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Technique of hepatic vascular exclusion for extensive liver resection
HOWIDOIT
Technique Claude Huguet,
MD,
of Hepatic Vascular Exclusion for Extensive Liver Resection
Paola Addario-Chieco, MD, Adolf0 Gavelli, MD, Ettore Arrigo, R&gine Roger Clement, MD, Monaco, Principality of Monaco
Hepatic vascular exclusion, which includes clamping of the portal pedicle along with the inferior vena cava below and above the liver, may be a useful procedure for resection of liver tumors close to the hepatic veins or the vena cava that are usually considered unresectable by conventional techniques. Since complete caval exclusion is the key to good hemodynamic tolerance and a bloodless transection of the liver parenchyma, several technical aspects of the procedure must be accomplished and are detailed.
MD,
Joseph Harb,
MD,
H
epatic resection is now widely indicated and performed, and the operative risk has been considerably lowered in the last two decades, below 5% in most qualified centers [I]. However, centrally located massive tumors, near the vena cava or the hepatic veins, represent to most surgeons a contraindication to resection, or, alternatively, they may be responsible for increased operative mortality if hepatectomy is undertaken. The main complication of these difficult operations is laceration of the retrohepatic inferior vena cava (IVC) or the main hepatic veins, which results in massive hemorrhage and eventually air embolism, which is often lethal. The classic Pringle maneuver [2], which interrupts the arterial and venous inflow to the liver, does not prevent the risk of major bleeding from the hepatic veins or the vena cava itself. Hepatic vascular exclusion (HVE), achieved by the concomitant clamping of the IVC below and above the liver, may allow a bloodless field even in unusually difficult circumstances [3]. The observance of some technical aspects of HVE may ensure its success and, consequently, increase hemodynamic tolerance to the procedure. TECHNIQUE
From the Departments of Surgery and Anesthesiology, princess Grace Hospital, Monaco, F’rincipalityof Monaco. Requests for reprints should be addressed to Claude Huguet, MD, Department of Surgery, Princess Grace Hospital, Monaco, Principality of Monaco. Manuscript submitted July 30,199 1, and accepted in revised form December 6,199l.
602
THE AMERICAN JOURNAL OF SURGERY
Whatever type of hepatic resection is performed, the patient is placed in the supine position on a warming blanket. The standard approach is a generous subcostal incision completed with a vertical upper midline extension, which allows sufficient exposure in most cases if two strong separate retractors are used to lift the costal margins (Figure 1). However, when the volume of the liver mass precludes a safe approach to the upper part of the liver and the suprahepatic vena cava, a thoracic extension through the seventh or eighth right intercostal space is done (Figure 1). This route is preferable to that of a median stemotomy, which may represent an alternative approach. Mobilization of the liver is a crucial step in obtaining good exposure of the retrohepatic vena cava. All the liver ligaments are divided by electrocautery. Any adhesion of the liver to the diaphragm or to the retroperitoneal surface should be separated, and hemostasis should be performed with accuracy. Neoplastic extension to the undersurface of the diaphragm may require partial diaphragmatic resection along with the liver specimen. Clamping of the hepatic inflow is easily accomplished by applying a vascular clamp to the whole hepatoduodenal ligament. A careful search for a left hepatic artery originating from the left gastric artery is made, and separate clamping is done to avoid liver congestion during the HVE period.
VOLUME 163 JUNE 1992
The infrahepatic IVC has to be clamped as high as possible. It is unnecessary to encircle the suprarenal IVC. The peritoneal fold at the posterior edge of the right lobe should be cut with electrocautery or with scissors to the anterior aspect of the IVC. Blunt dissection and retraction of the liver upwards make it possible to see the right adrenal gland. The infrahepatic clamp should be applied above this structure, excluding the right adrenal vein, which should not be dissected free or ligated. The suprahepatic IVC is dissected with scissors, taking care not to damage the phrenic veins, which may drain directly into a main hepatic vein [4]. The lateral aspects of the IVC have to be exposed, and, if possible, the vein is encircled with a tape. Technical difficulties related to the volume of the tumor may render this full dissection dangerous, and, in these circumstances, it is sufficient to free the lateral aspects of the IVC. The importance of a safe exposure with a thoracic extension, as previously mentioned, must be emphasized. Clamps are applied in the following order: hepatoduodenal ligament, infrahepatic vena cava, and suprahepatic vena cava. The positioning of the two caval clamps is most important. Inadequate technique results in a lack of control of the collateral veins feeding the excluded segment of the IVC (Figure 2), which may cause liver congestion, poor hemodynamic tolerance, and severe bleeding during liver transection. The appropriate technique consists of joining the tips of the two IVC clamps in order to exclude all the venous collaterals (Figure 3). In some favorable cases, when the exposure is simple, a single caval clamp may be used, occluding the infrahepatic, retrohepatic, and suprahepatic IVC (Figure 4). Liver transection is performed after the onset of HVE F&WO 1. standerd subcastal surgld approach and ttwacic without any previous hilar dissection. The liver capsule is cut by electrocautery along the chosen plane, and hemostat fracture allows exposure of intrahepatic vessels and biliary ducts, which are controlled by clips and cut. The hepatic veins are dissected in the same manner, exposed within the liver parenchyma, divided, and sutured with nonresorbable material. The main glissonian pedicle is controlled and divided with a stapler, and the line of section is reinforced with a continuous suture of resorbable material to avoid secondary arterial bleeding. Removal of the clamps is preceded by careful control of the raw surface of the liver in order to observe any opened vessel or bile duct that might need additional sutures. Fibrin glue may be applied, and the infrahepatic IVC clamp is released for a l- or 2-second trial to make sure that no major vessel has been missed that might need separate suture. The upper IVC clamp is then removed, followed by the infrahepatic IVC and the portal pedicle clamps. Control cholangiography through the cystic duct is done, if deemed necessary, to ascertain the patency of biliary drainage of the residual liver lobe and to look for biliary leaks. External biliary drainage through a T tube I is not routinely performed. Subphrenic and infrahepatic F&we 2. Schematicof hepaticvasadw exclusion(HVE). &te spaces are drained in most patients with one or two sili- ~-positlonof~-VeneccWaWC~damps, cone tubes connected to a closed sterile aspirative system. leavingsome wit cabling into the excluded&?gmentof WC.
THE AMERICAN
JOURNAL
OF SURGERY
VOLUME
163
JUNE
1992
603
Flgure3.AWpatepositkmofthe clamps of the inferbr vena CBVB,8xcludlng all the venous collaterals
Flgufe 4. Simplified technique of he patlc mscular exclusion with a single caval clamp, Cmtireiyexcmlg ths itlferior vena cava b&w, behind, and above the liver.
COMMENTS HVE for major liver resection has not been widely used, and some surgeons have been concerned with poor tolerance to the procedure and even with its ineffectiveness at controlling blood loss. A satisfactory HVE de pends on adequate surgical technique. Incomplete vascular exclusion results in hepatic congestion due to blood sequestration in the liver, leading to poor hemodynamic tolerance and severe bleeding during liver tmnsection. It should be stressed that complete mobilization of the liver and division of eventual pathologic adhesions to the dia-
fXk& THE AMERICAN JOURNAL OF SURGERY
phragm are mandatory before clamping. Retrograde filling of the liver through anatomic or pathologic venous channels, reaching the IVC between the two venous clamps, is the main explanation for an incomplete and poorly tolerated HVE. As previously mentioned, abnormal hepatic inflow through the left gastric artery may be another cause of failure. Apart from these surgical factors, HVE may be poorly tolerated if the patient is hypovolemic at the onset of clamping. As previously reported, a slight vascular overload should precede HVE [5,6l. Persistent hemody-
VOLUME 163 JUNE 1992
VASCULAR EXCLUSION FOR LIVER RESECTION
namic intolerance, with a drop in the cardiac index of more than 50%, which is a rare finding, might indicate the need for associated clamping of the aorta at the supraceliac level, as initially suggested by Heaney et al [7], performed by us in our early experience [ 31, and recently supported by Stephen et al [8]. The main disadvantage of clamping the aorta is that it may induce renal, intestinal, and spinal cord arterial ischemia, which may lead to severe complications. Another solution in the case of poor hemodynamic tolerance despite a technically satisfactory HVE may be the addition of a venovenous bypass to decompress systemic and splanchnic territories, as routinely done in liver transplantation. Surprisingly good metabolic tolerance of the liver to prolonged continuous normothermic ischemia has been reported [6,9,10] if the liver function is initially normal, which is the case in most patients with liver tumors amenable to surgical resection. HVE may thus allow the performance of technically difficult liver resections with minimal blood loss and without any blood transfusion. This represents a major advantage since operative mortality and morbidity are related to blood loss [6,10]. Furthermore, HVE may increase the resectabihty rate of liver tumors considered to be inoperable with conventional techniques.
REFERENCES 1. Iwatsuki S, Starxl T. Personalexperience with411 hepatic resections. Ann Surg 1988; 208: 421-34. 2. Pringle JH. Notes on the arrest of hepatic hemorrage due to trauma. Ann Surg 1908; 48: 541-9. 3. Huguet C, Nordlinger B, Galopin JJ, Bloch P, Gallot D. Norm* thermic hepatic vascular exclusion for extensive hepatectomy. Surg Gynecol Obstet 1978; 147: 689-93. 4. Chevallier JM, Delva E, Frileux P, et al. L’hkpatectomie sous exclusion vasculaire totale. Principe anatomiques d’aprks 64 disseu tions. Ann Chir 1990; 44: 444-51. 5. Delva E, Barberouse JP, Nordlinger B, et al. Hemodynamic and biochemical monitoring during major liver resections with use of hepatic vascular exclusion. Surgery 1984; 95: 309-18. 6. Delva E, Camus Y, Nordlinger B, et al. Vascular occlusion for liver resections. Operative management and tolerance to hepatic ischemia: 142 cases. Ann Surg 1989; 209: 211-8. 7. Heaney JP, Stanton WK, Halbert DS, Seidel J, Vice T. An improved technique for vascular isolation of the liver. Experimental study and case reports. Ann Surg 1966; 163: 237-41. 8. Stephen MS, Sheil AG, Thompson JF, Wilson T, Boland S. Aortic occlusion and vascular isolation allowing avascular hepatic resection. Arch Surg 1990, 125: 482-5. 9. Huguet C, Gavelli A, Addario Chieco P, et al. Liver ischemia for hepatic resection: where is the limit? Surgery 1992; 111: 25 l-9. 10. Nagasue N, Yukaya H, Ogawa Y, Hirose S, Okita M. Segmental and subsegmental resections of the cirrhotic liver under hepatic inflow and outflow occlusion. Br J Surg 1985; 72: 565-8.
THE AMERICAN JOURNAL OF SURGERY
VOLUME 163 JUNE 1992
605
Technique Claude Huguet,
MD,
of Hepatic Vascular Exclusion for Extensive Liver Resection
Paola Addario-Chieco, MD, Adolf0 Gavelli, MD, Ettore Arrigo, R&gine Roger Clement, MD, Monaco, Principality of Monaco
Hepatic vascular exclusion, which includes clamping of the portal pedicle along with the inferior vena cava below and above the liver, may be a useful procedure for resection of liver tumors close to the hepatic veins or the vena cava that are usually considered unresectable by conventional techniques. Since complete caval exclusion is the key to good hemodynamic tolerance and a bloodless transection of the liver parenchyma, several technical aspects of the procedure must be accomplished and are detailed.
MD,
Joseph Harb,
MD,
H
epatic resection is now widely indicated and performed, and the operative risk has been considerably lowered in the last two decades, below 5% in most qualified centers [I]. However, centrally located massive tumors, near the vena cava or the hepatic veins, represent to most surgeons a contraindication to resection, or, alternatively, they may be responsible for increased operative mortality if hepatectomy is undertaken. The main complication of these difficult operations is laceration of the retrohepatic inferior vena cava (IVC) or the main hepatic veins, which results in massive hemorrhage and eventually air embolism, which is often lethal. The classic Pringle maneuver [2], which interrupts the arterial and venous inflow to the liver, does not prevent the risk of major bleeding from the hepatic veins or the vena cava itself. Hepatic vascular exclusion (HVE), achieved by the concomitant clamping of the IVC below and above the liver, may allow a bloodless field even in unusually difficult circumstances [3]. The observance of some technical aspects of HVE may ensure its success and, consequently, increase hemodynamic tolerance to the procedure. TECHNIQUE
From the Departments of Surgery and Anesthesiology, princess Grace Hospital, Monaco, F’rincipalityof Monaco. Requests for reprints should be addressed to Claude Huguet, MD, Department of Surgery, Princess Grace Hospital, Monaco, Principality of Monaco. Manuscript submitted July 30,199 1, and accepted in revised form December 6,199l.
602
THE AMERICAN JOURNAL OF SURGERY
Whatever type of hepatic resection is performed, the patient is placed in the supine position on a warming blanket. The standard approach is a generous subcostal incision completed with a vertical upper midline extension, which allows sufficient exposure in most cases if two strong separate retractors are used to lift the costal margins (Figure 1). However, when the volume of the liver mass precludes a safe approach to the upper part of the liver and the suprahepatic vena cava, a thoracic extension through the seventh or eighth right intercostal space is done (Figure 1). This route is preferable to that of a median stemotomy, which may represent an alternative approach. Mobilization of the liver is a crucial step in obtaining good exposure of the retrohepatic vena cava. All the liver ligaments are divided by electrocautery. Any adhesion of the liver to the diaphragm or to the retroperitoneal surface should be separated, and hemostasis should be performed with accuracy. Neoplastic extension to the undersurface of the diaphragm may require partial diaphragmatic resection along with the liver specimen. Clamping of the hepatic inflow is easily accomplished by applying a vascular clamp to the whole hepatoduodenal ligament. A careful search for a left hepatic artery originating from the left gastric artery is made, and separate clamping is done to avoid liver congestion during the HVE period.
VOLUME 163 JUNE 1992
The infrahepatic IVC has to be clamped as high as possible. It is unnecessary to encircle the suprarenal IVC. The peritoneal fold at the posterior edge of the right lobe should be cut with electrocautery or with scissors to the anterior aspect of the IVC. Blunt dissection and retraction of the liver upwards make it possible to see the right adrenal gland. The infrahepatic clamp should be applied above this structure, excluding the right adrenal vein, which should not be dissected free or ligated. The suprahepatic IVC is dissected with scissors, taking care not to damage the phrenic veins, which may drain directly into a main hepatic vein [4]. The lateral aspects of the IVC have to be exposed, and, if possible, the vein is encircled with a tape. Technical difficulties related to the volume of the tumor may render this full dissection dangerous, and, in these circumstances, it is sufficient to free the lateral aspects of the IVC. The importance of a safe exposure with a thoracic extension, as previously mentioned, must be emphasized. Clamps are applied in the following order: hepatoduodenal ligament, infrahepatic vena cava, and suprahepatic vena cava. The positioning of the two caval clamps is most important. Inadequate technique results in a lack of control of the collateral veins feeding the excluded segment of the IVC (Figure 2), which may cause liver congestion, poor hemodynamic tolerance, and severe bleeding during liver transection. The appropriate technique consists of joining the tips of the two IVC clamps in order to exclude all the venous collaterals (Figure 3). In some favorable cases, when the exposure is simple, a single caval clamp may be used, occluding the infrahepatic, retrohepatic, and suprahepatic IVC (Figure 4). Liver transection is performed after the onset of HVE F&WO 1. standerd subcastal surgld approach and ttwacic without any previous hilar dissection. The liver capsule is cut by electrocautery along the chosen plane, and hemostat fracture allows exposure of intrahepatic vessels and biliary ducts, which are controlled by clips and cut. The hepatic veins are dissected in the same manner, exposed within the liver parenchyma, divided, and sutured with nonresorbable material. The main glissonian pedicle is controlled and divided with a stapler, and the line of section is reinforced with a continuous suture of resorbable material to avoid secondary arterial bleeding. Removal of the clamps is preceded by careful control of the raw surface of the liver in order to observe any opened vessel or bile duct that might need additional sutures. Fibrin glue may be applied, and the infrahepatic IVC clamp is released for a l- or 2-second trial to make sure that no major vessel has been missed that might need separate suture. The upper IVC clamp is then removed, followed by the infrahepatic IVC and the portal pedicle clamps. Control cholangiography through the cystic duct is done, if deemed necessary, to ascertain the patency of biliary drainage of the residual liver lobe and to look for biliary leaks. External biliary drainage through a T tube I is not routinely performed. Subphrenic and infrahepatic F&we 2. Schematicof hepaticvasadw exclusion(HVE). &te spaces are drained in most patients with one or two sili- ~-positlonof~-VeneccWaWC~damps, cone tubes connected to a closed sterile aspirative system. leavingsome wit cabling into the excluded&?gmentof WC.
THE AMERICAN
JOURNAL
OF SURGERY
VOLUME
163
JUNE
1992
603
Flgure3.AWpatepositkmofthe clamps of the inferbr vena CBVB,8xcludlng all the venous collaterals
Flgufe 4. Simplified technique of he patlc mscular exclusion with a single caval clamp, Cmtireiyexcmlg ths itlferior vena cava b&w, behind, and above the liver.
COMMENTS HVE for major liver resection has not been widely used, and some surgeons have been concerned with poor tolerance to the procedure and even with its ineffectiveness at controlling blood loss. A satisfactory HVE de pends on adequate surgical technique. Incomplete vascular exclusion results in hepatic congestion due to blood sequestration in the liver, leading to poor hemodynamic tolerance and severe bleeding during liver tmnsection. It should be stressed that complete mobilization of the liver and division of eventual pathologic adhesions to the dia-
fXk& THE AMERICAN JOURNAL OF SURGERY
phragm are mandatory before clamping. Retrograde filling of the liver through anatomic or pathologic venous channels, reaching the IVC between the two venous clamps, is the main explanation for an incomplete and poorly tolerated HVE. As previously mentioned, abnormal hepatic inflow through the left gastric artery may be another cause of failure. Apart from these surgical factors, HVE may be poorly tolerated if the patient is hypovolemic at the onset of clamping. As previously reported, a slight vascular overload should precede HVE [5,6l. Persistent hemody-
VOLUME 163 JUNE 1992
VASCULAR EXCLUSION FOR LIVER RESECTION
namic intolerance, with a drop in the cardiac index of more than 50%, which is a rare finding, might indicate the need for associated clamping of the aorta at the supraceliac level, as initially suggested by Heaney et al [7], performed by us in our early experience [ 31, and recently supported by Stephen et al [8]. The main disadvantage of clamping the aorta is that it may induce renal, intestinal, and spinal cord arterial ischemia, which may lead to severe complications. Another solution in the case of poor hemodynamic tolerance despite a technically satisfactory HVE may be the addition of a venovenous bypass to decompress systemic and splanchnic territories, as routinely done in liver transplantation. Surprisingly good metabolic tolerance of the liver to prolonged continuous normothermic ischemia has been reported [6,9,10] if the liver function is initially normal, which is the case in most patients with liver tumors amenable to surgical resection. HVE may thus allow the performance of technically difficult liver resections with minimal blood loss and without any blood transfusion. This represents a major advantage since operative mortality and morbidity are related to blood loss [6,10]. Furthermore, HVE may increase the resectabihty rate of liver tumors considered to be inoperable with conventional techniques.
REFERENCES 1. Iwatsuki S, Starxl T. Personalexperience with411 hepatic resections. Ann Surg 1988; 208: 421-34. 2. Pringle JH. Notes on the arrest of hepatic hemorrage due to trauma. Ann Surg 1908; 48: 541-9. 3. Huguet C, Nordlinger B, Galopin JJ, Bloch P, Gallot D. Norm* thermic hepatic vascular exclusion for extensive hepatectomy. Surg Gynecol Obstet 1978; 147: 689-93. 4. Chevallier JM, Delva E, Frileux P, et al. L’hkpatectomie sous exclusion vasculaire totale. Principe anatomiques d’aprks 64 disseu tions. Ann Chir 1990; 44: 444-51. 5. Delva E, Barberouse JP, Nordlinger B, et al. Hemodynamic and biochemical monitoring during major liver resections with use of hepatic vascular exclusion. Surgery 1984; 95: 309-18. 6. Delva E, Camus Y, Nordlinger B, et al. Vascular occlusion for liver resections. Operative management and tolerance to hepatic ischemia: 142 cases. Ann Surg 1989; 209: 211-8. 7. Heaney JP, Stanton WK, Halbert DS, Seidel J, Vice T. An improved technique for vascular isolation of the liver. Experimental study and case reports. Ann Surg 1966; 163: 237-41. 8. Stephen MS, Sheil AG, Thompson JF, Wilson T, Boland S. Aortic occlusion and vascular isolation allowing avascular hepatic resection. Arch Surg 1990, 125: 482-5. 9. Huguet C, Gavelli A, Addario Chieco P, et al. Liver ischemia for hepatic resection: where is the limit? Surgery 1992; 111: 25 l-9. 10. Nagasue N, Yukaya H, Ogawa Y, Hirose S, Okita M. Segmental and subsegmental resections of the cirrhotic liver under hepatic inflow and outflow occlusion. Br J Surg 1985; 72: 565-8.
THE AMERICAN JOURNAL OF SURGERY
VOLUME 163 JUNE 1992
605