Before total vascular exclusion can be performed, the liver needs to be completely mobilized as for a liver transplantation (see chapter "Orthotopic Liver Transplantation").
The infrahepatic vena cava is prepared on its right and left side for 2-3cm. The right adrenal vein needs to be identified and transected through ligatures (A).
STEP 2 (continued)
A finger is passed under the cava from the right to the left, and the connective tissue is dissected on the finger with electrocautery (B-1). A large right angle is then passed under the infrahepatic vena cava (B-2), and isolated with a Mersilene band (B-3), which is then pulled through a catheter as when performing inflow occlusion (tourniquet technique as in the Pringle maneuver, see above).
Mobilize the retrohepatic and suprahepatic vena cava up to the diaphragm. This is accomplished by passing a finger behind the vena cava and cauterizing the connective tissue. There are no venous branches in this area.
Occlude the infrahepatic cava with the corresponding tourniquet. If this is not tolerated, total vascular exclusion cannot be performed. If it is tolerated, lift up the left hepatic hemiliver and place a large curved vascular clamp from left to right on the suprahepatic cava as high as possible. Check if it can be closed, then occlude hepatic inflow by closing the tourniquet on the hepatoduodenal ligament. Clamp the suprahepatic vena cava including a little bit of diaphragm (if possible) (A). The liver is now in total vascular exclusion (B). We do not routinely use venovenous bypass in this setting (see section on venovenous bypass in the chapter "Orthotopic Liver Transplantation").
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