Ex-Vivo Liver Surgery

The incorporation of techniques developed in living-donor and split-liver transplantation to hepatobiliary surgery have advanced the safety and applicability of liver resection for primary as well as metastatic disease of the liver. The most technically challenging and physiologically demanding resection technique currently employed is ex-vivo hepatectomy with autotransplantation (EVAT), which is reserved for tumors involving hepatic veins, vena cava, or portal veins which require complex vascular reconstructions. Ex-vivo hepatectomy with autotransplantation limits warm ischemia, provides a bloodless field to optimize complete tumor resection, and permits complex vascular reconstructions. The procedure has been sparingly applied to conventionally unresectable primary benign and malignant tumors as well as colorectal metastases. It has also been utilized to avoid the need for liver transplantation. Since being reported almost three decades ago, ex-vivo hepatectomy with autotransplantation remains a controversial procedure limited to centers with significant experience in transplantation and hepatobiliary surgery. To date, available data have not clearly demonstrated a survival benefit for this procedure; however, there are an increasing number of long-term survivors reported after completion of this procedure. This manuscript reviews the most current data on candidate selection, technical performance, and outcomes of ex-vivo hepatectomy with autotransplantation, as well as the experience and resources of the surgical team required to balance the risks and the potential benefits for a particular patient.