Right hepatic lobectomy and removal of inferior vena caval tumor embolus in a patient with hepatocellular carcinoma, using veno-venous bypass while preserving perfusion in the remnant liver: A case report

We describe a successful hepatectomy and the removal of a tumor embolus in a 43-year-old woman with hepatocellular carcinoma occupying the right lobe extending to the right branch of the portal vein and the inferior vena cava (IVC). Intraoperative echography revealed the tumor embolus in the IVC to originate from the main tumor via the right inferior hepatic vein, which extended cephalad from the confluence of the right hepatic vein to the IVC. Right hepatc lobectomy was performed via the anterior approach. Using femoro-axillary veno-venous bypass, we opened the IVC at the root of the inferior right hepatic vein to remove the tumor embolus after oblique clamping of the IVC between the right and middle hepatic veins was carried out to preserve perfusion in the remnant liver. Preserving perfusion in the remmant liver in radical hepatectomy for hepatocellular carcinoma with tumor embolism in the IVC appears to be a safe and advantageous technique in patients with poor liver reserve.     

Thrombectomy before hepatic resection for hepatocellular carcinoma with a tumor thrombus extending to the inferior vena cava

Tumor thrombi of hepatocellular carcinoma occasionally invade into the inferior vena cava (IVC) through the hepatic vein. Once the tumor thrombus is dislodged, severe and lethal complications, such as pulmonary infarction, can develop. We successfully operated on a hepatocellular carcinoma (HCC) patient with a tumor thrombus extending to the IVC through the right hepatic vein. To avoid dislodging the thrombus during surgery, a thrombectomy using selective hepatic vascular exclusion was performed before a hepatic resection, which is the most dangerous procedure to dislodge the thrombus.     

In situ graft-trimming method using polyester vascular prosthesis for inferior vena cava reconstruction after hepatectomy

Hepatectomy for secondary liver cancer that has invaded the inferior vena cava (IVC) can be the only way to achieve long-term survival. We describe a method for hepatectomy combined with partial IVC resection without venous bypass circulation and an in situ graft-trimming method to avoid graft size mismatch after reconstruction. We carried out left hepatectomy extended to segment 1 with partial IVC resection first. During resection and reconstruction of the IVC, it was clamped below the right hepatic vein and above the inferior right hepatic vein to maintain systemic circulation. The graft was trimmed in situ, after a half running suture of the graft was finished to ensure the correct size. Preservation of both inferior right hepatic vein and right hepatic vein helps to maintain systemic circulation during reconstruction of the IVC. The in situ graft-trimming method is an easy and safe method to ensure the correct graft size after IVC reconstruction.     

Balloon control of the suprahepatic inferior vena cava: a novel technique for renal cell carcinoma tumor thrombus

Renal cell carcinoma has a tendency to extend via the renal vein into the inferior vena cava (IVC), and we describe a novel approach to this situation. A 64-year-old male presented with metastatic right renal cell carcinoma and tumor thrombus extending into the retrohepatic IVC. Preoperative imaging revealed a large hemangioma adjacent to the IVC, potentially complicating hepatic mobilization. Instead, we used a compliant balloon to occlude the suprahepatic IVC, securing the wire in the right hepatic vein. With the infrarenal IVC and left renal vein occluded, the thrombus was extracted via a right renal venotomy/partial cavotomy with minimal bleeding. Balloon occlusion of the suprahepatic IVC offers a safe alternative to surgical control of this vessel in difficult situations. In addition, it allows for nephrectomy through a conventional, small retroperitoneal incision rather than the extended exposure needed for the IVC. Hepatic vein positioning of the wire prevents thrombus manipulation during balloon placement.     

Left trisegmentectomy and combined resection of the inferior vena cava, without reconstruction, for giant cystadenocarcinoma of the liver

A 54-year-old woman with giant liver cystadenocarcinoma underwent left trisegmentectomy with combined resection of the inferior vena cava (IVC) and the right hepatic vein. As a result, only the right inferior hepatic vein was preserved as a drainage vein. Because the perivertebral plexus and the azygos vein were both well developed, neither veno-venous bypass nor IVC reconstruction was performed. The developed collateral veins acted as the venous drainage pathway to maintain a stable systemic circulation. On the seventh postoperative day, portal vein flow dramatically decreased and the patient tended to liver failure. Prostaglandin E₁ (PGE₁) was administrated via the superior mesenteric artery. The portal flow then gradually increased and liver failure was avoided. Six months after the operation, she was re-admitted due to obstructive jaundice and presented with complete stenosis of the common bile duct (CBD). The jaundice persisted and liver dysfunction progressed. The patient died seven months after the operation. The confluence of the right inferior vein and the IVC could have been deformed, causing outflow blockade. The intrinsic shunt was not good enough to act as the drainage pathway, and IVC reconstruction may have been needed.     

Outflow block secondary to stenosis of the inferior vena cava following living-donor liver transplantation?

Although it is well known that outflow block is caused by stenosis or occlusion of hepatic vein anastomoses following living donor liver transplantation (LDLT), there have been few reports on inferior vena cava (IVC) stenosis following LDLT. In this paper, we report two cases of IVC stenosis and hepatic vein outflow block following right hepatic LDLT in the absence of stenosis of any of the anastomoses. Both patients presented with liver dysfunction, an ascitic fluid volume of approximately 2000 mL, and congestion in their biopsy specimens, and venocavography demonstrated IVC stenosis with gradients of more than 10 mmHg in patients with a dominant inferior right hepatic vein (IRHV) anastomosis. After a Gianturco expandable metallic stent successfully implanted in the IVC, the patient's liver function recovered and the volume of ascitic fluid decreased. The pathogenesis of hepatic vein outflow block secondary to IVC stenosis following LDLT may involve the anastomosis with the IRHV, which is the dominant draining vein of the graft and larger than the RHV, caudal to the IVC stenosis and a significant IVC pressure gradient that results in increased IRHV pressure. In conclusion, it is important to include hepatic vein outflow block in the differential diagnosis when patients who have undergone right hepatic LDLT in which anastomosis of the large IRHV has been performed develop manifestations of liver dysfunction.     

Hepatectomy with total vascular exclusion. Anatomical principles based on 64 dissections

Intra-operative hemorrhage is the main surgical risk during liver resections. Nowadays hepatectomies for large or posterior liver tumors close to the hepatocaval junction can benefit from total hepatic vascular exclusion (HVE) involving portal triad exclusion and clamping of the inferior vena cava (IVC) below and above the liver. Anatomical aspects of HVE have been studied in 64 subjects by segmental occlusive phlebographies of the IVC, injection of corrosive substances into the hepatocaval network, biometry of the retrohepatic IVC and serial sections of injected livers. A total HVE should exclude the right suprarenal and phrenic veins. Clamping of the suprahepatic IVC depends on the termination of the left inferior phrenic vein. Clamping of the subhepatic IVC must be retrohepatic: the right lobe of the liver has to be mobilized to free the right border of the retrohepatic IVC into which flows the right suprarenal vein 40 +/- 20 mm above the right renal vein and under the superior right hepatic vein. Both suprahepatic and retrohepatic clamps excluding the retrohepatic portion of the IVC (46.6 +/- 13 mm) and the hepatocaval junction should come in contact behind the IVC without overlapping.     

Interrupted Inferior Vena Cava Combined with Partial Anomalous Pulmonary Venous Return Drainage to the IVC in a 67‐Year‐Old Adult

A 67‐year‐old woman presented with lower body edema and was found to have a suprarenal inferior vena cava (IVC) obstruction without hepatic vein obstruction and partial anomalous pulmonary venous return (PAPVR) draining the right pulmonary veins to the IVC below the obstructed IVC on CT angiography. The patient underwent retrohepatic cavoatrial bypass with a polytetrafluoroethylene (PTFE) 16‐mm ringed graft via a posterolateral thoracotomy and retroperitoneal approach.     

肝后隧道手术高危区的解剖特点及临床应用研究

目的:探讨肝后隧道及手术高危区的解剖特点及临床应用价值。方法:解剖20具成人尸体肝脏标本,收集经前入路绕肝提拉法右半肝切除术27例患者的临床资料,分别统计汇入肝后下腔静脉和肝后隧道路径上肝短静脉总数。结果:解剖研究中发现,肝短静脉主要从左右两侧汇入肝后下腔静脉,且较多集中于中、下1/3段;在肝后隧道路径上,汇入肝后下腔静脉的肝短静脉主要集中在下1/3段前方,平均(2.90±1.07)支,上1/3段仅有1例出现1支肝短静脉,中1/3段20例中仅4例出现1支肝短静脉;肝右后下静脉多出现在肝后下腔静脉的中、下1/3段,出现率达85.0%(17/20)。临床手术中发现,在肝后隧道路径上,汇入肝后下腔静脉肝短静脉主要集中在下1/3段,平均(3.21±1.67)支,多数病例此区域上下距离约3～4 cm,同时此区域中肝右后下静脉出现率达85.2%(23/27);27例中仅1例有1支肝短静脉汇入中段肝后下腔静脉前方。结论:肝后隧道手术高危区位于肝后下腔静脉下段前方3～4 cm区域,有较多肝短静脉伴随肝右后下静脉汇入。准确把握此区域的解剖特点并进行解剖分离是成功建立肝后隧道的关键。     

No-Touch En Bloc Right Lobe Living-Donor Liver Transplantation with Inferior Vena Cava Replacement for Hepatocellular Carcinoma Close to Retrohepatic Inferior Vena Cava: Case Report

Current studies have shown that living-donor liver transplantation (LDLT) for hepatocelluar carcinoma (HCC) satisfying the Milan criteria does not compromise patient survival or increase HCC recurrence compared with deceased-donor liver transplantation (DDLT). For patients with HCC beyond the Milan criteria, however, worse outcomes are expected after LDLT than after DDLT, despite insufficient data to reach a conclusion. Regarding operative technique, LDLT might be a less optimal cancer operation for HCC located at the hepatic vein confluence and/or paracaval portion. The closeness to the wall of the retrohepatic inferior vena cava (IVC) is greater than in conventional DDLT, rendering it difficult to perform a no-touch en bloc total hepatectomy. An LDLT, which must preserve the native IVC for the piggyback technique during engraftment, may lead to tumor remnants. To reduce recurrences after LDLT, we successfully performed a no-touch en bloc total hepatectomy including the retrohepatic IVC and all 3 hepatic veins. IVC replacement with an artificial vascular graft together with a modified right-lobe LDLT was performed for a patient having advanced HCC close to the hepatic vein confluence and paracaval portion. There was no artificial vascular graft-related complication, such as thrombosis or infection. Despite the limitations of LDLT, requiring the piggyback technique for graft implantation, IVC replacement using an artificial graft led us to perform a no-touch en bloc total hepatectomy as with a conventional DDLT.     

前入路联合肝下下腔静脉阻断切除右肝巨大肝细胞癌

目的探讨入前入路联合肝下下腔静脉阻断在右肝巨大肝细胞癌(10 cm)切除术中的安全性和有效性。方法回顾分析2012年1月至2017年4月间采用前入路联合肝下下腔静脉阻断治疗右肝巨大肝细胞癌的42例病人的临床资料。结果 42例患者平均下腔静脉阻断时间38.5分钟。肝下下腔静脉阻断后中心静脉压对比阻断前明显降低(4.1±2.1cm H_2Ovs.7.3±2.5cm H_2O,P0.05),术中平均出血量为430.6±260.7 ml。输血率、术后并发症和死亡率分别为26.1%、38.1%和0%。结论前入路联合肝下下腔静脉阻断治疗右肝巨大肝细胞癌有效、安全。     

肝细胞癌合并下腔静脉癌栓的手术治疗

目的 探讨肝细胞癌(简称肝癌)合并下腔静脉癌栓的手术治疗方法。方法 采用肝切除 腔静脉取栓治疗4例肝癌合并下腔静脉癌栓患者,取栓方法包括经荷栓肝静脉取栓(1例)和下腔静脉切开取栓(3例),后者又分在全肝血流阻断下取栓(2例)和在萨氏钳局部血管阻断下取栓(1例)。结果 4例肝癌及下腔静脉癌栓均得到成功切除,术中无明显并发症发生;术后除l例发生中等量胸水外,无其他并发症发生;随访中3例已死亡,分别生存30、10和14个月;1例尚存活,已生存7个月。结论 肝癌合并下腔静脉癌栓的手术治疗安全可行,其基本术式为肝切除 下腔静脉切开取栓。     

A case of aplastic inferior vena cava with right hypofunctional kidney

We report a rare case of anomalous inferior vena cava (IVC) in a 46-year-old woman hospitalized for the examination of right hypofunctional kidney. She had no history of trauma or pyelonephritis and there were no abnormalities in laboratory findings except serum creatinine value. Excretory urography showed no excretion of contrast medium from right kidney and retrograde pyelography revealed moderate hydronephrosis of right kidney but the obstruction of the ureter was not recognized. Abdominal computed tomographic scan showed a total trace of IVC and inferior venacavography demonstrated complete obstruction of the IVC from its origin with collateralization of upper lumber veins and vertebral veins. Surgical exploration was performed and demonstrated that IVC was a trace from the postrenal segment to hepatic segment. Two right renal veins were draining into the upper lumber vein and the right ureter was compressed slightly by lower renal vein, dilated ovarian vein and fibrotic connective tissue.     

主肝静脉和肝短静脉的解剖学研究及其临床意义

目的:探讨主肝静脉和肝短静脉（SHVs）的数量、位置、分型、口径等参数。方法:取60具成人尸体标本, 测量肝左、中、右静脉的肝外长度、注入下腔静脉（IVC）管径;按其SHVs汇入下腔静脉左侧壁、前壁和右侧壁分为左、中、右3排，测量SHVs的数量、位置、口径及其与主肝静脉的关系。结果:肝左、中、右静脉开口于IVC肝后段上l/4段，其中肝左、中静脉共干者73.3%（44例），肝左、中、右静脉共开口者1.7%（1例），3支分别汇入者25.0%（15例），SHVs直径为1.5～17.8（5.4±1.4）mm,3～35支SHV从不同方向和节段注入下腔静脉。肝右静脉直径与SHVs直径呈负相关（r=-0.34，P＜0.05);肝左静脉直径与SHVs数目呈负相关（r=0.24， P＜0.05)。肝右后下静脉（IRHV）出现率为83.3%，平均直径为2.6～8.0（4.3±1.2）mm。结论:SHVs变异较大，管径粗者数量少。SHVs的口径、数目与主肝静脉口径、数目呈相互消长。肝右静脉直径愈大，SHVs直径愈小;反之SHVs直径愈大。肝左静脉直径愈大，SHVs数量愈少;反之SHVs数量愈多。     

下腔静脉与肝静脉的外科应用解剖

在３２例成人尸体上进行腔静脉与肝静脉的应用解剖学的研究，观测了右肾上腺静脉、左膈下静脉、主肝静脉的长度、横径、注入角度和部位及主肝静脉的汇合类型和下腔静脉各段长度。结果表明，术中阻断肝上膈下下腔静脉，有８４．４％的人可经腹部切口完成，另１５．６％者可能需开胸在心包内阻断下腔静脉，下腔静脉下阻断，有８７．５％可在网膜孔后分离阻断，１２．５％需行下腔静脉肝后段分离阻断。在游离肝右叶时，需注意可能出现的     

Superior approach for the exclusion of hepatic veins in major liver resection: A safe and easy technique

We describe a technique for isolating and excluding the hepatic veins during liver resection. First, the bare area near the right and left wall of the suprahepatic inferior vena cava (IVC) is dissected, exposing the right, left, and superior walls of the right hepatic vein (RHV) and the left-middle hepatic vein (LMHV). Two Satinsky clamps are used to clamp the roots of the right and common trunk of the LMHV, parallel to the IVC. It is not necessary to dissect the posterior wall of the hepatic veins. We used this method during major liver resection in 65 patients. The mean dissecting time of each hepatic vein was 7.31 ± 3.6 min. No hepatic vein was lacerated during dissection and exclusion. The postoperative complication rate was 31.2%. Thus, the superior approach is a safe and easy maneuver when the posterior wall of the hepatic vein is difficult to dissect due to tumor invasion. Li Aijun and Pan Zeya contributed equally to this work.     

A suitable animal model for laparoscopic hepatic resection training

Background There is a growing interest in using laparoscopy for hepatic resection. However, structured training is lacking in part because of the lack of an ideal animal training model. We sought to identify an animal model whose liver anatomy significantly resembled that of the human liver and to assess the feasibility of learning laparoscopic hepatic inflow and outflow dissection and parenchyma transection on this model. Methods The inflow and outflow structures of the sheep liver were demonstrated via surgical dissection and contrast studies. Laparoscopic left major hepatic resections were performed. Results The portal hepatis of all 12 sheep (8 for anatomic study and 4 for laparoscopic hepatic resection) resembled that of human livers. The portal vein (PV) was located posteriorly; the common hepatic artery (CHA) and the common bile duct (CBD) were located anterior medially and anterior laterally with respect to the portal hepatis. The main PV bifurcated into a short right and a long left PV. The extrahepatic right PV then bifurcated into right posterior and anterior sectoral PV. The CBD and CHA bifurcated into left and right systems. The cystic duct originated from the right hepatic duct. The cystic artery originated from the right HA in 11/12 animals. The left hepatic vein drained directly into the inferior vena cava (IVC). The middle and the right hepatic veins formed a short common channel before entering the IVC. Multiple venous tributaries drained directly into IVC. Familiarity with sheep liver anatomy allowed laparoscopic left hepatic lobe (left medial and lateral segments) resection to be performed with accuracy and preservation of the middle hepatic vein. Conclusions The surgical anatomy of sheep liver resembled that of human liver. Laparoscopic major hepatic resection can be performed with accuracy using this information. Sheep is therefore an ideal animal model for advanced surgical training in laparoscopic hepatic resection.     

Surgical resection combined with chemotherapy for advanced hepatocellular carcinoma with tumor thrombus: report of 19 cases

BACKGROUND: Prognosis of hepatocellular carcinoma (HCC) with tumor thrombus in the main portal vein (MPV), inferior vena cava (IVC), or extrahepatic bile duct (EBD) treated by conventional therapies has been considered poor. This study aimed to evaluate the efficacy of hepatic arterial infusion chemotherapy after surgical resection as an adjuvant therapy or as a treatment for intrahepatic recurrence of HCC with tumor thrombus in MPV, IVC, or EBD. METHODS: Nineteen patients with HCC and tumor thrombus in the MPV, IVC, or EBD who underwent hepatectomy with thrombectomy were reviewed retrospectively. RESULTS: The overall 3-year survival rate was 48.5%. Two patients with postoperative residual tumor thrombus died within 6 months owing to rapid progression of the residual tumor thrombus. Five patients survived more than 5 years after their operations. Tumors disappeared completely in 3 patients after hepatic arterial infusion chemotherapy with a combination of cisplatinum and 5-fluorouracil, and the longest survival period was 17 years and 11 months in a patient with EBD thrombus. CONCLUSIONS: If hepatic reserve is satisfactory, an aggressive surgical approach combined with chemotherapy seems to be of benefit for patients having HCC with tumor thrombus in the MPV, IVC, or EBD.     

Budd-Chiari syndrome treated by Senning's procedure

Two patients with Budd-Chiari syndrome who underwent a new surgical procedure developed by Senning are reported. A 33-year-old man was diagnosed as having Budd-Chiari syndrome with a membranous obstruction of the inferior vena cava (IVC) and right hepatic vein and short segmental obstruction of the left hepatic vein. Removal of the obstruction by dorsocranial resection of the liver and reconstruction of the veins by hepatoatrial anastomosis was carried out. In a 53-year-old female, the same procedure was carried out for a short segmental obstruction of the IVC and left hepatic vein. In both patients, postoperative examination revealed good patency of the IVC and the hepatic veins and increased portal venous flow as measured by Doppler-echography. This procedure is considered the method of choice for Budd-Chiari syndrome with membranous and/or short segmental obstruction of the IVC and hepatic veins.     

A rare case of complex vascular reconstruction in liver transplantation.

Abnormalities of recipient or donor vascular structures are associated with reconstructive difficulties in liver transplantation. A patient with thrombosis of the right hepatic vein and associated stricture of the inferior vena cava (IVC), portal vein thrombosis and multiple aberrant arteries underwent orthotopic liver transplantation. The donor's suprahepatic IVC was anastomosed to the recipient's intrathoracic IVC. The portal vein flow was restored by venous graft interposition, while the arterial flow was ensured by interposing an iliac arterial graft anastomosed to the infrarenal aorta. In conclusion, graft function remains excellent more than 5 years postoperatively.