Korean J Hepatobiliary Pancreat Surg.  2016 Aug;20(3):97-101. 10.14701/kjhbps.2016.20.3.97.

Standardized surgical techniques for adult living donor liver transplantation using a modified right lobe graft: a video presentation from bench to reperfusion

• Hwang S
• Ha TY
• Ahn CS
• Moon DB
• Kim KH
• Song GW
• Jung DH
• Park GC
• Lee SG

• KMID: 2351295
• DOI: http://doi.org/10.14701/kjhbps.2016.20.3.97

Abstract

After having experienced more than 2,000 cases of adult living donor liver transplantation (LDLT), we established the concepts of right liver graft standardization. Right liver graft standardization intends to provide hemodynamics-based and regeneration-compliant reconstruction of vascular inflow and outflow. Right liver graft standardization consists of the following components: Right hepatic vein reconstruction includes a combination of caudal-side deep incision and patch venoplasty of the graft right hepatic vein to remove the acute angle between the graft right hepatic vein and the inferior vena cava; middle hepatic vein reconstruction includes interposition of a uniform-shaped conduit with large-sized homologous or prosthetic grafts; if the inferior right hepatic vein is present, its reconstruction includes funneling and unification venoplasty for multiple short hepatic veins; if donor portal vein anomaly is present, its reconstruction includes conjoined unification venoplasty for two or more portal vein orifices. This video clip that shows the surgical technique from bench to reperfusion was a case presentation of adult LDLT using a modified right liver graft from the patient's son. Our intention behind proposing the concept of right liver graft standardization is that it can be universally applicable and may guarantee nearly the same outcomes regardless of the surgeon's experience. We believe that this reconstruction model would be primarily applied to a majority of adult LDLT cases.

Keyword

Modified right lobe graft; Right hepatic vein; Middle hepatic vein; Interposition graft; Living donor liver transplantation

MeSH Terms

Adult*
Hepatic Veins
Humans
Intention
Liver Transplantation*
Liver*
Living Donors*
Portal Vein
Reperfusion*
Tissue Donors
Transplants*
Vena Cava, Inferior

Figure

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  Fig. 1 Right hepatic vein (RHV) reconstruction technique with RHV angle blunting and inferior vena cava enlargement. The central defect was firmly tied for bleeding control and patch coverage and then the suture was extended bidirectionally. (A) After caudal incision of the RHV orifice, a vein patch was attached to the defect. (B) Recipient RHV stump was incised by sequential longitudinal and transverse incisions, and then a small vein patch was attached to the inferior vena cava.5

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  Fig. 2 Middle hepatic vein reconstruction using a cryopreserved iliac vein graft (A), a cryopreserved aorta graft (B), a polytetrafluoroethylene grafts, (C) and a cryopreserved iliac artery graft (D).789

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  Fig. 3 Refined surgical techniques for reconstruction of two adjacent small-sized inferior right hepatic veins. A narrow vein neck (A) was opened by a small incision (arrows) into the liver parenchyma (B). A small vein patch was tightly placed between the incised orifices (C) and then sutured (D). Two thirds of the orifice circumference was fenced with a narrow vein patch to facilitate reconstruction at the recipient inferior vena cava (E). Additional small incisions converted a conventional unification venoplasty (F) to a unification funneling venoplasty (G), making it hemodynamically more resistant to stretching or compression.10

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  Fig. 4 Schematic illustration of the conjoined unification venoplasty technique. A 5 mm-long segment of the autologous sectional portal vein (PV) branch was excised and inserted as a central vein patch between the two sectional PV orifices with small niches. The crotch-opened autologous Y-graft was anastomosed to the unified graft PV orifice, making a potbelly-shaped PV confluence.11

Reference

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