Large hepatic tumors can invade the retrohepatic inferior vena cava (IVC). Resecting the involved IVC wall is necessary to achieve complete tumor resection. We present detailed surgical procedures of IVC resection and patch venoplasty under the standard and modified total hepatic vascular exclusion (THVE) techniques applied to two patients who underwent aggressive surgery for hepatic tumors. The first case was a 55-year-old male with advanced intrahepatic cholangiocarcinoma. The extent of resection was extended right hepatectomy with caudate lobe resection, right adrenalectomy, and portal vein segmental resection-anastomosis. The invasion site at the IVC was excised and repaired with an expanded polytetrafluoroethylene patch under modified THVE. This patient recovered uneventfully. At postoperative 10 months, second primary cancer occurred in the duodenum. The patient underwent pancreaticoduodenectomy but passed away at post-surgery 6 weeks due to pneumonia-associated sepsis. The second case was a 35-year-old female with giant cavernous hemangioma. As separating the right liver from the IVC was infeasible through conventional dissection techniques, standard THVE was performed. The short hepatic vein was too large to repair directly without risk of IVC stenosis. Thus, a cryopreserve iliac vein allograft patch was applied to repair the defect. The patient recovered uneventfully from the operation. The patient is currently doing well for 6 years. However, progressive hemangiomatosis occurred. In conclusion, standard and modified THVE techniques are proposed as useful techniques to achieve complete tumor resection in patients with large liver tumors invading the retrohepatic IVC.

BACKGROUND: Total hepatic vascular exclusion (THVE) is an essential technique to control hemorrhage during surgical treatment of advanced liver tumors or injury. However, surgeons often have difficulty securing the intrapericardial inferior vena cava (IVC) because few reports have described the anatomy around the supra-diaphragmatic IVC or the techniques and surgical outcomes for this procedure. This study presents our safe and feasible intrapericardial IVC approach, which is based on anatomical landmarks, and reports the surgical outcomes of this procedure.
METHODS: We performed THVE using our technique for hepatectomy, accompanied by resection of the hepatic vein confluence or tumor thrombectomy of the supra-hepatic IVC, in five patients between August 2011 and March 2018.
RESULTS: The mean operative time was 568 min (range: 240-820 min). The mean THVE time was 10 min (range: 5-15 min), with a mean blood loss of 1882 mL (range: 1010-3100 mL). Postoperatively, one patient was classified as Clavien-Dindo grade II due to medication for tachycardia, and two patients were classified as grade IIIa due to drainage of bile and pleural effusion, including one patient with tachycardia. The mean postoperative hospital stay was 26 days (range: 18-34 days). No patient exhibited decreased cardiac function during surgery or postoperatively, and no patient experienced thoracotomy or phrenic nerve paralysis.
CONCLUSIONS: Anatomical landmarks are important to ensure a safe approach to the intrapericardial IVC. Incising the pericardium does not lead to serious problems. The transmediastinal, intrapericardial IVC approach for THVE is a feasible method to secure the supra-diaphragmatic intrapericardial IVC.

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.

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