Ante-Situ Resection: A Novel approach to minimize vascular exclusion complications

Abstract

Background: Ex-vivo techniques provide excellent accessibility to hepatic tumours located around the inferior vena cava (IVC) that otherwise would be unresectable. These techniques usually require long-duration vascular exclusion or a veno-venous bypass. A novel technique in ante-situ resection to avoid the extracorporeal bypass using an in-vivo veno-venous bypass between the portal vein and the IVC with a cadaveric venous graft in a patient with IVC replacement is described. Methods: Recurrent colorectal liver metastases in a 27-year-old female with a previous right hepatic trisectionectomy. The lesion compromised the hepatocaval confluence and the only remaining hepatic vein. Results: A shunt between the infrahepatic IVC and the portal vein, using a bank-preserved cadaveric vein graft was performed, achieving a side-to-side porta-caval shunt. The IVC was replaced by a prosthetic graft. With the liver in an ante-situ position, cooled with ice and with the hypothermic preservation solution, the tumour resection was performed involving retrohepatic IVC and the confluence with the left hepatic vein. After resection and vascular reconstruction were completed (with a cadaveric bank preserved vein placed between the goretex graft and the remaining hepatic vein), the portal cannula was removed, and the portacaval shunt divided using staplers. Conclusion: With this novel technique we were able to avoid splanchnic congestion or a extracorporeal veno-venous bypass in an ante-situ liver resection.