title: Extraparenchymal control of hepatic veins during mesohepatectomy.
abstract: BACKGROUND
  Bleeding is the most relevant operative risk during mesohepatectomy because of the wideness of the resection surfaces and the exposure of main intrahepatic vascular structures. Preliminary extraparenchymal exposure of the main hepatic veins, with the possibility of clamping them in association with the Pringle maneuver, and the maintenance of a low central venous pressure during mesohepatectomy, can contribute to substantially reducing operative bleeding.
  
  
  METHODS
  We report the results obtained in 18 mesohepatectomies, performed for liver metastases (13 patients) and for hepatocellular carcinoma (5 patients). Liver resection was performed without preliminary exposure of the main hepatic veins in nine patients (group A) and with preliminary looping of the main hepatic veins in nine patients (group B), without complications related to the maneuver.
  
  
  RESULTS
  Intermittent pedicle clamping was used in all patients; in six patients in group B (66.7%), clamping of the main hepatic veins was also performed (mean duration, 37 minutes; range 16 to 68 minutes). Intraoperative blood transfusions were needed in 5 patients (5 of 18, 27.8%): 4 belonged to group A (44.4%) and 1 to group B (11.1%). Mortality was nil and morbidity was 33.3%, involving four patients in group A and two in group B (none related to the exposure, looping, and clamping of the main hepatic veins).
  
  
  CONCLUSIONS
  Preliminary control of the main hepatic veins is a safe maneuver. During mesohepatectomy, clamping of these veins, associated with pedicle clamping, is effective in reducing operative bleeding. In our patients, this resulted in a low blood transfusion rate, similar to that of classic major hepatectomies, despite the higher complexity of mesohepatectomy.
authors.affiliation: Department of Surgery, Hepatobiliary Surgery Unit, Catholic University of the Sacred Heart, School of Medicine, Rome, Italy.
authors.forename: Felice
authors.initials: F
authors.lastname: Giuliante
authors.forename: Gennaro
authors.initials: G
authors.lastname: Nuzzo
authors.forename: Francesco
authors.initials: F
authors.lastname: Ardito
authors.forename: Maria
authors.initials: M
authors.lastname: Vellone
authors.forename: Germano
authors.initials: G
authors.lastname: De Cosmo
authors.forename: Ivo
authors.initials: I
authors.lastname: Giovannini
mesh_terms: D000368:Aged; D016063:Blood Loss, Surgical / Q000517:prevention & control*; D006528:Carcinoma, Hepatocellular / Q000473:pathology / Q000601:surgery*; D015331:Cohort Studies; D005260:Female; D006488:Hemostasis, Surgical / Q000379:methods*; D006498:Hepatectomy / Q000009:adverse effects / Q000379:methods*; D006503:Hepatic Veins; D006801:Humans; D008026:Ligation; D008113:Liver Neoplasms / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D016896:Treatment Outcome