  uncontrolled bleeding and extensive damage of the liver should be considered a rare but possible complication during elective liver surgery for giant retrohepatic tumours [ 14 ] .
total vascular exclusion after first - step total hepatectomy followed by ex vivo liver surgery is sometimes indicated for huge vascular tumours of the liver characterized by caval and cavo - hepatic junction infiltration .
we present here a patient with giant caudate lobe neoplasm who remained anhepatic as a consequence of uncontrollable bleeding during hepatic mobilization .
a 46-year - old male patient with compression and dislocation of the inferior vena cava ( ivc ) by a giant hepatic haemangioma was referred to our surgical department after two episodes of pulmonary thromboembolism .
based on abdominal and thoracic ct scan , the patient was diagnosed to have a giant cavernous hepatic haemangioma , arising from the caudate lobe .
the tumour was surrounding the inferior vena cava ( ivc ) and occupying segment i , iii , iv , v , and in part segment viii .
a ct scan showed compression of the retrohepatic ivc ( figure 1 ) with thrombosis of the left and middle suprahepatic veins . on the basis of ct - scan imaging , hepatic malignancy such as haemangiosarcoma could not be ruled out ( figure 2 ) .   in order to prevent the risk of further episode of pulmonary embolism ,
the exploration of the abdomen confirmed the presence of a huge smooth mass , violaceous in colour , occupying the left and the central segments of the liver surrounding and compressing the ivc .
a laceration of the ivc at the junction of right and the middle suprahepatic veins caused an important bleeding which was difficult to control .
after pringle 's manoeuvre a running suture by a 3 - 0 prolene was carried out .
soon thereafter a worsening of the venous hepatic outflow was evident as suggested by darkening of the whole liver surface .
the mass became diffusely hemorrhagic and despite of hilar clamping the bleeding became soon uncontrollable .
we decided to proceed to total hepatectomy and to evaluate the feasibility of ex vivo bench liver surgery .
the hilar structures were quickly double ligated and resected . a heparinless veno - venous bypass ( vvbp )
was inserted from the right femoral vein and from the portal vein to the left axillary vein .
the huge mass also caused compression of the right hepatic vein that impaired liver flushing trough the portal perfusion .
the extensive parenchymal congestion made mandatory to give up each attempt for a left extended hepatectomy by ex vivo bench surgery .
a request for liver transplantation on a top priority basis was launched in the national and european organ sharing network .   through the waiting time for a liver from a deceased donor , the haemostatic condition of the patient worsened as evidenced by a diffuse bleeding all over the operative field .
the vvbp was considered at high risk of worsening coagulopathy and hypothermia and it was disconnected .
a dacron interposition prosthesis was inserted to replace the retrohepatic vena cava in order to restore the caval outflow .
a porto - caval shunt was also performed by anastomosing end - to - side the recipient portal vein with the dacron prosthesis .
the relatives of the patient were informed about his dramatic clinical conditions and an informed consent was obtained to proceed to a super urgent liver transplantation .
the liver graft was harvested and available in our transplant center 12 hours after hepatectomy .  
removal of the dacron graft was considered but the donor liver was harvested with a caval segment shorter than the dacron graft .
the iliac venous graft harvested from the donor was unsuitable as an extension caval graft .
the suprahepatic and infrahepatic vena cava orifices of the donor liver allograft were sutured by endovascular stapler .
a wide side - to - side cavo - caval anastomosis was performed between retrohepatic vena cava of the liver and the dacron interposition graft ( figure 3 ) .
there were no postoperative complications and the patient was discharged 26 days after the transplant procedure .
ct scan 4 months after the transplant procedure showed a normal liver graft with patent dacron prosthesis ( figure 4 ) . at the moment , after 25 months , the patient is in good physical condition with normal liver function tests .
doppler ultrasound studies at 3 and 15 months showed perfect permeability of cavo - cavostomy and patency of the dacron graft .
emergency liver transplantation as a consequence of a massive bleeding during elective liver surgery for tumours infiltrating the ivc , is a rare dramatic clinical condition .
surgery of the caudate lobe , due to its unique anatomical site , is considered at high risk of intraoperative complications even by experienced surgeons   with a perioperative mortality ranging from 2% to 9% rate [ 14 ] .
however , we were unable to flush the liver at bench surgery and superurgent liver transplantation was the only available option .
although with a size mismatch , an ab0 compatible liver graft was soon available . during the anhepatic phase , a severe coagulopathy and hypothermia contraindicated the prolonged use of the vvbp by centrifugal pump .
the restoration of the caval integrity was carried out by a dacron interposition prosthesis to prevent renal failure , splanchnic congestion and to restore cardiac function [ 8 , 9 ] .
the vena cava of donor liver was shorter than the dacron interposition graft as a result of the size mismatch between the donor and the recipient .
dacron prosthesis has been sometimes employed for caval reconstruction during resection of huge liver tumours .  
a synthetic prosthesis as a bridge for a short vena cava during liver transplantation has recently been reported ; however , the same authors reported a severe anastomotic stenosis occurring six months after operation .
our technique is a modification of the side - to - side cavo - cavostomy previously described by belghiti et al .   and lerut and gertsch .
it simply differs from the original technique for the utilization of the dacron prosthesis .   in conclusion ,
superurgent liver transplantation should be considered a rescue procedure in selected patients when challenging liver resections are carried out .  
synthetic vascular graft should not be recommended during organ transplantation for the high risk of infection and graft thrombosis .
however , we were able to demonstrate that , in difficult situations when technical and anatomical difficulties threaten the completion of the liver transplant procedure , the utilization of dacron prosthesis can be considered a viable option with long term good results .
 we describe a modified technique of side - to - side cavo - cavostomy by dacron interposition prosthesis during a super urgent liver transplantation . 
 a liver graft from a deceased donor was immediately requested on a top priority basis as a consequence of massive bleeding during extended left hepatectomy for a huge hepatic haemangioma arising from the caudate lobe . 
 veno - venous bypass was employed during anhepatic phase but it was disconnected due to severe fibrinolysis and hypothermia . 
 a porto - caval shunt was performed and the inferior vena cava outflow was restored by a dacron interposition prosthesis . 
 a liver graft from a deceased donor was available 16 hours later . due to the shortness of the vena cava of the donor liver graft , the removal of the dacron graft was impossible and a modified side - to - side cavo - cavostomy between the dacron interposition graft and the vena cava of the donor liver was than performed . 
 liver transplantation was uneventful and the patient is doing well 25 months after the surgical procedure . 
 although the use of synthetic vascular prosthesis should usually be discouraged during organ transplantation , its exceptional use during liver transplantation is possible with long - term good 
 results . 
1. Introduction
2. Case Report
3. Discussion