■ Always search for anatomical variants, especially an aberrant left hepatic artery. This has to be selectively clamped in addition to occlusion of llie ligament.
■ Best inflow occlusion is accomplished by pushing down the tourniquet, clamping the band right behind it to hold the tension and then pushing it down again with some force,before fixing it in position by clamping the tourniquet and the band. This can be repeated several limes ("milking down technique"). When inflow occlusion is insufficient, especially in a very large hepatoduodenal ligament, a second tourniquet can be placed and occluded. » When bleeding is encountered under total vascular exclusion the most likely reason is incomplete inflow occlusion. It" an obvious reason cannot be identified, open outflow (but keep inflow occlusion and intrahepatic caval occlusion) and ask the anesthesiologist to lower the CVP.
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