Liver resection using total vascular exclusion of the liver preserving the caval flow, in situ hypothermic portal perfusion and temporary porta-caval shunt: a new technique for central tumors

Standard total vascular exclusion (TVE) of the liver is indicated for resection of tumors involvingor adjacent to the vena cava and/or the confluence of the hepatic veins. The duration of liver ischemia canbe prolonged by combined portal hypothermic perfusion of the liver (in or ex situ). The use of a venovenousbypass (VVB) during standard TVE maintains stable hemodynamics as well as optimal renal and splanchnicvenous drainage. When the hepatic veins can be controlled, TVE preserving the caval flow negates the needfor VVB. However this technique remains limited in duration as it is performed under warm ischemia (socallednormothermia) of the liver. To prolong the ischemia time, we have designed a modification of TVEwith preservation of the caval flow including the use of temporary porta-caval shunt (PCS) and hypothermicperfusion of the liver. We describe here the first two cases of this new technique. Two patients underwentleft hepatectomy extended to segments 5 and 8 (also called extended left hepatectomy) for large centrallylocated tumors. TVE lasted seventy-two and seventy-nine minutes, respectively. The postoperative coursewas uneventful and both patients were discharged on day ten and day twenty-five respectively. Both are alivewithout recurrence at ten and seven months following surgery. Provided the roots of the hepatic veins can becontrolled, this technique combines the advantages of standard TVE with in situ hypothermic perfusion andVVB and obviates the need and the subsequent risks of the latter.