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ORIGINAL ARTICLE - HEPATOBILIARY TUMORS
Ante Situm Liver Resection for Tumors Invading the Inferior Vena Cava Hepatic Vein Confluence
Pietro Addeo, MD, PHD, FACS, Pierre de Mathelin, MD, Chloe Paul, MD, and Philippe Bachellier, MD
Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Hépatiques et Digestives, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
ABSTRACT
Background. Liver malignancy invading the retrohepatic inferior vena cava beyond the cavo-hepatic vein venous confluence can be resected by an ante situm technique first described by Hannoun et al.1 In this approach, a major hepa- tectomy is performed and the hepatic veins are sectioned to allow the inferior vena cava reconstruction while the liver is cold perfused and the liver remains within the abdominal cavity. The hepatic vein is then reimplanted on the recon- structed inferior vena cava in “a liver autotransplantation fashion.”
Patient and Methods. The patient was a 66-year-old with a recurrent adrenocortical carcinoma cancer invading the right liver and the retrohepatic inferior vena cava with intralumi- nal thrombus extending beyond to the hepatic vein conflu- ence. A right hepatectomy extended to segment 1 and the retrohepatic inferior vena cava was planned because of the intracaval tumoral thrombus and the infiltration of the right liver. The future liver remnant (FLR) (646 cc) to total liver volume (1526 cc) ratios was 42% while the FLR to patient weight ratio was 0.9%.
Results. The parenchymal liver transection was performed under a total vascular exclusion, venovenous bypass, and hypothermic perfusion of the left liver.2 The common trunk of the left and middle hepatic veins was sectioned, allowing the liver to be rotated toward the left. Vena cava reconstruc- tion was achieved by a ringed Gore-Tex prosthesis, with
reimplantation of the left and middle hepatic veins directly over the prosthesis. Surgery lasted 580 min, total duration of venovenous bypass and liver vascular exclusion was 143 min and 140 min, respectively. Blood loss was 2 liters and 8 red blood cell (RBC) units were transfused. The patient spent 5 days in the ICU, liver function tests normalized by postoperative day 8 and patient was discharged home on postoperative day 20; 1 year later, the patient is alive and disease free under mitotane treatment.
Conclusions. The ante situm technique represents a safe surgical option for complex liver resection for malignancy involving the cavo-hepatic venous confluence. Compared with the ex situ liver resection, this technique allows liver remnant outflow reconstruction to be performed while the liver is cold perfused within the abdominal cavity with an intact hepatic pedicle.
Keywords Ante situm technique · Liver resection · Cold perfusion · Total vascular exclusion · Adrenocortical carcinoma
SUPPLEMENTARY INFORMATION The online version con- tains supplementary material available at https://doi.org/10.1245/ s10434-024-15849-x.
FUNDING This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sector.
DISCLOSURE The authors have nothing to disclose.
@ Society of Surgical Oncology 2024
Published online: 22 July 2024
REFERENCES
1. Hannoun L, Panis Y, Balladur P, et al. Ex-situ in-vivo liver sur- gery. Lancet. 1991;337:1616-7.
2. Azoulay D, Lim C, Salloum C, et al. Complex liver resection using standard total vascular exclusion, venovenous bypass, and
in situ hypothermic portal perfusion: an audit of 77 consecutive cases. Ann Surg. 2015;262:93-104.
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