TOTAL VASCULAR EXCLUSION: INDICATIONS, TECHNIQUES AND RESULTS

INTRODUCTION

Improvement of surgical and anesthesiological techniques and intensive postoperative support have contributed to reduce considerably mortality and morbidity of resective surgery of the liver. However intraoperative bleeding is still the main concern of this kind of surgery. The demonstration of a good tolerance of the liver to normothermic ischemia, also for prolonged periods of time (1-5), has permitted use of ischemic techniques; these allow control of intraoperative hemorrhage, reduction of the number of transfused blood units and resection of liver tumors which, because of location or size, were previously considered unresectable, or resectable with excessive risk of bleeding (2,6-17).
It is already largely demonstrated that pedicle clamping (Pringle maneuver)(Fig. 1) is a safe and efficacious manoeuvre to reduce parenchymal surface bleeding, from venous and arterial glissonian branches. Control of bleeding from hepatic veins or from vena cava, which is a fearful event during liver resection, is not obtained by the Pringle manoeuvre, but total vascular exclusion (TVE) of the liver is needed. With this technique all the hepatic vascular connections are interrupted by associating occlusion of the vena cava below and above the liver to pedicle clamping. Moreover TVE prevents air embolism during resection of lesions which are close to hepatic veins or vena cava (Fig. 2).
Hemodynamic and metabolic modifications during TVE are relevant. For this reason careful intraoperative monitoring of the patient and perfect concordance with the anesthesiologist are needed, in order to obtain a good hemodynamic preparation to the maneuver, and to maintain hemodynamic stability during and after caval clamping.

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