Extreme In Situ Liver Surgery Under Total Vascular Exclusion with Right Hepatic Vein and Inferior Vena Cava Grafts for an Intrahepatic Cholangiocarcinoma

In this multimedia article, we demonstrate an extreme in situ liver surgery under total vascular exclusion with right hepatic vein and inferior vena cava grafts for an intrahepatic cholangiocarcinoma in a centre with experience in highly complex hepatobiliary surgery and liver transplantation. This surgical approach after neoadjuvant chemotherapy provides an opportunity for surgical salvage in patients with large tumors invading the hepatocaval confluence. This patient was considered unresectable at another hospital and referred to our unit. We performed an accurate preoperative assessment with new generation 3D modelling to plan the type of vascular reconstruction that would allow adequate hepatic venous outflow and the volume of the future liver remnant sufficient to avoid postoperative liver failure. For hemodynamic management of the patient, we performed a total hepatic vascular exclusion with veno-venous bypass without intraoperative adverse events. We used a cryopreserved carotid artery graft after previously planning the most appropriate diameter and length for right hepatic vein reconstruction. The inferior vena cava was reconstructed with gore-tex graft. During the hospital stay there were no postoperative complications. The patient is free of disease. We conclude that patients with advanced malignant liver disease should always be referred to highly specialized liver surgery centers to assess the most appropriate oncological management and the possibility of surgical resectability.