Total vascular hepatic exclusion for tumor resection: a new approach to the intrathoracic inferior vena cava through the abdominal cavity by cutting the diaphragm vertically without cutting the pericardium

For the resection of advanced liver tumors in which the tumor thrombus extends into the intrathoracic inferior vena cava (IVC) above the diaphragm, surgeons need very skillful techniques and much experience. However, after detachment of the line of fusion of the pericardium to the diaphragm (LFPD), the intrathoracic IVC can be exposed easily. We herein present this novel surgical method, an approach to the intrathoracic IVC through the abdominal cavity. A 66 year-old man was referred to our hospital because of high-grade fever. Computed tomography revealed a large tumor of the left hepatic lobe with tumor thrombus extending into the intrathoracic IVC through the left hepatic vein. Laboratory data showed elevated levels of alpha-fetoprotein (AFP) (726 ng/ml) and protein induced by vitamin K absence (114 AU/ml). The patient was diagnosed with hepatocellular carcinoma (HCC) of the left hepatic lobe with tumor thrombus extending into the IVC. He underwent left hepatectomy with partial resection of the IVC and intravascular tumor thrombectomy under total hepatic vascular exclusion (THVE) without the use of cardiopulmonary bypass (CPB). Before THVE, we approached the IVC through the abdominal cavity with vertical dissection of the diaphragm after detachment of the LFPD without cutting the pericardium or performing median sternotomy. This procedure could be very beneficial and helpful for many liver surgeons.