OMENTAL FLAP TO CORRECT AN HAMPERED VENOUS OUTFLOW AFTER EXTENDED LEFT HEPATECTOMY FOR LESIONS INVOLVING THE HEPATOCAVAL CONFLUENCE.

BACKGROUND Tumor extension and tumor location in crucial area of the liver can make particularly complex some extended liver resections. Indeed an outflow problem may sudden arise when only an accessory sovrahepatic vein is preserved. OBJECTIVES SCOPO è QUELLO DI SUGGERIRE UNA SOLUZIONE TECNICA IN PRESENZA DI PROBLEMI DI OUTFLOW.We tried in 3 patients with lesions situated on the convergence of the sovrahepatic veins, to take advantage of the anatomical variations relative to venous outflow and/or technical solutions to carry out extended left hepatectomy without hampering venous outflow. METHODS This study includes 3 patients submitted to extended liver resection for lesions involving the hepato-caval junction. 2 patients (1 cholangiocarcinoma, 1 multiple metastases from rectal adenocarcinoma) underwent a left hepatectomy extended to segments V-VIII, with resection of the 3 sovrahepatic veins and conservation of an accessory right inferior sovrahepatic vein (RISV). In the third case (1 Caroli disease) we performed a left hepatectomy with resection of S VIII and extensive dissection of the right sovrahepatic vein (RSV), compressed by a cystic lesion. Immediately after resection, the residual liver, without anatomical ligament, become congested due to the kinking of the RISV or the RSV. The hampered venous outflow, documented by an intraoperatory doppler echography, caused an immediate serious bleeding from the liver cut surface. The use of an omental flap, fixed to the diaphragm as an hammock, allowed a correct spatial repositioning of the residual parenchyma with limited chance of kinking of the residual sovrahepatic vein. RESULTS In all the procedures, we had no post-operative complications/ mortality and the Doppler US confirmed a normal venous outflow. CONCLUSIONS An accurate preoperative imaging study (volumetric CT scan/Doppler US) of the hepatic vascular flow and anatomy should be recommended in the surgical managment of major hepatectomy for tumors of the liver dome involving the hepato-caval confluence. In patients with an adequate omentum, an omental flap fixed to the diaphragm can be considered a good technical solution to stabilize the residual parenchyma, preserving a correct venuos outflow, otherwise hampered by kinking of the residual sovrahepatic vein.