Transversal hepatectomies: Classification and intention-to-treat validation of new parenchyma-sparing procedures for deep-located hepatic tumors.

BACKGROUND:Deep-located liver tumors involving hepatic veins at the caval confluence or main Glissonean pedicles generally require a major hepatectomy. An intraoperative ultrasound guidance policy opened a possibility to opt for parenchyma-sparing procedures as alternatives to major hepatectomy, called transversal hepatectomies. We ought to standardize the procedure and analyze the surgical outcome, oncological suitability, and salvageability. METHODS:This is a retrospective cohort study. All consecutive patients undergoing hepatectomies for liver tumors between January 2005 and August 2020 were reviewed. Transversal hepatectomies were classified as follows: upper transversal hepatectomy: resection of the posterosuperior segments along with at least 1 hepatic vein and preservation of the anteroinferior ones; roller coaster hepatectomy: transversal hepatectomy with tumor vessel detachment from at least 2 hepatic veins; and lower transversal hepatectomy: amputation of the distal portion of at least 1 hepatic vein with tumor vessel detachment from first/second-order Glissonean pedicles. Morbidity, mortality, local recurrences, and salvageability in cases of relapse were considered. RESULTS:A total of 61 transversal hepatectomies were performed: 40 (66%) upper transversal hepatectomies, 19 (31%) roller coaster hepatectomies, and 2 (3%) lower transversal hepatectomies. The median preserved liver volume was 67% (range 41-86). Mortality was 0, and major morbidity was 6%. Local recurrence occurred in 7 (11%) patients. Ten out of 34 (29%) patients with liver-only recurrence received redo surgery. CONCLUSION:Transversal hepatectomies offer a new parenchyma-sparing perspective for the management of complex tumor presentation, which would otherwise demand major tissue removal or even unresectability. Safety, adequate local control, and salvageability are further pillars of this approach herein systematized.