title: Transhepatic anterior approach to the inferior vena cava in large retroperitoneal tumors resected en bloc with the right liver lobe.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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 all cases, the anterior approach and the hanging maneuver were applied intentionally to expose the IVC without 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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, Istituto Nazionale Tumori (National Cancer Institute) IRCCS Foundation, Milan, Italy.
authors.forename: Jorgelina
authors.initials: J
authors.lastname: Coppa
authors.forename: Davide
authors.initials: D
authors.lastname: Citterio
authors.forename: Christian
authors.initials: C
authors.lastname: Cotsoglou
authors.forename: Alessandro
authors.initials: A
authors.lastname: Germini
authors.forename: Federico
authors.initials: F
authors.lastname: Piccioni
authors.forename: Carlo
authors.initials: C
authors.lastname: Sposito
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Mazzaferro
mesh_terms: D015331:Cohort Studies; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D008875:Middle Aged; D011446:Prospective Studies; D012186:Retroperitoneal Neoplasms / Q000601:surgery*; D014682:Vena Cava, Inferior / Q000601:surgery*