Double Mini Upper Transversal Hepatectomy for Colorectal Liver Metastases Infiltrating the Right and the Left Hepatic Veins at the Hepatocaval Confluence

Abstract Background: Patients with tumor infiltration of both the right hepatic vein (RHV) and left hepatic vein (LHV) at the caval confluence traditionally are considered unresectable. Presence of peripheral communicating veins (CVs) allows the resection of these tumors through an innovative parenchyma-sparing strategy1-3-transversal hepatectomies.4,5 PATIENTS AND METHODS: A 48-year-old woman with sigmoid colon cancer and synchronous bilateral liver metastases presented with one metastasis in segments 7-8 invading the RHV at its confluence with the inferior vena cava (IVC) and one metastasis in segment 2 involving the LHV at the caval confluence. The middle hepatic vein (MHV) was uninvolved. She underwent primary tumor resection followed by 12 cycles of FOLFOX-bevacizumab, achieving a partial response with persistent infiltration of RHV and LHV. Computed tomography (CT) imaging demonstrated CVs between distal RHV and LHV branches and the MHV, providing venous outflow to the future liver remnant (FLR). Results: Intraoperative ultrasound confirmed MHV patency and adequate drainage from segments 3 and 6 via CVs. R0 resection of segment 2 (with LHV division) and segments 7-8 (with RHV division) was performed under ultrasound guidance and IVC clamping. The MHV was preserved, ensuring venous outflow of the FLR. Post-resection doppler ultrasound confirmed adequate inflow and outflow. No major postoperative complications occurred, and the patient was discharged on postoperative (PO) day 12. Conclusions: An innovative parenchyma-sparing resection is described: double mini upper transversal hepatectomy. This procedure can be performed when both RHV and LHV confluences are involved and CVs are present. Preservation of a single major hepatic vein supplemented by CV drainage can achieve oncologic radicality while sparing functional reserve.