Ante-situm resection: a novel approach to avoid extracorporeal circulation using a transient portacaval shunt

Abstract

Hepatic tumours located at the hepatocaval confluence or compromising the inferior vena cava (IVC) are not often resectable using conventional techniques. To overcome this problem, different surgical procedures have been described. Ex-vivo resection techniques provide excellent accessibility to tumours placed around the IVC that otherwise would be unresectable. These ex-vivo techniques include in-situ, ante-situm and ex-situ resections. The in-situ technique performs hypothermic perfusion of the liver, with cross-clamping but without sectioning of the vena cava and the hepatic pedicle. The ante-situm approach also includes hypothermic perfusion, with cross-clamping of the major vessels and division of the suprahepatic IVC for complete exposure of the liver, preserving the hepatic artery and biliary tree. And finally, the ex-situ technique requires cross-clamping and division of the major vessels for complete removal of the liver, allowing a bench procedure before re-implantation of the organ. The two main problems regarding ex-vivo procedures are the low hepatic tolerance to warm ischaemia and the splanchnic congestion secondary to vascular exclusion. Hypothermic hepatic perfusion and veno-venous bypasses, frequently used in classic ex-vivo resections, are two well-known strategies to avoid these complications. This report describes a novel technique of ante-situm resection 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. Case