Hepatic vascular occlusion during liver resection
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310 Hellenic Journal of Surgery 2010; 82: 5
Hepatic Vascular Occlusion During Liver Resection Review Article G. Sgourakis, S. Lanitis, Ch. Kontovounisios, M. Korontzi, Ch. Karaliotas, K. Zacharioudakis, B. Armoutidis, C. Karaliotas Received 26/05/2010 Accepted 23/07/2010
Abstract This article reviews the various techniques of vascular occlusion that can be applied to reduce blood loss during liver resection and liver transplantation as well as the level of current evidence in regard to their application. Hepatoduodenal ligament occlusion can be either continuous or intermittent. The impact on cardiac preload, cardiac index, systemic vascular resistance and splanchnic congestion is minimal. Hemihepatic or segmental vascular occlusion selectively interrupts inflow to the tumour bearing hemi-liver/segment, offers obvious demarcation of the resection limits, protects the remnant liver from ischaemia and avoids splanchnic congestion and haemodynamic consequences. Should backflow from the hepatic veins cause major blood loss during portal clamping or should the tumour infiltrate the IVC or caval-hepatic junction, total hepatic vascular exclusion (THVE) may be applied. THVE is associated with haemodynamic intolerance in 10–20% of patients and requires close haemodynamic monitoring and anesthetic expertise. Alternatively extraparenchymal hepatic vein occlusion allows THVE without interruption of the IVC flow. Infrahepatic inferior vena caval clamping may be used in order to reduce backflow bleeding during portal clamping is to reduce CVP with minor negative haemodynamic consequences. The future of pharmacological strategies lessening or preventing ischaemia/reperfusion injury lies in a combination of drugs acting on several steps of the ischaemia/reperfusion injury cascades. Separating the molecular basis and differences after ischaemia/reperfusion injury in normal and marginal organs will finally lead to strategies for preconditioning, and organ preservation.
Keywords
Hepatoduodenal ligament occlusion, Hemihepatic vascular occlusion, Segmental vascular occlusion, Total hepatic vascular exclusion, Extraparenchymal hepatic vein occlusion, Infrahepatic inferior vena caval clamping 2nd Surgical Department and Surgical Oncology Unit of “Korgialenio – Benakio”, Red Cross Hospital, Athens, Greece e-mail: [email protected]
Introduction Even though some liver resections may be performed without vascular clamping, excessive intraoperative blood loss and transfusion are known predictors for patient outcome following hepatic resection [1,2]. Three fundamental issues have significantly contributed to our ability to manage blood loss: a) the understanding of liver surgical anatomy as described by Couinaud [3], who delineated the partition of the liver into segments, each with its own vascular supply and the somewhat avascular inter-segmental planes, b) the development of methods for parenchymal dissection [4] and c) the clamping of the hepatic pedicle, with or without simultaneous control of backflow from the hepatic veins [5,6
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