Transmediastinal, intrapericardial inferior vena cava approach based on anatomical landmarks for hepatectomy using total hepatic vascular exclusion

Background Total hepatic vascular exclusion (THVE) is an essential technique to control hemorrhage during surgical treatment of advanced liver tumors or injury. However, surgeons often have difficulty securing the intrapericardial inferior vena cava (IVC) because few reports have described the anatomy around the supra-diaphragmatic IVC or the techniques and surgical outcomes for this procedure. This study presents our safe and feasible intrapericardial IVC approach, which is based on anatomical landmarks, and reports the surgical outcomes of this procedure. Methods We performed THVE using our technique for hepatectomy, accompanied by resection of the hepatic vein confluence or tumor thrombectomy of the supra-hepatic IVC, in five patients between August 2011 and March 2018. Results The mean operative time was 568 min (range: 240-820 min). The mean THVE time was 10 min (range: 5-15 min), with a mean blood loss of 1882 mL (range: 1010-3100 mL). Postoperatively, one patient was classified as Clavien-Dindo grade II due to medication for tachycardia, and two patients were classified as grade IIIa due to drainage of bile and pleural effusion, including one patient with tachycardia. The mean postoperative hospital stay was 26 days (range: 18-34 days). No patient exhibited decreased cardiac function during surgery or postoperatively, and no patient experienced thoracotomy or phrenic nerve paralysis. Conclusions Anatomical landmarks are important to ensure a safe approach to the intrapericardial IVC. Incising the pericardium does not lead to serious problems. The transmediastinal, intrapericardial IVC approach for THVE is a feasible method to secure the supra-diaphragmatic intrapericardial IVC.