Techniques of Vascular Exclusion and Caval Resection

Felix Dahm, Pierre-Alain Clavien

Vascular exclusion techniques in liver surgery include continuous inflow occlusion (Fig. 1A) (first described by J.H. Pringle in 1908), intermittent inflow occlusion (Fig. 1B) (first described by M. Makuuchi in the late 1970s), and ischemic preconditioning (Fig. 1C) and (continuous) total vascular exclusion. The use of inflow occlusion varies considerably among centers - some use it routinely, while others use it only exceptionally. When using inflow occlusion, a low central venous pressure (CVP) (<3 mm Hg) needs to be maintained to reduce bleeding. The effect of a low CVP associated with a Pringle maneuver can be equivalent to total vascular exclusion. Total vascular exclusion, on the other hand, can lead to cardiovascular instability by reduced cardiac preload, and adequate volume loading with a high CVP (>10 mm Hg) needs to be maintained. A venovenous bypass is sometimes used in this setting.

Table 1. Maximum safe duration (min) of hepatic inflow occlusion with different techniques

Normal liver

Cirrhotic liver

Continuous inflow occlusion



Ischemic preconditioning



Intermittent clamping



Figure 1. Ischemia periods are drawn in black, reperfusion in white

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