Hepatic vascular exclusion with preservation of the caval flow for liver resections

Objective To report the technique and results of an alternative method of vascular cl amping during liver resections. Background Most liver resections require vascular clamping to avoid excessive blood lo ss. Portal triad clamping is often sufficient, but it does not suppress bac kflow bleeding, which can be prevented only by hepatic vascular exclusion. The latter method adds clamping of the inferior vena cava, which results in hypotension, requiring invasive anesthetic management. There is growing ev idence that intermittent clamping is better tolerated than continuous clamp ing, especially in the presence of underlying liver disease. Methods Hepatic vascular exclusion with preservation of the caval Row (HVEPC) invol ved conventional inflow clamping associated with outflow control by clampin g the major hepatic veins, thus avoiding caval occlusion. HVEPC was used in 40 patients undergoing major or complex liver resection, including 16 with underlying liver disease. HVEPC was total (clamping of the porta hepatis a nd all major hepatic veins) in 20 cases and partial (clamping of the porta hepatis and the hepatic veins of the resected territory) in 20, Clamping wa s continuous in 22 cases and intermittent in 18. Resections included 12 hem ihepatectomies, 12 extended hepatectomies, 3 central hepatectomies, and 13 uni- or bisegmentectomies. Results Hemodynamic tolerance of clamping was excellent in all cases, without the n eed for therapeutic adjustment. Median red cell transfusion requirements we re 0 units, and 28 patients (70%) did not receive any transfusions during t he hospital stay. There were no deaths, and the morbidity rate was 17.5%. M edian hospital stay was 10 days. Conclusion HVEPC is a safe and effective procedure applicable to liver tumors without invasion to the inferior vena cava. It offers the advantages of conventiona l hepatic vascular exclusion without its hemodynamic drawbacks, and it can be applied intermittently or partially.