Intrahepatic Vein Resection and Reconstruction with a Prosthethic Graft

Abstract

In the last decades the concept of liver surgery for the treatment of colorectal liver metastases (CLM) turned from “How much CLM can I resect?” to “How much liver parenchyma can I spare?”. In addition, the out-flow vascular preservation of the future liver remnant is crucial. Even if there are situations in which we can sacrifice 1, 2 or even 3 hepatic veins, there are others in which we cannot, or are not sure whether to do so. Hepatic vein resection and reconstruction with or without a vascular graft has already been reported. However, these procedures are usually performed near hepatocaval confluence. Here we present a technique to perform an intrahepatic deep segmental vein resection due to tumor infiltration, with a subsequent reconstruction with a vascular prosthesis. Regarding the technique itself, once vessel tumor infiltration has been established with IOUS, we then transect the liver parenchyma in depth with a 2 cm margin from tumor edge. After reaching the hepatic vein, we must encircle it proximally and distally respect of tumor infiltration site. Next, we perform a selected venous vascular exclusion using bulldog clamps. Once the in-block-tumor/vein has been resected, we suture a 6 mm PTFE vascular prosthesis to replace the vein. Continuous running suture is performed with 6.0 prolene. At the end of the procedure, “growth factor” maneuver is carried out to avoid vascular stenosis. Intraoperative antiaggregation with 100 mg aspirin is started through a nasogastric tube.