Extended left trisegmentectomy combined with the three main hepatic veins ligation and inferior vena cava (IVC) resection for intrahepatic cholangiocarcinoma (ICC)

Abstract

Purpose: ICC represents 10-15 % of all malignant hepatic neoplasms. Tumours infiltrating confluence of hepatic veins and IVC are often considered inoperable, especially in elderly patients, since maintainance or reconstruction of venous outflow would require ante situm resection or total vascular exclusion (TVE). Methods: We present the case of a 75 yo woman with history of pulmonary embolism in chronic oral anticoagulant treatment, incidentally diagnosticated with a hepatic mass infiltrating the confluence of hepatic veins and IVC. An extended left trisegmentectomy was performed, with ligation of the three main hepatic veins and IVC resection. Venous outflow of the remnant was guaranteed by preservation of the right inferior hepatic vein (RIHV). Results: Two units of packed red blood cells were transfused. Post operative course was complicated with grade A liver failure. Patient was discharged in 8 pod with normal liver function tests. Diagnosis of biliary type adenocarcinoma pT2N0M0 G2 was made after histological examination. Conclusion: RIHV draining the posteroinferior area of the right liver is described in 17-20 % of population. In 1987, Makuuchi proposed theoretically four types of hepatectomy with resection of the main right hepatic vein (RHV) and preservation of the RIHV. In 1991, Blumgart performed first the procedure, calling this new operation subtotal hepatectomy. Only 9 cases have been described in literature ever since. In 3 of these cases the IVC was also infiltrated. In 3 cases, the surgical procedure was preceded by left portal vein and/or RHV embolization to obtain liver remnant hypertrophy. In 2 cases the operation was performed in 2 steps (ALLPS). In our case, we combined the anterior approach with a modified Hanging Manouver to suspend and resect the liver cranially to the RIHV outlet, then proceeding with ligation of the three main hepatic veins and IVC resection on a tangential clamping. In this way it was possible to perform surgery without total vascular exclusion (TVE). This approach was well tolerated hemodynamically and more feasible than ante situm resection or TVE. Critical aspects remain the section line irregularity and the hepatic congestion due to the venous outflow block which causes more venous bleeding during the parenchymal transection. Another aspect of the procedure is the evaluation of the liver remnant congestion, which in our case was excluded by a clamp test of the posterior hepatic artery and of the RHV stump.