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2E). These cases are considered irresectable by most surgeons. However, a major hepatectomy with vascular reconstruction represents the only option offered by others. This last can be avoided when CVs between adjacent HVs are detected intraoperatively with US[69]. Upper transversal hepatectomy involves total or partial resection of the superior liver segments (S7, 8, 4a and 2) accompanied by the RHV and MHV or even all HVs. It can be performed only when an IRHV is present simultaneously with CVs connecting the IRHV with the MHV and the MHV with the LHV. After checking the function of the complete inter-venous circuit by IOUS and certifying the absence of macroscopic congestion, resection is IOUS-guided preserving the CVs. More recently, an even more conservative variant of this approach has been proposed also by Torzilli et al[70], denominated ��mini upper-transversal Selleckchem Verteporfin hepatectomy��. HV-sparing hepatectomy This approach has been recently introduced by Torzilli et al[71] for metastases located in S8, 4a involving both the RHV and MHV at the hepato-caval confluence but neither the IRHV nor CVs are present at imaging. In such cases, when vascular invasion comprises 1/3 of their circumference or less, partial resection of S7, 8, and 4a �� 1 paracaval can be performed sparing both RHV and MHV by partial resection and reconstruction by running suture. This approach has been proposed as an effective alternative to major resection performed Itraconazole immediately or in a staged perspective[71]. Systematic extended right posterior sectionectomy In case of vascular invasion of the RHV with multiple tumors in the right posterior section, and/or invasion of the right posterior portal branch (P6, 7) with tumor in close adjacency (Vandetanib mouse posterior sectionectomy (SERPS) has been proposed by Torzilli et al[72] as an alternative approach, performing a right posterior sectionectomy with a tailored extension to the right anterior section, either the right part of segment 8 �� the RHV and/or the right part of S5 exposing but not dividing the pedicle of S5, 8 on the cut surface just enough to guarantee complete tumor removal. In all the aforementioned conditions, portal blood flow at color-Doppler IOUS in the pedicle of S5, 8 (right anterior glissonean sheath) has to be hepatopetal once RHV is clamped for carrying out SERPS. SERPS serves also as an alternative to right hepatectomy when bisegmentectomy 7-8 is not possible (in cases where there is vascular invasion of the RHV but without tumor involving S6) because there is not a proper outflow for S6 once RHV is divided (absence of IRHV and hepatofugal portal blood flow at Doppler IOUS in P6 when RHV is clamped).