Total Vascular Exclusion Research Articles

In Situ Hypothermic Perfusion of the Liver for Complex Hepatic Resection: Surgical Refinements.

While total vascular exclusion (TVE) with veno-venous bypass and hypothermia may be undertaken to increase liver tolerance for complex liver resection, these procedures are still associated with elevated rates of postoperative complications and mortality. In particular, one of the main issues of this strategy is the management of bleeding after declamping, which is enhanced by both hypothermic state and acidosis. To overcome this high risk of morbidity, several technical refinements might be undertaken and here described (with video). All patients, requiring TVE>60 min and liver cooling during hepatectomy, were retrospectively included in this study. Technical key points as (a) patient selection, (b) anesthetic management, (c) two-surgeon's technique, (d) preparation for clamping, (e) veno-venous bypass, (f) cooling of the liver, and (g) parenchymal transection, rewarming, and declamping are described and detailed. From 2011 to 2013, we included 8 cases of liver resection with TVE, veno-venous bypass, and hypothermia for malignant disease. Due to the technical refinements, median observed overall blood loss of 550 ml (300-900) including 200 ml (50-300) at declamping and transfusion of packed red blood cell (PRBC) units was required in 5 patients with a mean of 1.25 PRBC/patient. The association of TVE, veno-venous bypass, and liver cooling can reduce the time of transection, and blue dye injection and liver rewarming before declamping can reduce blood loss and coagulopathy. Altogether, limited blood loss can be achieved for these complex procedures and may allow to decreasing morbidity.

Vascular reconstruction in hepatic surgery

Due to their size or location liver tumors can infiltrate important vascular structures, which are essential for postoperative liver function. To present the technical possibilities and results of current concepts of vascular resection and reconstruction in liver surgery. A literature search of the Medline and Cochrane databases was performed regarding currently available studies on vascular resection and reconstruction in liver surgery. Portal vein resections are routinely performed by many institutions and can be performed as an end-to-end anastomosis or graft interposition. This is the basis of the en bloc resection concept, especially for Klatskin tumors. Reconstruction of the inferior vena cava as well as the hepatic arteries is technically feasible and is increasingly being reported in smaller series. In particular, the resection of tumors near the hepatic veins may require total vascular exclusion for complete interruption of liver perfusion, which enables resection in the non-perfused liver and by this reduced blood loss. Furthermore, in situ cooling, ante situm and ex situ resections increase both technical resectability and the ischemic tolerance of the liver to more than 60min. The majority of vascular reconstructions can be performed without a significant increase in morbidity; however, vascular tumor infiltration is associated with impaired long-term survival. Based on the experience of transplantation surgery concepts for vascular reconstruction can be safely applied to liver surgery. These concepts contribute to increasing the resectability of liver tumors. Due to the often impaired prognosis of vascular tumor infiltration, the use of these concepts should be individually assessed by weighing the prognosis against the morbidity.

Retrocaval liver lifting maneuver and modifications of total hepatic vascular exclusion for liver tumor resection.

To evaluate the efficacy of technical modifications of total hepatic vascular exclusion (THVE) for hepatectomy involving inferior vena cava (IVC). Of 301 patients who underwent hepatectomy during the immediate previous 5-year period, 8 (2.7%) required THVE or modified methods of IVC cross-clamping for resection of liver tumors with massive involvement of the IVC. Seven of the patients had diagnosis of colorectal liver metastases and 1 had diagnosis of hepatocellular carcinoma. All tumors involved the IVC, and THVE was unavoidable for combined resection of the IVC in all 8 of the patients. Technical modifications of THVE were applied to minimize the extent and duration of vascular occlusion, thereby reducing the risk of damage. Broad dissection of the space behind the IVC coupled with lifting up of the liver from the retrocaval space was effective for controlling bleeding around the IVC before and during THVE. The procedures facilitate modification of the positioning of the cranial IVC cross-clamp. Switching the cranial IVC cross-clamp from supra- to retrohepatic IVC or to the confluence of hepatic vein decreased duration of the THVE while restoring hepatic blood flow or systemic circulation via the IVC. Oblique cranial IVC cross-clamping avoided ischemia of the remnant hemi-liver. With these technical modifications, the mean duration of THVE was 13.4 ± 8.4 min, which was extremely shorter than that previously reported in the literature. Recovery of liver function was smooth and uneventful for all 8 patients. There was no case of mortality, re-operation, or severe complication (i.e., Clavien-Dindo grade of III or more). The retrocaval liver lifting maneuver and modifications of cranial cross-clamping were useful for minimizing duration of THVE.

Clinical outcomes of left hepatic trisectionectomy for hepatobiliary malignancy.

Left hepatic trisectionectomy (LHT) is a challenging major anatomical hepatectomy with a high complication rate and a worldwide experience that remains limited. The aim of this study was to describe changes in surgical practice over time, to analyse the outcomes of patients undergoing LHT for hepatobiliary malignancy, and to identify factors associated with morbidity and mortality. A cohort study was undertaken of patients who underwent LHT at a single tertiary hepatobiliary referral centre between January 1993 and March 2013. Univariable and multivariable analysis was used to identify factors associated with short- and long-term outcomes following LHT. Some 113 patients underwent LHT for colorectal liver metastasis (57), hilar cholangiocarcinoma (22), intrahepatic cholangiocarcinoma (12) and hepatocellular carcinoma (11); 11 patients had various other indications. Overall morbidity and 90-day mortality rates were 46.0 and 9.7 per cent respectively. Overall 1- and 3-year survival rates were 71.3 and 44.4 per cent respectively. Total hepatic vascular exclusion and intraoperative blood transfusion were independent predictors of postoperative morbidity, whereas blood transfusion was the only factor predictive of in-hospital mortality. Time period analysis revealed a decreasing trend in blood transfusion, duration of hospital stay, and postoperative morbidity and mortality in the last 5 years. Morbidity, mortality and long-term survival after LHT support its use in selected patients with a significant tumour burden.

Mesohepatectomy for Centrally Located Tumors in Children.

Central hepatectomy or mesohepatectomy (MH) is a complex surgical technique rarely used in children. It is indicated in central tumors to preserve functioning liver mass avoiding an extended right hepatectomy. The purpose of this article is to analyze our experience with this technique. We reviewed five patients who underwent MH in the period from 2008 to 2014. Diagnoses were hepatoblastoma PRETEXT III (two cases), hepatic embryonal sarcoma (one case), focal nodular hyperplasia (one case), and vascular tumor with rapid growth in a newborn causing an acute liver failure, compartment syndrome, and multiple organ failure (one case). In all cases, the tumor was centrally located, including the segment IVb, with large displacement of the hepatic pedicle in two cases. MH was standard in three cases and under total vascular exclusion in two cases. All children are alive with a mean follow-up of 38 (6-70) months. None of the children required reoperation because of bleeding. One child developed a biliary fistula in the cutting area that closed spontaneously. The newborn with the vascular tumor required the placement of a Gore-Tex patch (W. L. Gore & Associates, Inc, Flagstaff, Arizona, United States) to relieve the compartment syndrome. He subsequently underwent partial embolization of the tumor and MH under vascular exclusion. In selected patients, MH is an alternative to trisegmentectomy and should be available in advanced pediatric hepatobiliary units.

Complex Liver Resection Using Standard Total Vascular Exclusion, Venovenous Bypass, and In Situ Hypothermic Portal Perfusion: An Audit of 77 Consecutive Cases.

To identify independent predictors of 90-day mortality after liver resection for patients undergoing standard total vascular exclusion (TVE) with hypothermic portal perfusion and venovenous bypass. The secondary endpoint was to evaluate the long-term outcomes. Tumors invading the vena cava and/or the hepatocaval confluence are indications for standard TVE. The inclusion of liver hypothermic perfusion permits safe TVE. There are a limited number of reports focusing on this complex technique and no relevant analysis of short-term and long-term results. Seventy-seven consecutive liver resections performed using standard TVE with hypothermic portal perfusion and venovenous bypass between 1998 and 2010 were analyzed. The independent predictors and rates of 90-day mortality, morbidity, and long-term survival were evaluated. The 90-day mortality rate was 19.5% (15 cases). Three independent predictors of mortality were identified: age-adjusted Charlson Comorbidity Index 3 or more (P = 0.0231; odds ratio = 47.565; 95% confidence interval = 1.701-1330.414), tumor size 10 cm or more (P = 0.0442; odds ratio = 6.374; 95% confidence interval = 1.049-38.734), and the presence of 50/50 criteria (P = 0.0407; odds ratio = 6.217; 95% confidence interval = 1.080-35.782). The overall 5-year survival rate was 30.4%. Liver resection using standard TVE with hypothermic portal perfusion and venovenous bypass is associated with a high mortality rate. The identification of preoperative predictors of mortality should improve the selection of patients for this aggressive surgery. Compared with nonsurgical management, the long-term results are acceptable and justify this aggressive surgery in selected patients.

Surgical treatment after hepatic arterial infusion chemotherapy for hepatocellular carcinoma extending into the right atrium.

A resected case of hepatocellular carcinoma which extended into the right atrium after treatment with hepatic arterial infusion chemotherapy (HAIC) is described. An 81-year-old man presented with right hypochondralgia. CT demonstrated a hypervascular tumor 11.5 cm in diameter extending into the right atrium through the right hepatic vein. The patient underwent HAIC with 100 mg of cisplatin (CDDP IA-call®) particles three times every month. The tumor showed a marked shrinkage and an involution of the venous thrombus around the orifice of the right hepatic vein. Right hemihepatectomy with tumor thrombectomy was performed as a salvage surgery using a total hepatic vascular exclusion technique. Histologically, the tumor turned into diffuse necrosis and fibrosis, so viable tumor cells were encountered neither in the main tumor nor venous thrombus. The therapeutic effect of HAIC was pathological complete remission. The patient has been doing well for 6 years after the surgery without evidence of tumor recurrence. The salvage operation was safely achievable for the initially unresectable advanced hepatocellular carcinoma extending into the right atrium.

Surgical efficacy of benign tumor of liver in the caudate lobe

Objective To evaluate the surgical efficacy of benign tumor of liver in the caudate lobe. Methods The clinical data of 112 patients with benign tumor of liver in the caudate lobe who were admitted to the Eastern Hepatobiliary Surgery Hospital from January 2003 to April 2014 were retrospectively analyzed. The left-sided approach, right-sided approach, bilateral approach, central anterior approach and retrograde caudate lobectomy were selected according to the location and size of the tumor. All the patients were followed up by outpatient examination and telephone interview up to October 2014. Results Of all the 112 patients who received complete resection of tumor, 33 patients received caudate lobectomy (22 by bilateral approach, 11 by left-sided approach) , 28 received left hemihepatectomy + caudate lobectomy (by left-sided approach) , 21 received mesohepatectomy + caudate lobectomy (by central anterior approach) , 19 received partial right hepatectomy + caudate lobectomy (by right-sided approach) , 11 received right hemihepatectomy + caudate lobectomy (9 by right-sided approach, 2 by retrograde caudate lobectomy) . During the operation, 72 patients received vascular inflow occlusion, 29 received vascular inflow occlusion combined with hepatic veins occlusion, 6 received total hepatic vascular exclusion and 5 did not receive vascular inflow occlusion. The operation time, mean time of vascular inflow occlusion, mean volume of intraoperative blood loss, cases of blood transfusion, mean volume of blood transfusion and duration of postoperative hospital stay were (192 ±69) minutes, 28 minutes (range, 0-94 minutes) , 590 mL (range, 100-12 000 mL) , 68, 600 mL (range, 200-10 000mL) and (8. 2 ±2. 7) days, respectively. Thirty-one patients had postoperative complications, including 21 with bile leakage, 7 with medium and above volume of pleural effusion, 2 with postoperative bleeding and 1 with hepatic failure. The complications were cured after symptomatic treatment. No patient died perioperatively. All the 112 patients were followed up for a median time of 12 months (range, 6-24 months) . All patients were survived well and without tumor recurrence during the follow-up. Conclusions Surgical treatment is an effective method for benign tumor of liver in the caudate lobe, with the good recovery of patients and definitive surgical efficacy. The key factors of surgical treatment include strictly following operative indication, rationally optimizing surgical approach, suitably selecting vascular inflow occlusion and the accurate operation. Key words: Liver neoplasms; Hepatic caudate lobe; Hepatectomy

Management of intraoperative and postoperative bleeding in liver surgery

The management of bleeding in liver surgery is multidisciplinary. In most cases traumatic liver injury can be treated conservatively. Surgical treatment of severe liver trauma is associated with a high mortality rate due to extensive parenchymal and vascular injury as well as blood loss associated with the trauma. Fundamental knowledge of liver anatomy and refined surgical techniques help to reduce intraoperative blood loss and improve outcomes in elective liver surgery; nevertheless, severe blood loss and augmented transfusion requirements during extensive liver resection are still key factors for increased morbidity and mortality. Intraoperative lowering of central venous pressure and selective hepatic inflow occlusion or even total hepatic vascular exclusion are effective means of further reducing intraoperative blood loss. Furthermore, the application of sophisticated surgical instruments provides the surgeon with the potential to operate without the requirement of additional blood transfusions.

肝切除先行total hepatic vascular exclusionにより開心術を避けえた心房内進展巨大肝細胞癌の1切除例

肝切除先行total hepatic vascular exclusionにより開心術を避けえた心房内進展巨大肝細胞癌の1切除例

Patterns of complications following intraoperative radiofrequency ablation for liver metastases

BackgroundIntraoperative radiofrequency ablation (IRFA) is added to surgery to obtain hepatic clearance of liver metastases. Complications occurring in IRFA should differ from those associated with wedge or anatomic liver resection. MethodsPatients with liver metastases treated with IRFA from 2000 to 2010 were retrospectively analysed. Postoperative outcomes are reported according to the Clavien–Dindo system of classification. ResultsA total of 151 patients underwent 173 procedures for 430 metastases. Of these, 97 procedures involved IRFA plus liver resection and 76 involved IRFA only. The median number of lesions treated by IRFA was two (range: 1–11). A total of 123 (71.1%) procedures were carried out in patients who had received preoperative chemotherapy. The mortality rate was 1.2%. Thirty (39.5%) IRFA-only patients and 45 (46.4%) IRFA-plus-resection patients presented complications. Immediate complications (n = 4) were associated with IRFA plus resection. American Society of Anesthesiologists (ASA) class, previous abdominal surgery or hepatic resection, body mass index, number of IRFA procedures, portal pedicle clamping, total vascular exclusion and preoperative chemotherapy were not associated with a greater number of complications of Grade III or higher severity. Length of surgery >4h [odds ratio (OR) 2.67, 95% confidence interval (CI) 1.1–6.3; P < 0.05] and an associated contaminating procedure (OR 3.72, 95% CI 1.53–9.06; P < 0.005) led to a greater frequency of complications of Grade III or higher. ConclusionsMortality and morbidity after IRFA, with or without resection, are low. Nevertheless, long interventions and concurrent bowel operations increase the risk for septic complications.

Liver resection using total vascular exclusion of the liver preserving the caval flow, in situ hypothermic portal perfusion and temporary porta-caval shunt: a new technique for central tumors.

Standard total vascular exclusion (TVE) of the liver is indicated for resection of tumors involving or adjacent to the vena cava and/or the confluence of the hepatic veins. The duration of liver ischemia can be prolonged by combined portal hypothermic perfusion of the liver (in or ex situ). The use of a venovenous bypass (VVB) during standard TVE maintains stable hemodynamics as well as optimal renal and splanchnic venous drainage. When the hepatic veins can be controlled, TVE preserving the caval flow negates the need for VVB. However this technique remains limited in duration as it is performed under warm ischemia (so-called normothermia) of the liver. To prolong the ischemia time, we have designed a modification of TVE with preservation of the caval flow including the use of temporary porta-caval shunt (PCS) and hypothermic perfusion of the liver. We describe here the first two cases of this new technique. Two patients underwent left hepatectomy extended to segments 5 and 8 (also called extended left hepatectomy) for large centrally located tumors. TVE lasted seventy-two and seventy-nine minutes, respectively. The postoperative course was uneventful and both patients were discharged on day ten and day twenty-five respectively. Both are alive without recurrence at ten and seven months following surgery. Provided the roots of the hepatic veins can be controlled, this technique combines the advantages of standard TVE with in situ hypothermic perfusion and VVB and obviates the need and the subsequent risks of the latter.

Mesohepatectomy for the treatment of patients with centrally located hepatocellular carcinoma.

Mesohepatectomy is considered a feasible option for patients with centrally located hepatocellular carcinoma (HCC). However, mesohepatectomy is a technically demanding and less frequently used procedure. In this study, we summarized the surgical experience and evaluated the clinical outcomes of mesohepatectomy in 24 patients with centrally located HCC. Of these patients, 9 were treated with hepatectomy of Couinaud's segments IV, V and VIII with concurrent cholecystectomy; 8 underwent resection of segments IVb, V and VIII, including 7 patients who also received a cholecystectomy; 4 underwent hepatectomy of segments IVa, V and VIII; and 3 patients were treated with hepatectomy of segments I, IV, V and VIII, with concurrent cholecystectomy. The Pringle maneuver was used on 17 patients during hepatectomy. Total hepatic vascular exclusion (HVE) was performed on 3 patients and HVE was not used on 4 patients. The average mesohepatectomy operative time was 238 min and the average intraoperative blood loss was 480 ml (200-2,200 ml). There was no intraoperative mortality and the postoperative morbidity rate was 25% (6/24). The 1- and 3-year overall survival rates were 76 and 46%, respectively. Therefore, mesohepatectomy is a safe and effective surgical procedure for the treatment of centrally located HCC and HVE during mesohepatectomy for centrally located HCC is crucial to the success of the operation and postoperative patient recovery.

Beneficial Effects of Hydrogen Gas on Porcine Liver Reperfusion Injury With Use of Total Vascular Exclusion and Active Venous Bypass

BackgroundLiver ischemia/reperfusion (I/R) injury is a high risk factor in liver transplantation and it influences graft survival. One of the major events during I/R injury is the generation of cytotoxic oxygen radicals. Recently, hydrogen gas has been reported to have antioxidant properties and protective effects against organ dysfunction induced by I/R injury. The aim of this study is to investigate effects of hydrogen on porcine liver reperfusion injury. Materials and MethodsSix outbred pigs weighing 20 kg were used for the experiment. Under general anesthesia, the venous bypass between the left femoral vein and the splenic vein to the left jugular vein was made using a centrifugal pump. Then, we used a total vascular exclusion clamp (all in- and out-flow to the liver was clamped) for 60 minutes. Hydrogen (5 ppm) saturated with lactate Ringer's solution was prepared. This solution was infused through the portal vein just before reperfusion (hydrogen group). ResultsAspartate aminotransferase levels in the control versus hydrogen group in 30, 60, and 120 minutes after reperfusion were 1560.3, 1925.3, and 2342.5 versus 175.3, 200.7, and 661.00 IU/L, respectively. Lactate dehydrogenase (LDH) levels in the control versus hydrogen groups in 30, 60, and 120 minutes after reperfusion were 23,235.0, 3496.7, and 4793.5 versus 663.3, 802.0, and 983.7 IU/L, respectively. The hydrogen gas level in liver tissue increased to 954.6 ppm immediately after reperfusion; however, it disappeared within 30 minutes. ConclusionThe solution containing hydrogen gas was safe and had remarkably protective effects on the porcine during liver I/R and may be applied in the clinical setting.

Liver-directed therapies: surgical approaches, alone and in combination with other interventions.

When feasible, surgical resection is typically the preferred therapeutic option in patients with both primary and secondary hepatic malignancies. Improved patient selection, preoperative management, and advances in perioperative care have had a considerable effect on short-term and long-term outcomes following hepatic resection. Parenchymal transection of the liver can be performed using many different techniques such as digitoclasia, clamp crushing, vessel sealing system, harmonic scalpel, water-jet, Cavitron Ultrasonic Surgical Aspirator, or radiofrequency dissecting sealer. At the time of surgery, one of the main factors that influences postoperative morbidity and mortality is blood loss. Different techniques are used to decrease blood loss, such as the Pringle maneuver, selective ligation of the right, left, or smaller branches of the portal system; extrahepatic dissection; isolation; and transection of the hepatic artery and portal vein and the total vascular exclusion. Liver resection is on occasion accompanied by a concomitant procedure. Given that colorectal liver metastasis is a common indication for liver resection, colon resection is one of the more common concurrent procedures, but also surgical management of other disease in the lung or pancreas may sometimes be indicated. A subset of patients with primary or secondary liver malignancies may also require the addition of an ablative therapy to treat the extent of disease in the liver. Moreover, occasionally, hepatic resection takes place following intra-arterial therapy administration to the liver. Although many of these patients may benefit from surgical therapy, a multidisciplinary team approach remains critical.

Giant hepatic hemangioma resection via chest and abdomen joint incision

Hepatic hemangioma is a common benign tumor of liver,while hepatic hemangioma with a diameter ＞ 3 cm is rarely seen in clinical practice.A female patient with a giant hepatic hemangioma (diameter =48 cm) received tumor resection via chest and abdomen joint incision at the Peking Union Medical College Hospital on April 10,2012.The patient received exploratory laparotomy for hepatic tumor via chest and abdomen joint incision 22 years ago,while the operation was failed due to intraoperative bleeding.The success of the operation benefited from comprehensive application of computed tomography angiography reconstruction technique,three-dimensional liver reserve function assessment,intraoperative controlled low central venous pressure,total hepatic vascular exclusion and precise hepatectomy technique. Key words: Liver hemagioma; Precise hepatectomy; Three-dimensional liver reserve function assessment

Transhepatic anterior approach to the inferior vena cava in large retroperitoneal tumors resected en bloc with the right liver lobe

The operative approach to large retrohepatic tumors can be challenging because of the difficulty in exposing the inferior vena cava (IVC) and controlling bleeding. The anterior approach to the IVC associated with the hanging maneuver for liver transection, originally described in large hepatic tumors, may also facilitate removal of large masses set behind the liver. A prospective cohort of 10 patients with large retrohepatic tumors involving the IVC was selected according to restrictive criteria (ie, single low-grade tumor, sufficient liver remnant, normal hepatic function, absence of cholestasis, and symptoms secondary to lower vena cava obstruction). In allcases, the anterior approach and the hanging maneuver were applied intentionally to expose the IVCwithout any liver mobilization. Depending on tumor invasiveness, either IVC-preserving (n = 7) or IVC-removing (n = 3) strategies were applied. Our aim was to assess the safety of the technique and the possible benefits for patient outcome. The cohort represented less than 1% of a series of 1,168 major hepatectomies performed in our unit between 2005 and 2011. The median age of the patients was 58; adrenal tumors and retroperitoneal sarcomas accounted for 70% of the series. Total vascular liver exclusion was necessary in 3 patients. Median operative time was 420 min. R0 resection was obtained in all cases, with no mortality and 40% overall morbidity. Overall survival was 83% at 5 years. The transhepatic, anterior approach to the IVC is a safe procedure that improves vascular control, facilitates vein repair or reconstruction, and allows potentially curative resection of large retrohepatic tumors. This approach should be the preferred choice to be adopted in properly selected patients.

A New Instrument for Intrahepatic Access of Glissonian Pedicles During Anatomical Liver Resections

The knowledge of liver anatomy has led to a rapid evolution based on the intrahepatic distribution of the portal pedicle. One great advance in liver surgery was the used of segment-based liver resections. Techniques based with intrahepatic Glissonian access of portal pedicles were described to safely perform anatomical liver resections. We have earlier described a standardized intrahepatic access to right and left liver segments' pedicles without hilar dissection for anatomical hepatectomies. To improve the intrahepatic Glissonian technique, we designed a new atraumatic instrument for liver pedicle retrieval based on the anatomical liver landmarks. This new instrument was successfully employed in seventeen consecutive liver resections with minimum blood loss and without any complications related to its use. This new instrument, atraumatic retriever, replaces the right angle dissector or Gray clamp. The new instrument can slide easily and smoothly around Glissonian pedicle with a simple movement. This new instrument is a useful adjunct for performing intrahepatic access for liver resections. It can also be used to compass delicate anatomical structures such as esophagus and major abdominal vessels. The retriever can further be used in other common situations, including access for Pringle maneuver, encircling proximal esophagus during total gastrectomies or esophagectomies, and access for total vascular exclusion of the liver. This instrument can also be adapted to be used for laparoscopic liver resections.

Microwaves assisted liver surgery in elderly patients: technical aspects of our first clinical experience

Surgical resection for liver malignancy, has been demonstrated to increase overall survival; although the rate of post-operative mortality was reduced from 20% to 4% in recent years, it remains in any case a procedure that requires experienced and dedicated surgeons so that it can be followed by satisfactory results [1]. Several techniques have been developed and proposed in recent years in order to reduce the bleeding during liver resection. Surgeons can use an low central venous pressure, the continuous or intermittent clamping of hepatic pedicle or total vascular exclusion. The parenchymal section may instead be performed by different devices: the HF, dissector or ultrasonic scalpel, laser, stapler, radiofrequency energy. Radiofrequency ablation (RFA) is the most widely used modality for radical treatment of small HCC (_3 cm). It improves 5-year survival compared with standard chemotherapy and chemical ablation, allowing down-staging of unresectable hepatic masses. Microwave ablation (MWA) has been extensively applied in Asia and was recently introduced in the United States of America and Europe with excellent results, especially with regard to large unresectable HCC [2]. Microwave assisted surgery technology with the introduction of the latest technical expedient (“mini-choke”) has gained excellent therapeutic capability in comparison with RF assisted surgery. Applying the concept of precoagulation of liver transection line we developed a new technique that provides the pre coagulation of the resection line using microwaves technologies [3]. The aim of this study is to evaluate the clinical feasibility and the results of liver resections in elderly patients performed using microwave energy to obtain blood-less surgery, rate of biliary leakege, speed of the procedure, and the onset of surgical complications.

An approach to the intra-thoracic inferior vena cava through the abdominal cavity preparing for total hepatic vascular exclusion by sagittal diaphragmotomy.

For resection of advanced liver tumors with tumor thrombus/invasion extending into the intra-thoracic inferior vena cava (IVC) above the diaphragm as well as huge liver tumors located at the root of hepatic vein, an appropriate approach to the intra-thoracic IVC through the abdominal cavity is the key to control the intraoperative massive bleeding. The pericardium and diaphragm are separated by using fingers without injury of the pericardium. From just below the xiphoid process to the IVC, the diaphragm is vertically dissected without cutting the pericardium and doing median sternotomy. Then the intra-thoracic IVC is exposed easily and encircled with an umbilical tape. This technique was applied in four patients (hepatocellular carcinoma: n = 3, cholangiocellular carcinoma: n = 1). The mean patient's age was 69 (59-81) year old, and three were male. The median duration of surgery and blood loss was 490 min and 3600 mL, respectively. The median peaked aspartate aminotransferase and total bilirubin was 428 IU/mL and 2.75 mg/dL, respectively. The median duration of hospital stay was 22 days. This approach to intra-thoracic IVC through the abdominal cavity is very beneficial and helpful for many liver surgeons.