Posterior Hepatectomy and Inferior Vena Cava Graft Reconstruction for En Bloc Resection of a Hepatocellular Carcinoma: A Tribute to Couinaud's Liver Anatomy Description.

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Hepatocellular carcinoma (HCC) associated with major vasculature tumor extension is considered an advanced stage of disease to which palliative radiotherapy or chemotherapy is proposed.1,2 Surgical resection associated with chemotherapy or chemoembolization could be an opportunity to improve overall survival and recurrence-free survival in selected cases in a high-volume hepatobiliary center.3,4 Moreover, it has been 25 years since Couinaud described the entity of a posterior liver located behind an axial plane crossing the portal bifurcation.5 The aim of this video was to show how to reproduce such a resection technique. We report the case of a 72-year-old male presenting with a 6cm HCC developed in a well-compensated Child-Pugh A alcohol-related cirrhosis and localized in the dorsal liver sector. The tumor invaded the retrohepatic inferior vena cava (IVC) as well as segment 2 and the right posterior section glissonean pedicles. The initial management of the patient was performed outside of a reference center for hepatobiliary surgery and the tumor was initially considered unresectable. Transarterial chemoembolization was judged ineffective due to the size and location of the tumor. Initial treatment included 6 months of atezolizumab-bevacizumab, permitting tumor volume stability and enabling surgical resection. The procedure included an enbloc posterior hepatectomy (H1267)6 with IVC resection and polytetrafluoroethylene (PTFE) graft replacement. A well-tolerated intermittent pedicle and IVC clamping of 30min in total was used. The duration of surgery was 240min, with 30min of total vascular liver exclusion, and total blood loss was 650mL. The patient was discharged on postoperative day 8. R0 resection was achieved and the patient was free of disease at 1year post-surgery. To our knowledge, this video reports the first posterior hepatectomy performed in clinical practice and demonstrates liver anatomy as described by Couinaud in 1999.5 Moreover, complex vascular resections for HCC should be considered a valid therapeutic option in selected cases and high-volume hepatobiliary centers.