Hepatic vascular occlusion during liver resection

Abstract

This article reviews the various techniques of vascular occlusion that can be applied to reduce blood loss during liver resection and liver transplantation as well as the level of current evidence in regard to their application. Hepatoduodenal ligament occlusion can be either continuous or intermittent. The impact on cardiac preload, cardiac index, systemic vascular resistance and splanchnic congestion is minimal. Hemihepatic or segmental vascular occlusion selectively interrupts inflow to the tumour bearing hemi-liver/segment, offers obvious demarcation of the resection limits, protects the remnant liver from ischaemia and avoids splanchnic congestion and haemodynamic consequences. Should backflow from the hepatic veins cause major blood loss during portal clamping or should the tumour infiltrate the IVC or caval-hepatic junction, total hepatic vascular exclusion (THVE) may be applied. THVE is associated with haemodynamic intolerance in 10–20% of patients and requires close haemodynamic monitoring and anesthetic expertise. Alternatively extraparenchymal hepatic vein occlusion allows THVE without interruption of the IVC flow. Infrahepatic inferior vena caval clamping may be used in order to reduce backflow bleeding during portal clamping is to reduce CVP with minor negative haemodynamic consequences. The future of pharmacological strategies lessening or preventing ischaemia/reperfusion injury lies in a combination of drugs acting on several steps of the ischaemia/reperfusion injury cascades. Separating the molecular basis and differences after ischaemia/reperfusion injury in normal and marginal organs will finally lead to strategies for preconditioning, and organ preservation.