Selective occlusion of the portal vein while maintaining hepatic artery blood flow during partial hepatectomy: a new method for preventing ischemia-reperfusion injury?

Hepatic Vascular Exclusion Minimizes Hemorrhage During Isolated Caudate Lobectomy

Objectives

Isolated caudate lobectomy is a challenging operation for hepatobiliary surgeons. Unexpected massive hemorrhage is one of the major concerns for successful operation. Addressing the issue of bleeding control and prophylaxis during isolated caudate lobectomy is necessary. Our aim was to summarize the application of hepatic vascular exclusion in the operation to decrease blood loss.

Methods

Twenty-six cases of isolated caudate lobectomy were reviewed. Different hepatic vascular exclusion and its outcome were analyzed.

Results

All the operations were accomplished successfully with satisfactory average blood loss (325.38 mL) and without major postoperative complications. Hepatic vascular exclusion was used in nearly four-fifths of the cases. Pringle maneuver, portal vein exclusion, total hepatic vascular exclusion, selective total hepatic vascular exclusion, and selective regional total hepatic vascular exclusion were applied selectively.

Conclusions

Hepatic vascular exclusion decreased possible blood loss effectively during isolated caudate lobectomy. Full mobilization of the liver facilitates hepatic vascular exclusion. Certain precautionary measures and effective remedies are necessary for unexpected bleeding. Isolated caudate lobectomy should be carried out by experienced hepatobiliary surgeons.

Key techniques and procedure optimization of laparoscopic hepatectomy for hepatolithiasis

Hepatolithiasis is a common and refractory benign biliary tract disease in China. Meta-analyses show that laparoscopic hepatectomy (LH) is safe and effective for this disease. LH for hepatolithiasis has its distinctive techniques and procedures due to its unique clinicopathological characteristic in the era of precise hepatecomy and enhanced recovery after surgery. The key techniques include individualized selection of operating hole, hepatic inflow occlusion, anatomical hepatectomy, fine dissection, and other combined techniques. As for procedures, hepatecomy should be completed before extrahepatic bile duct choledocholithotomy is performed, and the portal hepatis should be preferentially dissected before the perihepatic ligaments are separated.

Personalized stepwise vascular control during complex hepatectomy involving hepatocaval confluence

BACKGROUND

This study introduces an innovative stepwise vascular control technique to address the high risk of massive bleeding from main hepatic veins and the retro-hepatic inferior vena cava during hepatectomy involving hepatocaval confluence.

METHODS

From January 2010 to July 2016, 80 patients underwent stepwise vascular occlusion during complex liver resection involving hepatocaval confluence. Relevant clinical data were collected and compared with those obtained in parallel studies. The protocol has been registered in the Protocol Registration and Results System as protocol NCT02996006.

RESULTS

All 80 patients underwent portal triad (PT), infra-hepatic inferior vena cava (IIVC) and supra-hepatic inferior vena cava (SIVC) preparation for occlusion in that order; PT, PT + SIVC and PT + IIVC + SIVC occlusions were performed during liver resection for six, 42 and 32 patients, respectively. The PT, IIVC and SIVC clamping times were 12.9 ± 2.5, 9.1 ± 2.1 and 5.1 ± 1.4 min, respectively. The mean blood loss was 504.1 ± 234.5 mL. Sixteen patients received blood transfusions. Haemodynamic parameters remained stable. No patients had life-threatening complications or died (Clavien-Dindo grade IV or V). Compared with other techniques used in parallel studies, this technique has the advantage of decreased blood loss in less warm ischaemia time.

CONCLUSION

For complex hepatectomy involving hepatocaval confluence, this newly described stepwise vascular control technique was efficacious and feasible for controlling intraoperative bleeding.