Management of Retrohepatic Inferior Vena Cava Injury during Hepatectomy for Neoplasms

The aim of this article is to discuss the management of retrohepatic inferior vena cava injury during hepatectomy for neoplasms. Step-by-step hepatic vascular exclusion, digital compression, finger pinching, and surface-to-surface suturing were used in the management of retrohepatic inferior vena cava injury during hepatic resection in 16 cases: 12 patients underwent exclusion of the hepatic artery and portal vein by portal triad clamping (PTC) only; 3 underwent PTC and exclusion of the infrahepatic inferior vena cava (IVC); and 1 underwent PTC together with exclusion of the suprahepatic and infrahepatic IVC. In all cases, bleeding stopped immediately after the management described, with no intraoperative deaths and no postoperative bleeding. The median follow-up was 42.5 months (range 19–60 months) for all patients, and the 5-year survival rate of all patients with malignant tumors was 28.57%. One died of lung metastasis 19 months after operation, one with spontaneous rupture of a hepatocellular carcinoma 19 months after operation, and eight others from recurrence or metastasis 21, 23, 24, 27, 30, 35, 50, or 54 months after operation, respectively. Two patients had a recurrence 4 years and 4 years 6 months after the initial operation, respectively. The recurrent tumors of the liver were resected. The other patients are currently alive without recurrence or metastasis. The techniques described are safe, simple, practical, time-saving, and effective for controlling massive bleeding arising from injury to the retrohepatic inferior vena cava during hepatic resection.     

Liver resection under total vascular isolation. Variations on a theme.

Total vascular isolation (TVI) of the liver was employed during parenchymal transection in 16 patients undergoing hepatic resection for large tumors (mean diameter, 10.7 cm) located near hilar structures, hepatic veins, or the inferior vena cava (IVC). In 14 cases, TVI was achieved by clamping the suprahepatic and infrahepatic IVC and the porta hepatis, with or without aortic occlusion; in two, selective hepatic vein clamping was possible, obviating IVC occlusion. Procedures included standard and extended right and left lobectomies and caudate lobe resections. Concomitant resection and reconstruction of the portal vein (one case), IVC (one case), and bile duct (three cases) was required. Postoperative hepatic and renal failure did not occur. Mean intensive care unit and hospital stays were 2.8 +/- 1.9 and 12.5 +/- 5.2 days, respectively. There were two perioperative deaths. Total vascular isolation permits safe resection of large, critically located tumors that would otherwise present prohibitive operative risks.     

Hepatobiliary resection with inferior vena cava resection and reconstruction using an autologous patch graft for intrahepatic cholangiocarcinoma

Background In patients with advanced cholangiocarcinoma involving the inferior vena cava (IVC), an extended hepatobiliary resection with combined resection and reconstruction of the IVC is often prerequisite to obtain a clear resection margin. Materials and methods We present our approach to repair of approximately half of a cross-sectional wall defect of the IVC using an autologous external iliac venous patch graft during extended hepatobiliary resection with a total hepatic vascular exclusion technique. The harvested external iliac vein graft was incised longitudinally and trimmed to fit the IVC defect. After multiple stay sutures, a continuous running suture using 4–0 prolene was made. Results Two patients who underwent this complex surgery survive 20 and 27 months after surgery, respectively. Morbidity of transient edema of the ipsilateral lower leg potentially related to graft harvesting was noted in one patient after surgery. Conclusions The external iliac vein patch graft for IVC resection and reconstruction during hepatobiliary resection is technically simple, produces no stenosis or caliber change in the reconstructed IVC, and is applicable for at least half or less of a cross-sectional defect of the IVC wall to be reconstructed.     

Technical solutions for venous outflow reconstruction in damaged liver grafts during procurement: case reports

The incidence and clinical consequences of hepatic injuries (parenchymal, vascular, and biliary) due to surgical handling during multiorgan procurement are still underestimated. Surgical damage to liver grafts may lead to an increased mortality and graft dysfunction rate; therefore, multiorgan procurements require a high level of expertise and training. We report our experience in two cases of accidental venous outflow damage during liver procurement focusing on our repair strategies. In one case, a short suprahepatic inferior vena cava (IVC) was extended by a venous cuff obtained from a long infrahepatic IVC from the same liver graft. In the second case, we observed a complete transection of the middle hepatic vein during in situ splitting procedure. The damage was reconstructed by cadaveric iliac vein interposition. In both cases, liver transplantation was successfully performed without venous complication. An adequate surgical technique in liver procurement and venous reconstruction during living donor and domino liver transplantation are formidable tools to achieve successful liver transplantation with a damaged graft.     

Ex vivo and in situ resection of inferior vena cava with hepatectomy for colorectal metastases

OBJECTIVE: To describe the surgical techniques and early results of inferior vena cava (IVC) resection in patients with advanced liver tumors. SUMMARY BACKGROUND DATA: Involvement of the IVC by hepatic tumors, although rare, is considered inoperable by standard resection techniques. Concomitant hepatic and IVC resection is required to achieve adequate tumor clearance. METHODS: Between February 1995 and February 1999, 158 patients underwent hepatic resection for colorectal metastases in the authors' unit. Eight patients, aged 42 to 80 years (mean 62 years), with hepatic metastases from colorectal cancer underwent concomitant resection of the IVC and four to six hepatic segments. Resections were carried out under total hepatic vascular exclusion in four patients and ex vivo in four patients. Between 30 degrees and 360 degrees of the retrohepatic IVC was resected and replaced with an autogenous vein patch (n = 1), a ringed Gore-Tex tube graft (n = 2), a Dacron tube graft (n = 1), or a patch (n = 3) or was repaired by primary suturing (n = 1). RESULTS: There were two early deaths from multiple organ failure. One patient survived 30 months after ex vivo resection but died of renal cell carcinoma, and another died with recurrent disease at 9 months. The remaining four patients remained alive 5 to 12 months after surgery, with no hepatic failure or venous obstruction; tumor recurrence was present in two. Nonthrombotic occlusion of the neocava occurred in one patient and was stented successfully. CONCLUSIONS: Although concomitant hepatic and IVC resection is associated with a considerable surgical risk, this aggressive surgical approach offers hope for patients with hepatic tumors involving the IVC, who would otherwise have a dismal prognosis. This procedure can be performed under total hepatic vascular exclusion, with or without venovenous bypass, and by ex vivo bench resection.     

合并下腔静脉癌栓原发性肝癌的手术治疗及其价值

目的探讨合并下腔静脉癌栓原发性肝癌的手术治疗方法及其价值。方法自2000年11月～2004年12月我科采用全肝血流阻断技术,实施10例肝癌及下腔静脉、肝静脉内癌栓切除手术。其中肝血流阻断手术方法包括有：1、Pringle’s手法＋肝上下腔静脉侧壁肝静脉阻断（2例）;2．Pringle’s手法＋肝上肝下下腔静脉联合阻断（7例）;3．Pringle’s手法＋经膈下胸纵隔内下腔静脉阻断＋肝下IVC阻断（1例）。并对其疗效进行观察。结果10例手术均获成功。9例患者术后半年内复发,1例至今术后3月未见复发。全组病人中位生存期6个月。结论采用全肝血流阻断技术下,实施肝癌及下腔静脉、肝静脉内癌栓切除手术,技术安全可行,然而如何加强防止手术后复发是将来研究重点。     

Caudate lobectomy combined with resection of the inferior vena cava and its reconstruction by a pericardial autograft patch

A 53-year-old woman with remnant liver metastasis originating from colon cancer was referred to our department. She underwent successful caudate lobectomy combined with resection of the inferior vena cava (IVC), including reconstruction with a pericardial autograft patch. IVC clamping was performed between the IVC below the confluence of the left hepatic vein and the infrahepatic IVC in order to preserve the hepatic circulation. After 18 months, the graft was patent and there was no sign of recurrence. A part of the pericardium used as an autograft for patch repair of the defect of the IVC was very useful because it was easily available, required only division of the diaphragm, and was of sufficient length and width.     

The use of hypothermia and circulatory arrest to control intraoperative bleeding from the inferior vena cava

Bleeding from the suprahepatic inferior vena cava (IVC) was encountered in a patient undergoing repeat liver resection for the fourth time due to a recurrence of colorectal liver metastases. Bleeding was observed from an IVC tear above the liver and it was not possible to control it with traditional clamping procedures including total vascular exclusion (a suprahepatic clamp). Hypothermia, cardioplegia, and circulatory arrest were all required to control the bleeding. The inferior vena cava was reconstructed with a pericardial patch. The patient recovered well and was discharged on the 14th postoperative day.     

Combined hepatic resection with the inferior vena cava and diaphragm and reconstruction using an equine pericardial patch: Report of a case

We herein report a case of combined hepatic resection with inferior vena cava (IVC) and diaphragm resection, and reconstruction using an equine pericardial patch. A 54-year-old woman showed hepatic cancer recurrence on radiological imaging, with invasion to the caudate lobe of the liver, IVC, diaphragm, and adrenal gland. We resected 10 × 5 cm of the diaphragm. After dissecting the hepatic parenchyma, the caudate lobe was connected only to the IVC. Clamping of the IVC was performed between the IVC below the confluence of the hepatic vein and the suprarenal IVC. A 6 × 3-cm segment of the IVC was then resected. The IVC and diaphragm were reconstructed using an equine pericardial patch, as both defects were too large to repair without a patch. The equine pericardium represents a suitable graft material for repairing both the IVC and diaphragm. Further investigation is needed to determine the durability and anti-infection properties of equine pericardial grafts.     

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.     

下腔静脉及肝静脉短段病变型布-加氏综合征的外科治疗

目的 探讨布-加氏综合征的下腔静脉短段闭塞及肝静脉主干病变根治性切除的优缺点、术中的注意事项。方法 下腔静脉闭塞或狭窄段切除、人工血管原位移植术42例,肝静脉主干闭塞段切除、肝静脉流出道成形、人工血管原位移植术10例,肝静脉主干闭塞段切除、肝静脉-右心房吻合3例,经皮肝穿肝或副肝静脉破膜、扩张10例。结果 1例死于并发症,随访58例,平均30个月,介入复发3例,手术复发1例。结论 下腔静脉或肝静脉病变段切除、人工血管原位移植治疗布-加氏综合征,能根治病变、符合正常解剖生理、远期疗效好。     

Rat liver transplantation for total vascular reconstruction, using a suture method

We developed a novel protocol for rat orthotopic liver transplantation (OLT), using a suture method to establish hepatic artery flow. After determining that early inferior vena cava (IVC) unclamping maintained better circulation compared with the portal vein (PV) using porto-systemic shunted recipients, we developed a rat OLT model with total vascular reconstruction using a suture method. After connecting the suprahepatic IVC, the infrahepatic IVC was anastomosed, using a running suture method. IVC circulation was established immediately. The PV was anastomosed without intestinal congestion, using porto-systemic shunted recipients. The aortic conduit, including the donor celiac and hepatic artery, was anastomosed to the recipient abdominal aorta end-to-side. Eight of 11 OLT cases (72.7%) survived indefinitely. Biliary connection was achieved using a one-stent method. Three cases died 3-5 days postoperatively. Hepatic angiography showed good patency. The graft liver was histologically normal in long-surviving rats.     

Continuing experience with liver resection and vena cava reconstruction using cardiopulmonary bypass and hypothermic circulatory arrest

When the suprahepatic vena cava or the hepatic vein confluence with the inferior vena cava (IVC) is obscured by tumor or a clot in the IVC extends above the liver, cross-clamping the IVC during liver or retroperitoneal resection is hazardous. This report describes a 10-year experience with ten patients who had liver (seven) or retroperitoneal (three) resections with vena cava reconstruction using cardiopulmonary bypass and hypothermic circulatory arrest. There were no perioperative deaths. Morbidity consisted of prolonged bile leak (one), pulmonary embolism (one), and stroke (one). Control of the liver was secured in six of seven patients who had a liver resection. There were three significant advantages to this technique. First, the median sternotomy provided superior exposure to the suprahepatic IVC. Second, the bypass technique avoided the risks of hemodynamic instability and prevented air embolism and sudden uncontrolled hemorrhage incurred by resection or IVC cross-clamping. Third, hypothermia provided a method of protection for residual liver function especially in the face of chronic liver disease induced by infection or chemotherapy.     

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.     

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.     

下腔静脉重建联合肝叶切除治疗肝癌的初步研究

目的 探讨在全肝血流控制下不采用静脉转流技术行下腔静脉重建的肝叶切除治疗侵犯下腔静脉的肝癌的临床经验和疗效。方法 自2004年8月至2005年7月，对3例胆管细胞性肝癌和2例肝细胞性肝癌合并下腔静脉直接侵犯而无癌栓患者，在全肝血流控制而无静脉转流技术下行解剖性肝叶切除联合下腔静脉重建术（局部切除修复2例、局部切除补片2例、人工血管移植1例）。结果 5例患者手术均成功。平均手术时间345（300～450）min，平均手术失血量1375（1200～1800）ml。累计平均肝门阻断时间、全肝血流阻断时间和下腔静脉阻断时间分别为19min、21．2min、56min。术后发生胸腔积液1例，胆漏1例，腹水1例，均治愈。患者平均住院时间15．5（11～19）d。随访4～15个月，1例术后9个月死于肿瘤复发，4例已存活4、8、10、15个月。结论 在全肝血流控制而无静脉转流技术下行下腔静脉重建联合解剖性肝叶切除治疗直接侵犯下腔静脉的肝癌不仅可安全施行，而且可延长患者生存时间。     

Diagnosis and Treatment of Inferior Vena Caval Invasion by Hepatic Cancer

Hepatectomy with concomitant resection of the inferior vena cava (IVC) has become common for hepatic malignancies involving the IVC. However, diagnosing IVC invasion and the procedure of choice have yet to be standardized. Medical records of nine patients with liver cancer (five metastatic tumors from colorectal cancer and four intrahepatic cholangiocarcinomas) believed to have directly invaded the IVC wall were retrospectively abstracted for data on preoperative radiologic studies, surgical procedures, histology of the resected specimen, and treatment outcome. All nine patients underwent hepatectomy: Five did not undergo IVC resection because the IVC could be isolated from the tumor; the remaining four underwent combined IVC resection (wedge and segmental resections in two each). The segmentally resected IVC was reconstructed using an external iliac vein graft. Total hepatic vascular exclusion, venovenous bypass, and the ex vivo technique were not used. Interestingly, the tumor was smaller and the percentage of the IVC circumference in contact with tumor as seen on computed tomography (CT) was less in patients with IVC invasion than in those without it (40 ± 11 vs. 134 ± 61 mm, p < 0.05; 30% ± 8% vs. 60% ± 20%, p < 0.05). The length of the IVC compressed by tumor on cavography was similar in the two patient groups (47 ± 9 vs. 55 ± 8 mm). All patients were discharged from the hospital in good condition: Seven died of cancer recurrence, and the remaining two are currently alive and disease-free 15 and 73 months after surgery, respectively. In conclusion, imaging modalities demonstrating caval deformation, such as CT and cavography, are unreliable for diagnosing direct invasion of the IVC wall. Even when IVC invasion is strongly suggested by conventional radiologic studies, the surgeon should endeavor to peel the tumor from the IVC. This strategy is important to avoid unnecessary resection of the IVC, use of a prosthetic graft, or ex vivo hepatectomy.     

Left Renal Vein Graft for Vascular Reconstruction in Abdominal Malignancy

Background Advanced abdominal malignancies are occasionally invasive for the major blood vessels, such as the portal vein (PV), inferior vena cava (IVC), and major hepatic veins (HVs), and complete removal of the tumors is required for patients undergoing vascular resection and reconstruction. We used left renal vein (LRV) grafts for vascular reconstruction in patients with these malignancies and evaluated their clinical relevance. Methods A total of 113 patients underwent vascular resection including the PV (42 patients), IVC (68 patients), and HV (3 patients) for hepatobiliary-pancreatic or abdominal tumor resection. Of these, 11 patients underwent vascular reconstruction with a LRV graft of the PV, superior mesenteric vein (SMV), and HVs in 3 patients each, and the IVC in 2 patients. The HVs were resected with segmentectomy involving Couinaud’s segments VII, VIII, and IV; VII, VIII, and II; or III, IV, VIII in each patient. The PV and SMV were resected in 5 patients undergoing pancreaticoduodenectomy for pancreatic carcinoma, and in 1 patient being treated with extended right hepatectomy and pancreaticoduodenectomy for hepatic hilar carcinoma. The IVC was partially resected in 1 patient with advanced colon cancer and 1 with malignant schwannoma. Results The mean graft length of LRV obtained was 3.6 (3.5–4.0) cm. The graft was used as a tube in 9 patients, and as a patch in 2 patients. The mean duration of clamping time was 41.9 (35–60) min. Portal vein thrombosis was encountered in 2 patients, and anastomotic stenosis in 1 patient. Other morbidity was not related to vascular reconstruction. One patient who underwent extended right hepatectomy and pancreaticoduodenectomy died of liver failure in the hospital. The serum creatinine level after surgery did not deteriorate except in the one patient who died in the hospital. Graft patency was maintained during the follow-up period in all patients. Conclusions A LRV graft may enhance the possibility of vascular reconstruction without deteriorating serum creatinine level, and it provides sound graft patency.     

Venous reconstruction of the inferior vena cava bifurcation for retroperitoneal rhabdomyosarcoma in a child. Case report

Retroperitoneal tumors, as well as traumatic lesions and occlusions of the bifurcation of the inferior vena cava (IVC) and the common iliac veins may require venous vascular reconstruction. We present a method for inferior vena caval bifurcation reconstruction which employs the advantages of a large size straight expanded polytetrafluorethylene (ePTFE) graft in this position after a new IVC bifurcation has been created by uniting the stumps of both common iliac veins, and construction of an arteriovenous (A-V) fistula with controlled flow to decrease the rethrombosis rate of the graft, and still not cause heart failure. This method was used in a case of recurrent rhabdomyosarcoma in an 8 year old child encroaching upon the bifurcation of the IVC as well as on both common iliac veins. The situation was managed by radical resection of the tumor and by creating a new caval bifurcation of the common iliac veins, followed by interposition of a straight ePTFE graft. An A-V fistula was created between the left femoral vein and left femoral artery using the left greater saphenous vein in controlled fashion. The arterial defect of the right common iliac artery was reconstructed by interposition of a PTFE graft end-to-end.     

Tissue-engineered patch for the reconstruction of inferior vena cava during living-donor liver transplantation

In living-donor liver transplantation, only a portion of the donor's liver is grafted into the recipient; therefore, if the hepatic vein and inferior vena cava (IVC) in the recipient fail to be transformed or dilated properly, it could cause inadequate blood flow from the liver graft to the IVC. We have developed an easy-to-use tissue engineered patch that can be used for the reconstruction of the hepatic vein and IVC. Five hybrid pigs (weighing 15-30 kg) served as the recipients of the patch. A bioabsorbable polymer sheet was used to produce the patch, with no cells seeded. The pigs were laparotomized, followed by the removal of a 3 x 2-cm portion of the infrahepatic IVC, which was then patched with the polymer sheet. Three months after the operation, the graft site was removed and subjected to gross and histologic examinations. All five pigs survived until they were killed 3 months after the operation. On gross examination, the polymer sheet grafted onto the IVC was completely absorbed, and the graft site was morphologically similar to the native IVC. In all five pigs, the patched IVC was free of stenosis or deformation. Immunohistochemical examination revealed that the patch site was lined with endothelial cells and that smooth muscle was present under the epithelium. Like the native IVC, the patch site tested positive for factor VIII. These findings suggest that this polymer sheet may be useful for the reconstruction of the IVC and hepatic vein during living-donor liver transplantation in humans.