Surgical strategy and venous vascular control during central hepatectomy

Abstract

Purpose: Central hepatectomy (CH) is a technically demanding procedure normally performed in high-volume hepatobiliary surgery centres. The rationale for this technique is to avoid extensive right or left resection leaving insufficient future liver remnant volume (FLR),but ensuring, however, oncological resections with clear surgical margins. CH remains an under-used technique due to its complexity. In presence of large tumours venous vascular control, when needed, may be demanding.The aim of this surgical descriptive study is to present a safe surgical strategy for the treatment of large central neoplasms for which venous vascular control is difficult. Methods: We propose a surgical strategy to reduce intraoperative and postoperative complications. It consists in obtaining a progressive control of suprahepatic veins, in a counterclockwise fashion. Hepatic transection starting from the left (left border of the segment 4) to arrive on the terminal part of the middle hepatic vein. After his section, the transection line and the future specimen are pulled on the right in order to allow an easier controle of the temrinal part of the right hepatic vein. Finally, the right part of the transection line begins from the bottom upward, following the right hepatic vein. Results: We used this strategy in 10 patients with large central hepatic neoplasms with compression, but without infiltration, of the right suprahepatic vein, and associated to a difficult right vein controle before transection. This approach was not associated to any intra- or post-operative complications (bleeding, bile duct leakage,post operative liver failure, post operative haemorrhages). Conclusion: Central hepatectomy is a complexc surgical procedure that maybe associated to intraoperative venous hemorrage, especially in case of large tumours. The surgical strategy allows a safer control of the hepatic veins in difficult situations where total vascular liver exclusion is not possible for hemodynamic reasons.