INTERMITTENT COMPLETE VASCULAR EXCLUSION OF THE LIVER DURING HEPATECTOMY - TECHNIQUE AND INDICATIONS

BACKGROUND/AIMS: 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 advant ages 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 techniq ue is the necessity of looping the terminal part of the hepatic veins. METHODOLOGY: In this prospective study, 41 cases of IVEL (Representin g 19% of the hepatectomies carried out for cancer during the same peri od) used for difficult hepatectomies were analyzed, and the operative technique is presented. RESULTS: IVEL was feasible in 90% of the 46 at tempted cases, and completely controlled the bleeding in 90% of the ca ses. The mean duration of IVEL was 69.2 minutes (Range: 37 to 140), an d was greater than 130 minutes in three patients. No liver failure occ urred during the postoperative course. CONCLUSION: We conclude that TV EL without caval clamping is a new, and valuable, technique of vascula r exclusion of the liver. Its application is indicated in the followin g conditions: 1. For patients who should have classical vascular exclu sion 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, requ iring conservative surgery that leads to anatomic or non-anatomic rese ction close to a vein (Example: A tumor located in the dihedral angle of the terminal part of two hepatic veins), 4. for patients with tumor s 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 inf iltrating the major hepatic veins, constraining a hepatic vein reconst ruction to preserve liver function.