Intermittent Hepatic Inflow Occlusion Research Articles

Clinical application of regional and intermittent hepatic inflow occlusion in laparoscopic hepatectomy.

AimThe aim of this study is to investigate the advantages and disadvantages of regional and intermittent hepatic inflow occlusion in laparoscopic hepatectomy.MethodsThe clinical data of 180 patients who underwent laparoscopic liver surgery in Taizhou People’s Hospital from 2015 to 2021 were analyzed retrospectively. The patients were divided into the regional occlusion group (n = 74) and the Pringle’s maneuver occlusion group (n = 106) according to the technique used in the intraoperative hepatic inflow occlusion. The pre- and intra-operative indicators, postoperative recovery indicators, and complications of the two groups were compared.ResultsThere were no significant differences (p > 0.05) between the groups in terms of sex, age, preoperative alanine aminotransferase (ALT), preoperative aspartate aminotransferase (AST), preoperative albumin, alpha-fetoprotein, liver cirrhosis, hepatitis B, tumor location, gas embolism, intraoperative blood transfusion, postoperative albumin, postoperative total bilirubin (TBIL), postoperative hospital stays, and complications. The preoperative TBIL and operation time were higher in the regional occlusion group than in the Pringle’s maneuver occlusion group, while the amount of intraoperative bleeding, postoperative ALT, and AST in the regional occlusion group were significantly lower than those in the Pringle’s maneuver occlusion group (p < 0.05).ConclusionThe two occlusion techniques are equally safe and effective, but regional hepatic inflow occlusion is more advantageous in operation continuity, intraoperative bleeding, and postoperative liver function recovery. The long duration and high precision of the regional blood flow occlusion technique demands a more experienced physician with a higher level of operation; therefore, it can be performed by experienced laparoscopic liver surgeons.

The Effects of Intermittent Hepatic Inflow Occlusion Using the Pringle Maneuver During Hepatectomy

The Effects of Intermittent Hepatic Inflow Occlusion Using the Pringle Maneuver During Hepatectomy

Intermittent regional hepatic vascular inflow occlusion for laparoscopic right anterior sectionectomy

Objective To compare the efficacy and safety of intermittent regional hepatic vascular inflow occlusion with Pringle’s maneuvre for laparoscopic anterior sectionectomy. Methods From January 2014 to December 2018, 54 patients who underwent laparoscopic right anterior sectionectomy at the Department of Hepatopancreatobiliary Surgery, the Third Affiliated Hospital, Soochow University were recruited into this study. The patients were 40 to 60 years old, and 27 were males and 27 females. Intermittent regional hepatic vascular inflow occlusion was carried out in 24 patients (the intermittent occlusion group). The remaining patients underwent Pringle’s maneuvre (the Pringle group). Postoperative liver function, intraoperative blood loss, intraoperative blood transfusion, operation time and postoperative complications between the two groups were compared. Results Intraoperative hemorrhage and blood transfusion of the Pringle group (534±42)ml, (2.88±0.54)U were significantly higher than the intermittent occlusion group (374±21)ml, (1.86±0.29)U (all P 0.05). Conclusion Intermittent regional hepatic vascular inflow occlusion reduced intra-operative hemorrage and hepatic impairment, and shortened hospital stay. However, it required higher operation skills and it should gradually be promoted. Key words: Hepatectomy; Laparoscopes; Inflow occlusion; Liver function

Adhesiolysis for Liver Resection in a Patient with a Reconstructed Stomach Tube after Esophagectomy

To our knowledge this is the first report to provide a detailed description of surgical procedure for adhesiolysis and hepatectomy in patients who have undergone esophagectomy and reconstruction. We performed a hepatic resection of the left medial segment in a patient with a reconstructed stomach tube after esophagectomy for the esophageal carcinoma. The reconstructed stomach tube overlapped with the left medial segment of the liver and the hepatoduodenal ligament and was extensively and strongly adhered to them. It is important for clinicians to know how to perform the detachment procedure successfully in order to secure a surgical field for liver resection without damaging the fragile reconstructed gastric tube. In order to avoid vascular injury of the stomach tube, it was decided that detachment around the hepatoduodenal ligament preceded detachment of the stomach tube from the liver. After complete separation of the hepatoduodenal ligament from the stomach tube, the hepatoduodenal ligament was encircled with tape. Subsequently, adhesiolysis was performed between the stomach tube and the liver. Finally, parenchymal transection was performed using the intermittent hepatic inflow occlusion and crush clamping techniques to dissect the parenchyma. The patient was discharged two weeks after surgery without complication.

Hepatic resection using ultrasonic surgical aspirator

Abstract Background Hepatic resections conducted for malignant tumors can be difficult because of the need to create cancer-free margins. Objectives To examine the outcome of hepatic resections after the introduction of a Cavitron Ultrasonic Surgical Aspirator (CUSA). Methods A retrospective study of patients who underwent hepatic resection by a single surgeon between April 1999 to March 2013. Results We included 101 patients with 104 hepatectomies. Most hepatic parenchymal transections were performed using a CUSA under intermittent hepatic inflow occlusion (Pringle maneuver). Thirty-five patients underwent a right hepatectomy, 11 a left hepatectomy, 6 a right hepatectomy and segment I resection, 6 a right lobectomy, and 46 underwent segmentectomies, wedge resections, or other types of hepatic resections. Biliary-enteric reconstruction with a Roux-en-Y limb of the jejunum to a hepatic duct of the hepatic remnant was performed in 28 patients. Operative time was 90–720 min (median 300 min, mean 327 ± 149 min). Operative blood transfusion was 0–17 units (median 3 units, mean 3.9 ± 3.6 units). Twenty-one hepatectomies were conducted without blood transfusion. Thirty-four postoperative complications occurred in 30 patients with a 9% reoperation rate. Perioperative mortality was 6%. Age, operative time, operative blood transfusion, reoperation, and complications were significantly associated with mortality. Conclusion Careful preoperative diagnosis and evaluation of patients, faultless surgical techniques, and excellent postoperative care are important to avoid potentially serious postoperative complications and mortality. The CUSA is an effective assisting device during hepatic parenchymal transection with a concomitant Pringle maneuver, apparently reducing operative blood loss.

Association between Serum Bilirubin and Acute Intraoperative Hyperglycemia Induced by Prolonged Intermittent Hepatic Inflow Occlusion in Living Liver Donors.

BackgroundIntermittent hepatic inflow occlusion (IHIO) is associated with acute hyperglycemia during living donor hepatectomy when the ischemia is prolonged. Bilirubin is a potent antioxidant to play an important role for maintaining insulin sensitivity and preventing hyperglycemia. Thus, we aimed to test whether serum bilirubin level is associated with prolonged IHIO-induced intraoperative hyperglycemia.MethodsSeventy-five living liver donors who underwent a prolonged IHIO with a >30 minute cumulative ischemia were included. The association between preoperative serum bilirubin concentrations and the risk of intraoperative hyperglycemia (blood glucose concentration >180 mg/dl) was analyzed using binary logistic regression with adjusting for potential confounders including age and steatosis.ResultsThe number of donors who underwent 3, 4, 5, and 6 rounds of IHIO was 41, 22, 7, and 5, respectively. Twenty-nine (35%) donors developed intraoperative hyperglycemia. Total bilirubin concentration was inversely associated with hyperglycemia risk (odds ratio [OR] 0.033, 95% confidence interval [CI] 0.004–0.313, P = 0.003). There was an interaction between age and total bilirubin concentration: the effect of lower serum total bilirubin (≤0.7 mg/dl) on the development of hyperglycemia was greater in older donors (>40 years) than in younger donors (P = 0.0.028 versus P = 0.212). Both conjugated bilirubin (OR 0.001 95% CI 0.001–0.684) and unconjugated bilirubin (OR 0.011 95% CI 0.001–0.246) showed an independent association with hyperglycemia risk.ConclusionsLower preoperative serum bilirubin was associated with greater risk of prolonged IHIO-induced hyperglycemia during living donor hepatectomy particularly in older donors. Thus, more meticulous glycemic management is recommended when prolonged IHIO is necessary for surgical purposes in old living donors with lower serum bilirubin levels.

Glycemic responses to intermittent hepatic inflow occlusion in living liver donors.

The occurrence of glycemic disturbances has been described for patients undergoing intermittent hepatic inflow occlusion (IHIO) for tumor removal. However, the glycemic responses to IHIO in living liver donors are unknown. This study investigated the glycemic response to IHIO in these patients and examined the association between this procedure and the occurrence of hyperglycemia (blood glucose > 180 mg/dL). The data from 154 living donors were retrospectively reviewed. The decision to perform IHIO was made on the basis of the extent of bleeding that occurred during parenchymal dissection. One round of IHIO consisted of 15 minutes of clamping and 5 minutes of unclamping the hepatic artery and portal vein. Blood glucose concentrations were measured at predetermined time points, including the start and end of IHIO. Repeated hyperglycemic episodes occurred after unclamping. The mean maximum intraoperative blood glucose concentration was greater in donors who underwent ≥3 rounds of IHIO versus those who underwent 1 or 2 rounds (169 ± 30 versus 149 ± 31 mg/dL, P = 0.005). The incidence of intraoperative hyperglycemia was also greater in donors who underwent ≥3 rounds of IHIO versus those who underwent 1 or 2 rounds (38.7% versus 7.7%, odds ratio = 7.1, 95% confidence interval = 2.5-20.4, P < 0.001). Donors who did not undergo IHIO and those who underwent 1 or 2 rounds of IHIO exhibited similar maximum glucose concentrations and similar incidence rates of hyperglycemia. In conclusion, IHIO induced repeated hyperglycemic responses in living donors, and donors who underwent ≥3 rounds of IHIO were more likely to experience intraoperative hyperglycemia. These results provide additional information on the risks and benefits of IHIO in living donors.

Intraoperative hyperglycemia during liver resection: predictors and association with the extent of hepatocytes injury.

BackgroundPatients undergoing liver resection are at risk for intraoperative hyperglycemia and acute hyperglycemia is known to induce hepatocytes injury. Thus, we aimed to evaluate whether intraoperative hyperglycemia during liver resection is associated with the extent of hepatic injury.MethodsThis 1 year retrospective observation consecutively enrolled 85 patients undergoing liver resection for hepatocellular carcinoma. Blood glucose concentrations were measured at predetermined time points including every start/end of intermittent hepatic inflow occlusion (IHIO) via arterial blood analysis. Postoperative transaminase concentrations were used as surrogate parameters indicating the extent of surgery-related acute hepatocytes injury.ResultsThirty (35.5%) patients developed hyperglycemia (blood glucose > 180 mg/dl) during surgery. Prolonged (≥ 3 rounds) IHIO (odds ratio [OR] 7.34, P = 0.004) was determined as a risk factors for hyperglycemia as well as cirrhosis (OR 4.07, P = 0.022), lower prothrombin time (OR 0.01, P = 0.025), and greater total cholesterol level (OR 1.04, P = 0.003). Hyperglycemia was independently associated with perioperative increase in transaminase concentrations (aspartate transaminase, β 105.1, standard error 41.7, P = 0.014; alanine transaminase, β 81.6, standard error 38.1, P = 0.035). Of note, blood glucose > 160 or 140 mg/dl was not associated with postoperative transaminase concentrations.ConclusionsHyperglycemia during liver resection might be associated with the extent of hepatocytes injury. It would be rational to maintain blood glucose concentration < 180 mg/dl throughout the surgery in consideration of parenchymal disease, coagulation status, lipid profile, and the cumulative hepatic ischemia in patients undergoing liver resection for hepatocellular carcinoma.

Comparison of the tolerance of hepatic ischemia/reperfusion injury in living donors: Macrosteatosis versus microsteatosis

A safe use of intermittent hepatic inflow occlusion (IHIO) has been reported for living donor hepatectomy. However, it remains unclear whether the maneuver is safe in steatotic donors. In addition, the respective importance of macrosteatosis (MaS) and microsteatosis (MiS) is an important issue. Thus, we compared MiS and MaS with respect to the tolerance of hepatic ischemia/reperfusion (IR) injury induced by IHIO. One hundred forty-four donors who underwent a right hepatectomy were grouped according to the presence of MaS and MiS: a non-MaS group (n = 68) versus an MaS group (n = 76) and a non-MiS group (n = 51) versus an MiS group (n = 93). The coefficients of the regression lines between the cumulative IHIO time and the peak postoperative transaminase concentrations were used as surrogate parameters indicating the tolerance of hepatic IR injury. The coefficients were significantly greater for the MaS group versus the non-MaS group (4.12 ± 0.59 versus 2.22 ± 0.46 for alanine aminotransferase, P = 0.01). Conversely, the MiS and non-MiS groups were comparable. A subgroup analysis of donors who underwent IHIO for >30 minutes showed that MaS significantly increased the transaminase concentrations, whereas MiS had no impact. Also, IHIO for >30 minutes significantly increased the biliary complication rate for MaS donors (12.1% for ≤ 30 minutes versus 32.6% for >30 minutes, P = 0.04), whereas MiS donors were not affected. In conclusion, the tolerance of hepatic IR injury might differ between MaS livers and MiS livers. It would be rational to assign more clinical importance to MaS versus MiS. We further recommend limiting the cumulative IHIO time to 30 minutes or less for MaS donors undergoing right hepatectomy.

Liver transplantation: macrosteatosis and microsteatosis respond differently to intermittent hepatic inflow occlusion.

Liver transplantation: Macrosteatosis and microsteatosis respond differently to intermittent hepatic inflow occlusion

Effect of intermittent hepatic inflow occlusion with the Pringle maneuver during donor hepatectomy in adult living donor liver transplantation with right hemiliver grafts: A prospective, randomized controlled study

To evaluate the effects of intermittent hepatic inflow occlusion (IHIO) during donor hepatectomy for living donor liver transplantation (LDLT) in recipients and donors, we performed a single-center, open-label, prospective, parallel, randomized controlled study. Adult donor-recipient pairs undergoing LDLT with right hemiliver grafts were randomized into IHIO and control groups (1:1). In the IHIO group, IHIO was performed during donor hepatectomy. The primary endpoint was the peak serum alanine aminotransferase (ALT) concentration in the recipients within 5 days after the operation. Blood samples for measurements of interleukin-6 (IL-6), IL-8, tumor necrosis factor α (TNF-α), and hepatocyte growth factor (HGF) were taken from the donors and the recipients during the operation and postoperatively. Biopsy samples for measurements of caspase-3 and malondialdehyde (MDA) were taken from the donors and the recipients. In all, 50 donor-recipient pairs (ie, 25 pairs in each group) completed this study. The mean peak serum ALT levels within 5 days after the operation did not differ in the recipients between the 2 groups (P = 0.32) but were higher in the donors of the IHIO group (P = 0.002). There were no differences in the prothrombin times or total bilirubin levels in the recipients or donors between the 2 groups. The amount of blood loss during donor hepatectomy was significantly lower in the IHIO group versus the control group (P = 0.02). The mean hospital stay for donors was 19.3 ± 7.2 days in the control group and 15.8 ± 4.6 days in the IHIO group (P = 0.046). There were no in-hospital deaths within 1 month and no cases of primary nonfunction or initially poor function in the 2 groups. The concentrations of IL-6, IL-8, TNF-α, and HGF did not differ between the 2 groups, nor did the concentrations of caspase-3 and MDA. In conclusion, although we found differences in postoperative peak serum ALT levels in donors, donor hepatectomy with IHIO for LDLT using a right hemiliver graft with a graft-to-recipient body weight ratio > 0.9% and <30% steatosis can be a tolerable procedure for donors and recipients.

Liver Manipulation Causes Hepatocyte Injury and Precedes Systemic Inflammation in Patients Undergoing Liver Resection

BackgroundLiver failure following liver surgery is caused by an insufficient functioning remnant cell mass. This can be due to insufficient liver volume and can be aggravated by additional cell death during or after surgery. The aim of this study was to elucidate the causes of hepatocellular injury in patients undergoing liver resection.MethodsMarkers of hepatocyte injury (AST, GSTα, and L-FABP) and inflammation (IL-6) were measured in plasma of patients undergoing liver resection with and without intermittent inflow occlusion. To study the separate involvement of the intestines and the liver in systemic L-FABP release, arteriovenous concentration differences for L-FABP were measured.ResultsDuring liver manipulation, liver injury markers increased significantly. Arterial plasma levels and transhepatic and transintestinal concentration gradients of L-FABP indicated that this increase was exclusively due to hepatic and not due to intestinal release. Intermittent hepatic inflow occlusion, anesthesia, and liver transection did not further enhance arterial L-FABP and GSTα levels. Hepatocyte injury was followed by an inflammatory response.ConclusionsThis study shows that liver manipulation is a leading cause of hepatocyte injury during liver surgery. A potential causal relation between liver manipulation and systemic inflammation remains to be established; but since the inflammatory response is apparently initiated early during major abdominal surgery, interventions aimed at reducing postoperative inflammation and related complications should be started early during surgery or beforehand.

Partial hepatic resection under intermittent hepatic inflow occlusion in patients with chronic liver disease.

A partial hepatic resection was performed in 13 patients with chronic liver disease using intermittent hepatic inflow occlusion. Eleven patients had liver cirrhosis and two had chronic hepatitis. Seven patients were classified as Child's grade A and six as Child's grade B before operation. Dissection of the hepatic parenchyma was performed during intermittent inflow occlusion. The time of clamping and declamping was 10-20 min and 5-8 min, respectively. Postoperative data on liver function showed recovery to preoperative levels by about 10 days after operation. There were no life-threatening complications. These results indicate that intermittent hepatic inflow occlusion can be achieved easily and safely to allow non-anatomical resection in patients with chronic liver disease.

Mortality, endotoxaemia and cytokine expression after intermittent and continuous hepatic ischaemia

This study compared mortality rates, endotoxaemia, systemic tumour necrosis factor (TNF) and interleukin (IL)-6 concentrations after continuous and intermittent hepatic ischaemia. Two groups of rats were subjected to continuous or intermittent left hepatic inflow occlusion for a total period of 120 min in each group. Intermittent ischaemia was associated with significantly lower mortality rates than continuous ischaemia (four of 20 versus 15 of 20; P = 0.0015). In a separate study, again following 120 min continuous or intermittent ischaemia, systemic blood was sampled at 0 min, 1 h, 3 h and 5 h after final clamp release for measurement of endotoxin, TNF and IL-6 concentrations. Endotoxin concentrations were significantly lower at 1 h, as were TNF and IL-6 concentrations at 3 and 5 h, after final clamp release in the group having intermittent ischaemia (P < 0.05). Intermittent ischaemia is associated therefore with significantly reduced mortality rates and lower systemic endotoxin, TNF and IL-6 concentrations when compared with continuous ischaemia.

Safe upper limit of intermittent hepatic inflow occlusion for liver resection in cirrhotic rats.

To evaluate the effects of varying ischemic durations on cirrhotic liver and to determine the safe upper limit of repeated intermittent hepatic inflow occlusion. Hepatic ischemia in cirrhotic rats was induced by clamping the common pedicle of left and median lobes after non-ischemic lobes resection. The cirrhotic rats were divided into six groups according to the duration and form of vascular clamping: sham occlusion (SO), intermittent occlusion for 10 (IO-10), 15(IO-15), 20(IO-20) and 30(IO-30) minutes with 5 minutes of reflow and continuous occlusion for 60 minutes (CO-60). All animals received a total duration of 60 minutes of hepatic inflow occlusion. Liver viability was investigated in relation of hepatic adenylate energy charge (EC). Triphenyltetrazollum chloride (TTC) reduction activities were assayed to qualitatively evaluate the degree of irreversible hepatocellular injury. The biochemical and morphological changes were also assessed and a 7-day mortality was observed. At 60 minutes after reperfusion following a total of 60 minutes of hepatic inflow occlusion, EC values in IO-10 (0.749 +/- 0.012) and IO-15 (0.699 +/- 0.002) groups were rapidly restored to that in SO group (0.748 +/- 0.016), TTC reduction activities remained in high levels (0.144 +/- 0.002 mg/mg protein, 0.139 +/- 0.003 mg/mg protein and 0.121 +/- 0.003 mg/mg protein in SO, IO-10 and IO-15 groups, respectively). But in IO-20 and IO-30 groups, EC levels were partly restored (0.457 +/- 0.023 and 0.534 +/- 0.027) accompanying with a significantly decreased TTC reduction activities (0.070 +/- 0.005 mg/mg protein and 0.061 +/- 0.003 mg/mg protein). No recovery in EC values (0.228 +/- 0.004) and a progressive decrease in TTC reduction activities (0.033 +/- 0.002 mg/mg protein) were shown in CO-60 group. Although not significantly different, the activities of the serum aspartate aminotransferase (AST) on the third postoperative day (POD(3)) and POD(7) and of the serum alanine aminotransferase (ALT) on POD(3) in CO-60 group remained higher than that in intermittent occlusion groups. Moreover, a 60% animal mortality rate and more severe morphological alterations were also shown in CO-60 group. Hepatic inflow occlusion during 60 minutes for liver resection in cirrhotic rats resulted in less hepatocellular injury when occlusion was intermittent rather than continuous. Each period of 15 minutes was the safe upper limit of repeated intermittent vascular occlusion that the cirrhotic liver could tolerate without undergoing irreversible hepatocellular injury.

Safe upper limit of intermittent hepatic inflow occlusion for liver resection in cirrhotic rats

Safe upper limit of intermittent hepatic inflow occlusion for liver resection in cirrhotic rats

Safe upper limit of intermittent hepatic inflow occlusion for liver resection in cirrhotic rats

Safe upper limit of intermittent hepatic inflow occlusion for liver resection in cirrhotic rats

Prolonged continuous or intermittent vascular inflow occlusion during hemihepatectomy in pigs.

To assess ischemia and reperfusion (I/R) injury in a hemihepatectomy model in pigs after prolonged continuous or intermittent vascular inflow occlusion in the liver. Massive intraoperative blood loss during liver resections can be prevented by temporary vascular inflow occlusion, consequently leading to ischemia and reperfusion injury in the remnant liver. Previously, in a pig liver resection model in which only limited I/R injury was induced during brief (90 min) vascular inflow occlusion, the authors demonstrated reduced I/R injury after continuous (CNT) occlusion, compared to intermittent (INT). This liver resection study on pigs was undertaken to assess I/R injury after prolonged (120 min) CNT or INT occlusion. In pigs (37.0 +/- 1.5 kg), liver ischemia during 2 hours was CNT (n = 6) or INT (n = 6) (eight subsequent periods of 12 min ischemia and 3 min recirculation), followed by 6 hours of reperfusion. A left hemihepatectomy (45.5% +/- 1.4%) was performed within the first 12 minutes of ischemia. No hepatic pedicle clamping or liver resection was performed in control experiments (n = 6). Microvascular damage was assessed by hyaluronic acid (HA) uptake capacity of the liver (parameter of early sinusoidal endothelial cell damage) and restoration of intrahepatic tissue pO2 during reperfusion. Hepatocellular damage was tested by plasma concentrations of aspartate aminotransferase (AST), alanine aminotransferase, and lactate dehydrogenase (LDH). Hyaluronic acid uptake after 6 hours of reperfusion, compared to preischemic uptake, was unaltered in the control group, but was significantly reduced in both resection groups. However, more HA was taken up after INT occlusion, compared to CNT (60.4% +/- 5.6% and 39.5% +/- 3.7%, respectively; ANOVA: p = 0.001). Intrahepatic tissue pO2 distribution after 6 hours of reperfusion more closely returned to preischemic configuration in the INT group than in the CNT group, indicating reduced microcirculatory disturbances after INT occlusion. Release of AST and LDH after 6 hours of reperfusion was significantly increased in both CNT and INT groups. Lower AST levels, however, were found after INT occlusion than after CNT occlusion (267.0 +/- 74.7 U/l and 603.3 +/- 132.4 U/l, respectively; p = 0.06). Intermittent hepatic vascular inflow occlusion during prolonged liver ischemia in pigs resulted in less microcirculatory and hepatocellular injury, compared to continuous occlusion. Intermittent clamping is preferable when prolonged periods of vascular inflow occlusion are applied during liver resections.

Improvements in Hepatocellular Carcinoma Resection by Intraoperative Ultrasonography and Intermittent Hepatic Inflow Blood Occlusion

From September, 1989, to December, 1990 (late period), intraoperative ultrasonography (IOU) and intermittent hepatic inflow blood occlusion were introduced in hepatectomy. Compared with the early period from January, 1983, to August, 1989, the resectability of hepatocellular carcinoma (HCC) increased from 12.1 to 62.1% (P less than 0.0001). More resections on cirrhotic patients (P less than 0.05) and more combined resections with other organs (P less than 0.005) were carried out. Although the operation time was longer (P less than 0.01), less blood loss during surgery and fewer perioperative blood transfusions (P less than 0.001) were found during the late period. Since the rate at which classical resections were performed has reduced (P less than 0.001), postoperative morbidity has also decreased (P less than 0.05). Although the surgical mortality did not differ between the two periods, most deaths in the early period were caused by postoperative hepatic failure which was not found in the late period. Since IOU can clarify the intrahepatic vasculature and identify impalpable and invisible tumors, more precise resections can now be carried out. Intermittent hepatic inflow occlusion reduces blood loss during surgery without increasing risk. We suggest both techniques should be mandatory in hepatectomy for HCC in order for the safety range of resections to be broadened.