Ann Hepatobiliary Pancreat Surg.  2021 Nov;25(4):536-543. 10.14701/ahbps.2021.25.4.536.

Patch venoplasty for resecting tumor invading the retrohepatic inferior vena cava using total and selective hepatic vascular exclusion

• Kim SM
• Hwang S
• Moon DB
• Jung DH
• Lee SG

• KMID: 2523060
• DOI: http://doi.org/10.14701/ahbps.2021.25.4.536

Abstract

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 polytetraf luoroethylene 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.

Keyword

Inferior vena cava; Total hepatic vascular exclusion; Hepatic ischemia; Intrahepatic cholangiocarcinoma; Cavernous hemangioma

Figure

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  Fig. 1 Preoperative radiologic findings of Case no. 1. (A–C) Computed tomography scan shows a 10-cm-sized infiltrative tumor located at the right liver and invasion of the right portal vein (arrow), the duodenum (arrow), the right adrenal gland, and the retrohepatic inferior vena cava (arrow). (D) Magnetic resonance cholangiopancreatography shows invasion to the right hepatic duct.

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  Fig. 2 Intraoperative photographs of the wedge resection of the retrohepatic inferior vena cava (IVC) in Case no. 1. (A) The tumor-invaded IVC is isolated (arrow). (B) The invaded IVC wall was excised. (C, D) The wall defect in the IVC wall was repaired with an expanded polytetrafluoroethylene patch under modified total hepatic vascular exclusion.

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  Fig. 3 Gross photograph of Case no. 1 specimen and excision-reconstruction of the retrohepatic inferior vena cava (IVC). (A) A gross photograph of the right liver is visible. The arrow indicates the excised IVC wall. (B) Intraoperative photographs show resection and reconstruction of the IVC wall. (C) Computed tomography taken 1 week after right hepatectomy shows a good patency of the IVC (arrow).

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  Fig. 4 Gross photograph of Case no. 1 specimen after pancreatoduodenectomy for the second primary duodenal adenocarcinoma.

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  Fig. 5 Preoperative computed tomography of Case no. 2. (A–C) Computed tomography scan shows a huge cavernous hemangioma compressing the inferior vena cava and the left liver with displacement of the right kidney and pancreas. (D) Three-dimensional reconstruction of the hepatic arterial system shows the enlarged right hepatic artery.

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  Fig. 6 Intraoperative photographs of right hepatectomy in Case no. 2. (A, B) The enlarged right liver is visible. (C, D) An enlarged short hepatic vein was transected under the standard total hepatic vascular exclusion. (E, F) The wall defect in the inferior vena cava was repaired with a cryopreserve iliac vein allograft patch. (G, H) The remnant left liver is visible with full exposure of the inferior vena cava.

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  Fig. 7 Gross photographs of Case no. 2 specimen showing cavernous hemangioma with extensive necrosis.

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  Fig. 8 Follow-up computed tomography (CT) scans of Case no. 2 showing progressive hemangiomatosis. CT scan taken after 1 year (A) shows a few small hemangiomas. CT scans taken after 2 years (B), 3 years (C), and 4 years (D) show progressive growth of the hemangiomas in both size and number.

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