avoided, major haemodynamic changes due to caval clamping are escaped, and it allows a very long clamping time. Disadvantage of this technique is the necessity of looping the terminal part of the hepatic veins.

In this prospective study, 41 cases of IVEL (Representing 19% of the hepatectomies carried out for cancer during the same period) used for difficult hepatectomies were analyzed, and the operative technique is presented.

IVEL was feasible in 90% of the 46 attempted cases, and completely controlled the bleeding in 90% of the cases. The mean duration of IVEL was 69.2 minutes (Range: 37 to 140), and was greater than 130 minutes in three patients. No liver failure occurred during the postoperative course.

We conclude that IVEL without caval clamping is a new, and valuable, technique of vascular exclusion of the liver. Its application is indicated in the following conditions: 1. For patients who should have classical vascular exclusion but cannot tolerate vena cava clamping (18% of the cases), 2. for patients with pathological liver parenchyma when intrahepatic venous pressure is high, 3. for patients with impaired liver parenchyma, requiring conservative surgery that leads to anatomic or non-anatomic resection close to a vein (Example: A tumor located in the dihedral angle of the terminal part of two hepatic veins), 4. for patients with tumors closely located to a hepatic vein that must be preserved and sharply dissected (Example: A left trisegmentectomy that requires pelting of the right hepatic vein), and 5. for the scarce patient with tumors infiltrating the major hepatic veins, constraining a hepatic vein reconstruction to preserve liver function.