الفهرس 
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Abstract
Technical Refinements, Better Understanding Of Hepatic Architecture And Functions, Advancements In Surgical And Anesthetic Techniques And Equipments And Development Of Intensive Care Units Have Decreased Morbidity And Mortality Rates Following Hepatic Resections. However; Profuse Hemorrhage And Air Embolism Remain Major Risks During Major Hepatic Resections For Large Hepatic Tumors, Particularly Those Located Centrally Or Close To The Hepatic Veins Or Inferior Vena Cava. The Correlation Of Intraoperative Bleeding With Short And Long Term Outcome Of Hepatic Resection Has Been Repeatedly Confirmed. Limiting Blood Loss While Performing Safe, Expeditious Hepatic Resection Is A Prime Concern Of The Hepatobiliary Surgeon. Patients And Methods: This Prospective Randomized Study Included 40 Patients Presenting To National Cancer Institute , Cairo University To Be Subjected To Major Hepatic Resections. After IRB Approval Patients Were Randomized Into Two Groups. group A Included 20 Patients In Intermittent Conventional Total Vascular Exclusion .group B Included 20 Patients In Intermittent Hepatic Vascular Exclusion With Preservation Of The Caval Flow. Results: The Mean Operative Time, For group A Was 198.8±53.7 (Range 120-275min) And For group B Was 225.5 ±54.9 (Range 140-330 Min), P Value 0.13.The Mean Duration Of Normothermic Ischemia For group A Was 58.2±12.2 (Range 35-75 Min) And For group B Was 80.0±18.4 (Range 50-105 Min), P Value 0.0001. The Mean Operative Blood Loss, For group A Was 812.5 ±481.5 (Range 80-1800 Ml), And For group B Was 796 ±518.2 (Range 120-2250 Ml), P Value 0.92. Postoperative Hepatic Insufficiency Developed In 4 Patients I.E. 10% (3 In group A And 1 In group B, P Value 0.02), 3 Of Them Were Cirrhotic (3 Out Of 12 I.E. 25%), The Fourth Patient Was With Normal Hepatic Parenchyma (1out Of 28 I.E. 3.6%) P Value 0.001. The Mean Durations Of ICU And Hospital Stay Were Longer For Patients With Complications (ICU 2.3±2.4) And Hospital Stay 16.4±3.8 Then For Those Without Complications (ICU 1±1.1 And Hospital Stay 7.8±3.1, With P Values 0.01, 0.0007 Respectively, However There Was No Difference Between The Two Groups In ICU And Hospital Stay. No Intraoperative Or Postoperative Mortalities Were Encountered. Follow-Up: Regular Follow Up Was Available For Variable Periods Of Time Ranging from 3-24 Months With A Mean Of 11±5 Months. For The 27 Patients With Primary Hepatic Malignant Tumors It Shows That 19 Patients (70.4%) Were Alive And Free Of Disease, The 2-Year Disease Free Survival Was 64.7±0.07.There Were 8 Patients (29.6%) Who Experienced A Relapse Either Local In 3 Patients (11.1%) 14, 15 And 21 Months Following Hepatectomy, Distant Relapse In 2 Patients (7.4%), 16 And 18 Months Following Hepatectomy Or Both In 3 Patients (11.1%), 12, 15 And 20 Months Following Hepatectomy. Concerning The 9 Patients With Hepatic Metastases (7 Colorectal, 1 GIST And 1 Carcinoid Tumor Of Pancreatic Origin), 6 Patients Were Alive And Free Of Disease. The Remaining 3 Patients Experienced Local Recurrence Within The Liver In 2 Patients (1 Metastatic Colonic Cancer And 1 Metastatic GIST) 18 And 22 Months Following Hepatectomy Respectively. Conclusions: Both Techniques Are Equally Effective In Bleeding Control And Abolishing The Risk Of Air Embolism And Thus Allowing Almost All Range Of Hepatic Resections To Be Performed In A Safe Manner. Conventional Total Vascular Exclusion Is Associated With Cardiopulmonary And Hemodynamic Alterations And Maybe Not Tolerated By Some Patients. However In Some Circumstances Conventional Total Vascular Exclusion Is Useful Particularly When The Tumor Adheres To Or Is Very Close To The Retrohepatic IVC. Hepatic Vascular Exclusion With Preservation Of Caval Flow (Whether Total Or Partial) On The Other Hand Is Well Tolerated With Better Hepatic And Renal Functions And Shorter Hospital Stay.