Abstract
This article reviews the historical evolution of hepatic vascular clamping and their indications. The anatomic basis for partial and complete vascular clamping will be discussed, as will the rationales of continuous and intermittent vascular clamping.Specific techniques discussed and described include inflow clamping (Pringle maneuver, extra-hepatic selective clamping and intraglissonian clamping) and outflow clamping (total vascular exclusion, hepatic vascular exclusion with preservation of caval flow). The fundamental role of a low Central Venous Pressure during open and laparoscopic hepatectomy is described, as is the difference in their intra-operative measurements. The biological basis for ischemic preconditioning will be elucidated. Although the potential dangers of vascular clamping and the development of modern coagulation devices question the need for systemic clamping; the pre-operative factors and unforseen intra-operative events that mandate the use of hepatic vascular clamping will be highlighted.
Highlights
Efforts to reduce or eliminate operative bleeding, have been the primary focus throughout the history of liver surgery
When the hepatectomy includes the resection of segment 1, the latter is completely separated from the inferior vena cava (IVC) by division of all of its venous branches until the liver is connected to the IVC by the three major hepatic veins only
A central venous pressure (CVP) of less than 5 mmHg is recommended for all open liver resections without caval clamping [16]
Summary
Efforts to reduce or eliminate operative bleeding, have been the primary focus throughout the history of liver surgery. Left partial HVEPC excludes the left liver (segments 2 to 4) and part of the right anterior sector (segments 5 and 8); it involves clamping the porta hepatis (and not the left portal pedicle), the left hepatic artery if present, and the left and middle hepatic veins. When the hepatectomy includes the resection of segment 1, the latter is completely separated from the IVC by division of all of its venous branches until the liver is connected to the IVC by the three major hepatic veins only. If only the hepatic veins and IVC are involved, the portal structures can be left intact (though clamped) and the vena cava divided above and below the tumor, allowing the liver to be rotated up to the surface of the operative field. Ringer-glucose solution in this setting has been associated with encouraging results, further research is warranted to determine the best perfusion solution under these conditions
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