Hepatectomy with Hepatic Vein Resection and Reconstruction Under Total Vascular Exclusion and Venous Drainage via a Venovenous Bypass: An Additional Approach for Complex Hepatectomies.

Background: Total vascular exclusion (TVE) with liver hypothermic perfusion under venovenous bypass (VVB) is usually needed to perform hepatectomy with Inferior vena cava and hepatic veins resection-reconstruction. An alternative technique is represented by liver resection under intermittent pedicular clamping, IVC total clamping and VVB, without cold perfusion and liver outflow drainage through the VVB. PATIENTS AND METHODS: The patient is a 60-year-old woman with past medical history of right hepatectomy for leiomyosarcoma 14 years previously. She presented with a single liver recurrence on the left liver remnant invading the middle and the left hepatic veins. Upon multidisciplinary board meeting, surgery was indicated. An upper transversal hepatectomy resecting the tumor and the left and middle hepatic veins was planned. The liver was fully mobilized, VVB cannulas were placed (inferior mesenteric veins, axillary vein, and femoral vein). During parenchymal transection, the hepatic veins truncks were isolated far from the tumor. TVE was started and two additional cannulas were placed into the two hepatic veins to ensure venous drainage through the VVB. The liver was rotated toward the left, as per an ante situm approach, while continuously perfused by the hepatic pedicle and drained through the VVB. Hepatic veins (HVs) and the tumor were resected en bloc. Hepatic vein reconstruction was made sequentially by using one cryopreserved femoral graft anastomosed between the two HVs and the anterior face of the IVC.

Results: Postoperative course was uneventful, and pathology confirmed an isolated liver recurrence of leiomyosarcoma; 4 years later, the patient is alive and disease free.

Conclusions: Hepatectomy with hepatic vein resection and reconstruction can be performed without cold perfusion and venous drainage through the VVB. This technical variant integrates safely into the armamentarium of extreme liver surgery.