ABSTRACT
During liver resection, various techniques of hepatic vascular control have been proposed to minimize the intraoperative blood losses. They include the isolated occlusion of the hepatic inflow (pedicular clamping) or the combination of occlusion of the hepatic inflow and outflow (total vascular exclusion). Hepatic vascular exclusion which has been shown to consistently reduce the rate of intraoperative bleeding, has major drawbacks including longer continuous liver parenchymal ischemia, splanchnic venous congestion and more pronounced hemodynamic instability. Ischemic preconditioning, intermittent clamping and hepatic vascular exclusion with cavai flow preservation minimize hemodynamic instability. Currently, intermittent pedicular clamping has been shown to be the easiest procedure to reduce bleeding associated with the lower intra and postoperative morbidity. Anesthetic management during liver resection is crucial during hepatic vascular exclusion for prevention and adjustment of hemodynamic disturbance. In patients resected with pedicular clamping, low central venous pressure during liver transection is consistently associated with reduced blood loss. Compared with intermittent pedicular clamping, total hepatic vascular exclusion does not offer a greater reduction of blood loss and is associated with increased morbidity. This leads to limit its indications to tumors involving the major hepatic veins. Under these circumstances, the intraoperative management requires an appropriate tool for monitoring and anticipation of expected hemodynamic variations.
