Pringle manoeuvre versus selective hepatic vascular exclusion in partial hepatectomy for tumours adjacent to the hepatocaval junction: a randomized comparative study.

OBJECTIVE: To compare the efficacy of selective hepatic vascular exclusion versus Pringle manoeuvre in partial hepatectomy for tumours adjacent to the hepatocaval junction. METHODS: A randomized comparative trial was carried out. The primary endpoint was intraoperative blood loss. The secondary endpoints were operation time, blood transfusion, postoperative liver function recovery, procedure-related morbidity and in-hospital mortality. RESULTS: 160 patients were randomized into 2 groups: the Pringle manoeuvre group (n = 80) and the selective hepatic vascular exclusion (SHVE) group (n = 80). Intraoperative blood loss and transfusion requirements were significantly less in the SHVE group. In the SHVE group, laceration of hepatic veins happened in 18 patients. Profuse intraoperative blood loss of over 2 L happened in 2 patients but no patient suffered from air embolism because the hepatic veins were controlled. In the Pringle group, the hepatic veins were lacerated in 20 patients, with profuse blood loss of over 2 L in 7 patients and air embolism in 3 patients. The rates of postoperative bleeding, reoperation, liver failure and mortality were significantly higher and the ICU stay and hospital stay were significantly longer in the Pringle group. CONCLUSIONS: SHVE was more efficacious than Pringle manoeuvre for partial hepatectomy in patients with tumours adjacent to the hepatocaval junction.

Management of retrohepatic inferior vena cava injury during hepatectomy for neoplasms.

The aim of this article is to discuss the management of retrohepatic inferior vena cava injury during hepatectomy for neoplasms. Step-by-step hepatic vascular exclusion, digital compression, finger pinching, and surface-to-surface suturing were used in the management of retrohepatic inferior vena cava injury during hepatic resection in 16 cases: 12 patients underwent exclusion of the hepatic artery and portal vein by portal triad clamping (PTC) only; 3 underwent PTC and exclusion of the infrahepatic inferior vena cava (IVC); and 1 underwent PTC together with exclusion of the suprahepatic and infrahepatic IVC. In all cases, bleeding stopped immediately after the management described, with no intraoperative deaths and no postoperative bleeding. The median follow-up was 42.5 months (range 19-60 months) for all patients, and the 5-year survival rate of all patients with malignant tumors was 28.57%. One died of lung metastasis 19 months after operation, one with spontaneous rupture of a hepatocellular carcinoma 19 months after operation, and eight others from recurrence or metastasis 21, 23, 24, 27, 30, 35, 50, or 54 months after operation, respectively. Two patients had a recurrence 4 years and 4 years 6 months after the initial operation, respectively. The recurrent tumors of the liver were resected. The other patients are currently alive without recurrence or metastasis. The techniques described are safe, simple, practical, time-saving, and effective for controlling massive bleeding arising from injury to the retrohepatic inferior vena cava during hepatic resection.