Combined resection of the hepatic venous confluence following preoperative embolization of the right hepatic vein for liver tumor invading three hepatic veins

Abstract

Summary Primary or metastatic liver tumor invading the confluence of the three hepatic veins and inferior vena cava (IVC) is generally regarded as unresectable because the outflow of the future remnant liver cannot be maintained after resection. Refinement of surgical technique in liver resection and transplantation has enabled to safely perform reconstruction of the hepatic vein and IVC; however, the reconstruction procedure is complicated and still technically demanding. We have performed liver resection combined with resection of the right hepatic vein (RHV) following preoperative embolization of the right hepatic vein in the presence of a thin inferior hepatic vein (IRHV), to simplify the reconstruction of the hepatic venous confluence and IVC. The RHV is embolized with a vascular plug after confirming intrahepatic collateral vessels between the RHV and IRHV under balloon-occlusion of the RHV using interventional radiology technique about three weeks before surgery. First, the suprahepatic IVC and hepatic IVC just cranially to the confluence of the IRHV are taped. Second, extended left hepatectomy is done. Third, the invaded IVC and RHV are resected following the insertion of the atrio-venous shunting catheter. Finally, the IVC reconstructed using a ringed 20-mm polytetrafluoroethylene graft. Preoperative embolization of the RHV is useful to simplify the reconstruction of the hepatic venous confluence and IVC and may enhance the intrahepatic venous collateral to the IRHV in the future liver remnant.