63 Hellenic Journal of Surgery 2011; 83: 6 Abstract Background: Major and complex liver resections constitute a particular group of demanding op- erations which can be easily complicated by severe haemorrhage during vascular approach and liver resection, even when performed by experienced liver surgeons. In order to reduce bleeding, vari- ous surgical devices and manoeuvres have been used. Radiofrequency assisted (RFA) liver resec- tion is a relatively new method of transecting the liver parenchyma with favourable intra- and periop- erative results. Furthermore, in experienced hands, the hanging manoeuvre technique facilitates major hepatectomy with an “anterior approach,” reduc- ing several risks caused by liver mobilization. The combination of these techniques allows the achieve- ment of bloodless hepatectomy without vascular oc- clusions and the consequences of complications. Methods: A right hemihepatectomy for colorectal liver metastases using a new radiofrequency gen- erator (Surtron SB O) combined with the hanging manoeuvre was performed. The technique consist- ed of two parallel applications of the comb and a completely bloodless parenchymal transection with a scalpel along the second line. Results: Operative time was 245 minutes, intraop- erative blood loss was 120 ml, and transection blood loss was 70 ml. Conclusion: In our case, the combined use of an RF generator and hanging manoeuvre in right hemihe- patectomy provided a bloodless, safe, and relatively rapid parenchymal transection. Enhanced expo- sure contributes to better haemostasis and permits optimal allocation of the comb with protection of the IVC from injuries. Prospective and randomized studies are needed to compare this technique with the standard procedure. K. Bramis (Corresponding author), A. Manzelli, A. Petrou - Center of HPB and Transplant Surgery, Churchill Hospital, Oxford UK P. Rossi, A. Anselmo, G. Iaria, L. Toti, T. M. Tommaso, M. Berlanda, G. Tisone - Department of Transplatation, “Tor Vergata” University, Sant’ Eugenio Hospital, Rome, Italy e-mail: kbramis@gmail.com Key words: Bloodless, Liver resection, Hanging manoeuvre, Radiofrequency, RFA Introduction Hepatic resection is widely accepted as the only po- tential curative treatment for patients with a wide variety of liver conditions such as benign lesions, primary and metastatic liver malignancies and trau- ma. Excessive blood loss and blood transfusion con- tribute to poor short and long-term outcomes, al- though they may not represent the most important factors associated with unfavourable results after hepatectomy. Surgeons in fact still lack an efficient tool or method for transecting liver parenchyma without bleeding, especially in cases of major and non-anatomical resections [1, 2]. In order to reduce bleeding, many surgical manoeu- vres have been perfected: Pringle, total and selec- tive vascular exclusion, hanging manoeuvre, etc [3, 4]. To the same end, many devices have been de- veloped for liver transection, with rapid diffusion of RF-assisted liver resections [5, 6, 7]. We describe a right hemihepatectomy for colorectal metastases, using a new RF generator (Surtron SB O) combined with the hanging manoeuvre to facili- tate the application of the probe and to avoid po- tential injuries to the inferior vena cava (IVC). The combination of these two techniques allows better exposure and haemostasis of the deeper section plane with safer IVC protection Methods We present the case of a 63-year-old man with metachronous colorectal liver metastases (CLM), following an anterior resection for a pT3, N0, M0 tumour and subsequent multiple cycles of chemo- therapy treatments (XII FOLFIRI, XII FOLFOX). The CT scan was diagnostic of synchronous lung (2 cm lesion in the basal segment of the right inferior lobe), and CLM disease. An 11-13 cm lesion was demonstrated in the right hemi liver (Segments V, VI, VII, VIII), in proximity to the right hepatic vein (RHV) – IVC confluence, but without direct inva- RFA Assisted Liver Resection Combined With Hanging Mano- euvre: The Alternative Option for Safe and Bloodless Major Hepatectomy P. Rossi, A. Manzelli, A. Petrou, K. Bramis, A. Anselmo, G. Iaria, L. Toti, T. M. Tommaso, M. Berlanda, G. Tisone Received 17/08/2011 Accepted 21/09/2011 Original Article 347