Liver tumors involving hepatic vein (HV) at caval confluence have been always considered an indication for major hepatectomy and/or HV reconstruction. However, careful study by means of intraoperative ultrasonography (IOUS) of tumorvein relations and HV anatomy searching for accessory veins, together with color-Doppler IOUS analysis of portal flow, allows more conservative approaches also in these patients. Indeed, in our experience, only 12% of patients, who were operated because of liver tumors in contact or in close adjacency with one or more HVs, underwent removal of at least 3 segments: none of them required HV reconstruction, and no hospital mortality was seen. Therefore, IOUS allows sparing liver parenchyma without tumor recurrence in most patients with tumors involving HV at their caval confluence, avoiding more extended hepatectomies or HV reconstructions. This approach to complex presentations of liver tumors by the use of IOUS-guidance is a further confirmation of the importance of this tool for accomplishing a safe and effective surgical treatment.