Right hepatectomies without vascular clamping: report of 87 cases

Abstract

Background/Purpose. Portal triad clamping and total or intermittent hepatic vascular exclusion are usually used to reduce blood loss during major liver resections. We report, in this retrospective study, the results of right hepatectomy without vascular clamping. Methods. From January 1986 to July 2001, 87 right hepatectomies, including 14 extended right hepatectomies, were performed without vascular clamping. There was 53 men and 34 women, with a mean age of 60.2 Ϯ 12.5 years. Indications were 58 metastases, 16 hepatocellular carcinomas, 5 cholangiocarcinomas, 4 adenomas, 3 angiomas, and 1 carcinoid tumor. All the procedures were carried out using an ultrasonic dissector and intraoperative ultrasonography with only vascular control (looping of the hepatic pedicle and supra; and infrahepatic vena cava).Results. There were four postoperative deaths and 23 complications (26%), including hepatocellular failure (6), pulmonary complications (6), transient bile leakage (5), digestive bleeding (2), subphrenic abscess (1), inferior vena cava (IVC) thrombosis (1), disseminated intravascular coagulation (DIC; 1), and evisceration (1). Forty-two patients (48%) had no blood transfusion. The mean blood transfusion requirement was 1.5 Ϯ 2.7 units. The mean operative length was 280 Ϯ 60 min and the mean hospital stay was 12.8 Ϯ 8.1 days. Liver function test results were similar to those in other studies on days 1, 4, and 7 postoperatively, with a return to normal values after 1 week. Conclusions. In our experience with major liver resections, vascular clamping is not necessary.

Right hepatectomy with extra-hepatic vascular division prior to transection: intention-to-treat analysis of a standardized policy

“…This rate was only 5.5% in the present series. The peri‐operative RBC transfusion rate (17%) was also similar to previous series of major hepatectomy in non‐cirrhotic patients, in which it varies largely from 6% to 63%, as it may depend on centres transfusion policies 10,26,27,30,48,49,51,53,54 . In addition, as expected from the partial outflow control enabled by the technique, 25 the incidence of clinical air embolism was nil in the present series, although damage to the middle hepatic vein is still possible.…”

“…Post‐operative mortality and morbidity rates (1.6% and 42% respectively) were comparable to previous series of major hepatectomy in non‐cirrhotic patients 10,26,27,30,40,48,49,51,53,54 . The prospective collection of post‐operative data and the strict accordance to the five‐tier grading of the Dindo and Clavien classification, 22 may explain the high rate of overall morbidity, whereas less than 20% of patients experienced morbidity of grade II and more.…”

“…30,45,48 Thus, it is likely that the unclamping technique is associated with an increase in operative time, as suggested by a recent retrospective study. 45 In terms of intra-operative blood loss and transfusion rate, the present series compares favourably with previous reported series of a major hepatectomy in non-cirrhotic patients, 28,30,40,[48][49][50][51] in which the median blood loss varied from 250 to 989 ml. A recent Japanese study reported a 14% rate of blood loss exceeding 1500 ml in patients without underlying liver disease.…”

“…Post-operative mortality and morbidity rates (1.6% and 42% respectively) were comparable to previous series of major hepatectomy in non-cirrhotic patients. 10,26,27,30,40,48,49,51,53,54 The prospective collection of post-operative data and the strict accordance to the five-tier grading of the Dindo and Clavien classification, 22 may explain the high rate of overall morbidity, whereas less than 20% of patients experienced morbidity of grade II and more. Moreover, every single complication and its associated grade of severity was reported in detail (Table 4) in order to present a comprehensive analysis of the outcome after a right hepatectomy with the unclamping policy.…”

Bleeding in Hepatic Surgery: Sorting through Methods to Prevent It

“…Vascular staplers also can be used to divide the hepatic duct pedicle in the right or left hepatectomy [7]. The procedure starts by dividing the liver capsule by diathermy, the use of a stapler for transection of the liver parenchyma, followed by fracturing the liver tissue with a vascular clamp in a stepwise manner and subsequently divided with an ENDOGia vascular stapler.…”