Total hepatic vascular exclusion (THVE) is required for hepatectomy of hepatocellular carcinoma (HCC) complicated by tumor thrombus extending into the inferior vena cava (IVC). To determine the ideal IVC clamp position for THVE, it is important to confirm the position of advanced part of the tumor according to the heartbeat, and the orifice of the coronary sinus in the right atrium accurately; however, it is difficult to confirm the location of the coronary sinus via a standard computed tomography (CT) examination. Therefore, we confirmed the positions of the tumor thrombus and coronary sinus using electrocardiogram (ECG)-gated CT, according to a newly developed protocol featuring contrast medium injection to clearly depict the right atrium. If the tumor thrombus does not extend into the coronary sinus in the right atrium, we usually attempt THVE via a transmediastinal, intrapericardial IVC approach without thoracotomy or sternotomy. Herein, we present a surgical video involving HCC with tumor thrombus extending into the suprahepatic IVC. Case: A 58-year-old male presented with a tumor approximately 12 cm in size located between the anterior and medial segment of the liver, with tumor thrombus extending from the middle hepatic vein to the intrapericardial IVC. The advanced section of the tumor thrombus was found to be below the coronary sinus. We performed extended central bisegmentectomy under THVE using a transmediastinal, intrapericardial IVC approach. Adjuvant chemotherapy with sorafenib of the clinical trial was started on postoperative day 28. The patient survived and maintained good health under adjuvant chemotherapy for 15 months.