title: Retrocaval liver lifting maneuver and modifications of total hepatic vascular exclusion for liver tumor resection.
abstract: OBJECTIVE
  To evaluate the efficacy of technical modifications of total hepatic vascular exclusion (THVE) for hepatectomy involving inferior vena cava (IVC).
  
  
  METHODS
  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.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  The retrocaval liver lifting maneuver and modifications of cranial cross-clamping were useful for minimizing duration of THVE.
authors.affiliation: Saiho Ko, Yuuki Kirihatayfa, Yayoi Matsumoto, Tadataka Takagi, Masanori Matsusaka, Tomohide Mukogawa, Hirofumi Ishikawa, Akihiko Watanabe, Department of Surgery, Nara Prefecture General Medical Center, Nara 631-0846, Japan.
authors.forename: Saiho
authors.initials: S
authors.lastname: Ko
authors.affiliation: Saiho Ko, Yuuki Kirihatayfa, Yayoi Matsumoto, Tadataka Takagi, Masanori Matsusaka, Tomohide Mukogawa, Hirofumi Ishikawa, Akihiko Watanabe, Department of Surgery, Nara Prefecture General Medical Center, Nara 631-0846, Japan.
authors.forename: Yuuki
authors.initials: Y
authors.lastname: Kirihataya
authors.affiliation: Saiho Ko, Yuuki Kirihatayfa, Yayoi Matsumoto, Tadataka Takagi, Masanori Matsusaka, Tomohide Mukogawa, Hirofumi Ishikawa, Akihiko Watanabe, Department of Surgery, Nara Prefecture General Medical Center, Nara 631-0846, Japan.
authors.forename: Yayoi
authors.initials: Y
authors.lastname: Matsumoto
authors.affiliation: Saiho Ko, Yuuki Kirihatayfa, Yayoi Matsumoto, Tadataka Takagi, Masanori Matsusaka, Tomohide Mukogawa, Hirofumi Ishikawa, Akihiko Watanabe, Department of Surgery, Nara Prefecture General Medical Center, Nara 631-0846, Japan.
authors.forename: Tadataka
authors.initials: T
authors.lastname: Takagi
authors.affiliation: Saiho Ko, Yuuki Kirihatayfa, Yayoi Matsumoto, Tadataka Takagi, Masanori Matsusaka, Tomohide Mukogawa, Hirofumi Ishikawa, Akihiko Watanabe, Department of Surgery, Nara Prefecture General Medical Center, Nara 631-0846, Japan.
authors.forename: Masanori
authors.initials: M
authors.lastname: Matsusaka
authors.affiliation: Saiho Ko, Yuuki Kirihatayfa, Yayoi Matsumoto, Tadataka Takagi, Masanori Matsusaka, Tomohide Mukogawa, Hirofumi Ishikawa, Akihiko Watanabe, Department of Surgery, Nara Prefecture General Medical Center, Nara 631-0846, Japan.
authors.forename: Tomohide
authors.initials: T
authors.lastname: Mukogawa
authors.affiliation: Saiho Ko, Yuuki Kirihatayfa, Yayoi Matsumoto, Tadataka Takagi, Masanori Matsusaka, Tomohide Mukogawa, Hirofumi Ishikawa, Akihiko Watanabe, Department of Surgery, Nara Prefecture General Medical Center, Nara 631-0846, Japan.
authors.forename: Hirofumi
authors.initials: H
authors.lastname: Ishikawa
authors.affiliation: Saiho Ko, Yuuki Kirihatayfa, Yayoi Matsumoto, Tadataka Takagi, Masanori Matsusaka, Tomohide Mukogawa, Hirofumi Ishikawa, Akihiko Watanabe, Department of Surgery, Nara Prefecture General Medical Center, Nara 631-0846, Japan.
authors.forename: Akihiko
authors.initials: A
authors.lastname: Watanabe
keywords: Hepatectomy; Oblique clamping; Retrocaval liver lifting maneuver; Switching the clamp; Total hepatic vascular exclusion