Upper Transversal Hepatectomy with Two Hepatic Veins Reconstruction: Combining Parenchymal-Sparing Liver Surgery with Transplantation Techniques for Colorectal Liver Metastases

Background Colorectal liver metastases (CRLM) involving two or three main hepatic veins pose a surgical challenge. For these lesions, compelled surgical strategies have usually included major and/or extended liver resections according to the two-stage hepatectomy (TSH) strategy. More recently, a one-stage transversal hepatectomy resecting the posterosuperior liver segment (7,8,4 superior) along with one or more hepatic veins has been described, such as showed herein in a didactical video. Methods The patient is a 78-year-old woman with two large CRLMs located into segment 2 and into segment 8. Magnetic resonance imaging and computed tomography showed tumour stability after chemotherapy. The lesion of segment 2 is close to the left hepatic vein while the lesion of segment 8 infiltrates the middle (MHV) and the right hepatic veins (RHV). Results Under intermittent pedicular clamping, resection of the segment 7, 8, 4 superior along with the right and middle hepatic veins is performed. Reconstruction of the veins was performed with 2 cryopreserved autologous saphenous grafts. Postoperative course was uneventful and postoperative CT scan showed patency of the two venous graft reconstructions. Conclusions Surgery for CRLM has evolved over the last two decades shifting from large anatomical resections to parenchymal-sparing resections. Sparing liver parenchyma allows surgical radicality while reducing the risk of liver failure and allowing repeated liver resection. Associating vascular reconstruction to parenchymal-sparing surgery reduces the risk of venous congestion of the spared liver parenchyma.