Vascular Control during Hepatectomy: Review of Methods and Results |
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Authors: | Vassilios Smyrniotis MD PhD Charalampos Farantos MD Georgia Kostopanagiotou MD PhD Nikolaos Arkadopoulos MD PhD |
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Institution: | (1) Second Department of Surgery, Athens University Medical School, Aretaieion Hospital, 76 Vassilisis Sofias Avenue, Athens, 11528, Greece;(2) Second Department of Anesthesiology, Athens University Medical School, Attikon General University Hospital, Rimini 1 Street, Haidari, Athens, 12462, Greece;(3) Vassilios Smyrniotis, 22 Hanioti Street, Athens, 15452, Greece |
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Abstract: | The various techniques of hepatic vascular control are presented, focusing on the indications and drawbacks of each. Retrospective
and prospective clinical studies highlight aspects of the pathophysiology, indications, and morbidity of the various techniques
of hepatic vascular control. Newer perspectives on the field emerge from the introduction of ischemic preconditioning and
laparoscopic hepatectomy. A literature review based on computer searches in Index Medicus and PubMed focuses mainly on prospective
studies comparing techniques and large retrospective ones. All methods of hepatic vascular control can be applied with minimal
mortality by experienced surgeons and are effective for controlling bleeding. The Pringle maneuver is the oldest and simplest
of these methods and is still favored by many surgeons. Intermittent application of the Pringle maneuver and hemihepatic occlusion
or inflow occlusion with extraparenchymal control of major hepatic veins is particularly indicated for patients with abnormal
parenchyma. Total hepatic vascular exclusion is associated with considerable morbidity and hemodynamic intolerance in 10%
to 20% of patients. It is absolutely indicated only when extensive reconstruction of the inferior vena cava (IVC) is warranted.
Major hepatic veins/ and limited IVC reconstruction has been also achieved under inflow occlusion with extraparenchymal control
of major hepatic veins or even using the intermittent Pringle maneuver. Ischemic preconditioning is strongly recommended for
patients younger than 60 years and those with steatotic livers. Each hepatic vascular control technique has its place in liver
surgery, depending on tumor location, underlying liver disease, patient cardiovascular status, and, most important, the experience
of the surgical and anesthesia team. |
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