title: Inferior approach for the isolation of the left-middle hepatic veins in liver resections: a safe way.
abstract: BACKGROUND
  Control of blood outflow from the liver has become mandatory to reduce back-bleeding and prevent air emboli in difficult liver resections when dealing with the hepatic veins. Selective control of the major hepatic veins rather than unselective vena cava clamping is preferable in most of these cases. Extrahepatic isolation of the left-middle hepatic veins has been considered for a long time to be a hazardous maneuver, and there is no general agreement about the technique that should be used.
  
  
  OBJECTIVE
  The purpose of this article is to describe a technique used by us for the isolation of the left-middle hepatic veins so that total or selective (hemihepatic) vascular exclusion of the liver can be performed without vena cava clamping.
  
  
  METHODS
  The inferior approach is easily accomplished soon after the exposure of some anatomical landmarks, and a triangle is described in which a clamp is inserted or, alternatively, when one uses a superior approach, when the instrument tip exits to enable the veins' looping.
  
  
  CONCLUSIONS
  Compared with other techniques, this approach is easier and safer to perform in nearly all cases, providing that there is no tumor located close to the vena cava or hepatic vein junction that contraindicates this maneuver.
authors.affiliation: Unità di Chirurgia, Dipartimento di Fisiopatologia Clinica, Università degli Studi di Firenze, Viale GB Morgagni 85, 50134 Florence, Italy. g.batignani@unifi.it
authors.forename: Giacomo
authors.initials: G
authors.lastname: Batignani
authors.forename: Michele
authors.initials: M
authors.lastname: Zuckermann
mesh_terms: D006498:Hepatectomy / Q000379:methods*; D006503:Hepatic Veins / Q000601:surgery*; D006801:Humans; D008099:Liver / Q000098:blood supply* / Q000601:surgery; D014656:Vascular Surgical Procedures / Q000379:methods*