Recently, the indications for surgery have evolved, shifting from oncological criteria to surgical criteria, predominantly resectability. The technical feasibility of hepatectomy has to fulfill two mandatory conditions. First, it has to achieve a completely clear macroscopic resection margin [6], and second, a sufficient volume of functioning liver has to be spared.
Vascular resection combined with liver resection is the latest step. Recently, various methods have been reported for liver resection with vascular reconstruction, such as synthetic artificial grafts, cryopreserved vein, and IJV grafts. Each graft type has its own merits and demerits. The merits of synthetic vascular grafts are their universal availability and products having various lengths and diameters, while the demerits are the relatively rigid vascular walls and tendency to become infected [7]. Infections may be refractory because of the artificial nature of the graft. Furthermore, the tendency for thrombosis of artificial grafts may require that patients take anticoagulants or antiplatelet agents [8]. The merits of cryopreserved vein are its availability in various lengths and diameters, although its use is limited to relatively few institutions. Because of the biological nature of these grafts, the tunica intima may be injured to some extent by the cold storage, freezing, and thawing processes. In addition, the homologous nature of these grafts provokes an allogeneic immune reaction, which can result in lower long-term patency rates. The most serious problem in using cryopreserved vein is the possibility of transmitting serious pathogens [9, 10].
The merits of using IJV grafts are not only the best flexibility but also the most viable vessel wall among the various vascular graft types [5]. Although the theoretical disadvantage of procuring an IJV graft is cranial vascular congestion, this has not been reported, probably as a result of the presence of many drainage veins, including the opposite IJV [10]. Another disadvantage is the resultant operative scar in the neck. In order to obtain a long IJV graft, it is usually necessary to make an approximately 6-cm-long horizontal skin incision above the clavicle or a diagonal skin incision along the medial border of the sternocleidomastoid muscle. As a countermeasure, the scar can be hidden by wearing high-collared clothing or a scarf.
In selecting the graft for hepatic vein reconstruction, the patency of the reconstructing vein is important, because the obstruction of the graft can lead to severe congestion of the remaining liver tissue, deteriorating liver function, and accumulating ascites. We believe that the IJV graft is the most useful for hepatic vein reconstruction to maintain function [11].