Liver resection using total vascular exclusion

Abstract

Background: Total vascular exclusion (TVE) is a technique of liver resection that includes controlling both the suprahepatic and infrahepatic vena cava in addition to portal inflow at the time of parenchymal transection. We report a series of 61 liver resections in 60 patients using this technique. Methods: A retrospective review of 61 procedures in 60 patients using TVE between 1990 and 1997 was carried out. No patient had cirrhosis. Parameters analyzed included age, gender, diagnosis, procedure, operative time, clamp time, intraoperative transfusion requirements, postoperative laboratory studies, length of stay (intensive care unit, ward), mortality, and morbidity. Results: TVE was sustained hemodynamically in all patients. The mean age of the 34 men and 27 women was 56 years (± 15 years); 21% were older than 70 years. Eleven percent of the patients had benign lesions; 70% of the malignant tumors were metastatic. Seventy-five percent of the procedures were major or extended lobectomies. The mean operative and clamp times were 330 ± 83 and 39 ± 13.2 minutes, respectively; 68% had clamp times of <45 minutes. The mean intraoperative red blood cell units was 1.45 ± 1.93, with a range of 0 to 8 units; 48% required no transfusion and 80% received 2 units or less. There was 1 perioperative death for a mortality rate of 1.6%. The morbidity rate was 36%, which included 4 patients with postoperative liver dysfunction. Complications were not associated with transfusion but with clamp times exceeding 45 minutes. Liver dysfunction occurred with clamp times more than 60 minutes, particularly if the remaining liver parenchyma was histologically abnormal or the remnant was small. Conclusions: TVE is hemodynamically safe, even in patients older than 70 years. Blood loss during parenchymal transection is minimal; mortality and morbidity are low. The optimal clamp time is less than 45 minutes. Liver dysfunction is associated with clamp times exceeding 1 hour, particularly if the remaining parenchyma is abnormal or small. (Surgery 1998;124:807-15.)