Korean J Transplant.  2020 Sep;34(3):210-216. 10.4285/kjt.2020.34.3.210.

Graft outflow vein venoplasty for a laparoscopically harvested left lateral section graft in pediatric living donor liver transplantation

Affiliations
  • 1Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
  • 2Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

Abstract

Laparoscopically harvested left lateral section (LLS) grafts have drawbacks regarding the size of the graft left hepatic vein (LHV) orifice although they have the merit of cosmetics concerning the donor’s wound. We present a case of pediatric living donor liver transplantation (LDLT) using a laparoscopically harvested LLS graft and describe the refined surgical techniques for graft LHV venoplasty with a circumferential vein patch. The patient was a 46-month-old boy with marked growth retardation who was diagnosed with progressive familial intrahepatic cholestasis type 2. The donor was his 25-yearold mother. The LLS graft weighed 285 g. A circumferential patch of external iliac vein homograft was attached to the graft LHV orifice after incisions were made at the medial wall of the LHV trunk and superficial LHV branch, which made the graft LHV orifice much larger. The recipient’s hepatic vein orifice was also enlarged by unifying the three hepatic vein orifices. Other surgical procedures followed the standard LDLT operation. This patient recovered uneventfully and has been doing well for 1 year. In conclusion, our incision-and-patch venoplasty to enlarge the graft outflow vein orifice was beneficial for reducing the risk of hepatic vein outflow obstruction in LDLT using a laparoscopically harvested LLS graft.

Keyword

Left hepatic vein; Venoplasty; Vein patch; Stenosis; Pediatric transplantation

Figure

  • Fig. 1 Pretransplant computed tomography (CT) scans. Progression of hepatomegaly is shown between CT scans taken at 6 months (A) and 1 month (B) before transplantation.

  • Fig. 2 Preoperative imaging studies of the living donor. Computed tomography scan images showing the volume of the left lateral section (A) and the anatomy of the left hepatic vein (B). Magnetic resonance imaging study showing the vascular (C) and biliary (D) anatomy.

  • Fig. 3 Intraoperative photographs of the graft hepatic vein venoplasty at the back table. (A) The transverse diameter of the graft left hepatic vein (LHV) orifice was only 17 mm. (B) We made a 10 mm-long incision at the medial wall of the LHV trunk to enlarge the orifice. (C) A cryopreserved external iliac vein homograft patch was attached to the wall defect. Thereafter, we found a superficial LHV branch at the lateral side of the LHV orifice (arrow). (D, E) The overlying wall of this small vein was opened by 5 mm and the defect was covered with a small piece of the vein homograft. (F) A circumferential vein patch was finally attached at the graft LHV orifice and its transverse diameter was enlarged to 35 mm.

  • Fig. 4 Intraoperative photographs of the recipient hepatectomy. (A, B) We transected the right and left hepatic arteries at the highest level and transected the portal vein at the level of the second-order branch after marking the axis of the portal vein. (C, D) After total clamping of the inferior vena cava, we incised the hepatic parenchyma using a surgical knife, leaving the bulk of the hepatic parenchyma around the hepatic vein trunk. (E) The attached hepatic parenchyma was forcefully pulled out to detach it from the hepatic vein stumps. (F) The septa between the right and middle hepatic veins and the middle and left hepatic veins were incised to make a single large hepatic vein orifice with a 38 mm-wide transverse diameter.

  • Fig. 5 Intraoperative photographs of the graft implantation. (A, B) The right and left corners of the graft and recipient’s hepatic vein orifices were tagged with 5-0 polydioxanone (PDS) and anastomosed with continuous sutures at the posterior and anterior walls. (C, D) The portal vein was reconstructed with the branch patch of the recipient’s portal vein stump using a 6-0 PDS. (E) A vein homograft patch attached at the graft hepatic vein (arrow) made the graft hepatic vein anastomosis definitely wide. (F) The graft left hepatic artery was reconstructed under surgical microscopy using the recipient’s left hepatic artery branch.

  • Fig. 6 Posttransplant computed tomography scans taken 5 days after transplantation showing smooth-streamlined reconstruction of the hepatic (A, B) and portal (C, D) veins.


Reference

1. Scatton O, Katsanos G, Boillot O, Goumard C, Bernard D, Stenard F, et al. 2015; Pure laparoscopic left lateral sectionectomy in living donors: from innovation to development in France. Ann Surg. 261:506–12. DOI: 10.1097/SLA.0000000000000642. PMID: 24646560.
2. Broering DC, Elsheikh Y, Shagrani M, Abaalkhail F, Troisi RI. 2018; Pure laparoscopic living donor left lateral sectionectomy in pediatric transplantation: a propensity score analysis on 220 consecutive patients. Liver Transpl. 24:1019–30. DOI: 10.1002/lt.25043. PMID: 29489071.
Article
3. Gautier S, Monakhov A, Gallyamov E, Tsirulnikova O, Zagaynov E, Dzhanbekov T, et al. 2018; Laparoscopic left lateral section procurement in living liver donors: a single center propensity score-matched study. Clin Transplant. 32:e13374. DOI: 10.1111/ctr.13374. PMID: 30080281.
Article
4. Soubrane O, de Rougemont O, Kim KH, Samstein B, Mamode N, Boillot O, et al. 2015; Laparoscopic living donor left lateral sectionectomy: a new standard practice for donor hepatectomy. Ann Surg. 262:757–63. DOI: 10.1097/SLA.0000000000001485. PMID: 26583663.
5. Cho JY, Han HS, Kaneko H, Wakabayashi G, Okajima H, Uemoto S, et al. 2018; Survey results of the expert meeting on laparoscopic living donor hepatectomy and literature review. Dig Surg. 35:289–93. DOI: 10.1159/000479243. PMID: 29032378.
Article
6. Karakayali H, Boyvat F, Coskun M, Isiklar I, Sözen H, Filik L, et al. 2006; Venous complications after orthotopic liver transplantation. Transplant Proc. 38:604–6. DOI: 10.1016/j.transproceed.2006.01.011. PMID: 16549187.
Article
7. Galloux A, Pace E, Franchi-Abella S, Branchereau S, Gonzales E, Pariente D. 2018; Diagnosis, treatment and outcome of hepatic venous outflow obstruction in paediatric liver transplantation: 24-year experience at a single centre. Pediatr Radiol. 48:667–79. DOI: 10.1007/s00247-018-4079-y. PMID: 29468367.
Article
8. Katano T, Sanada Y, Hirata Y, Yamada N, Okada N, Onishi Y, et al. 2019; Endovascular stent placement for venous complications following pediatric liver transplantation: outcomes and indications. Pediatr Surg Int. 35:1185–95. DOI: 10.1007/s00383-019-04551-9. PMID: 31535198.
Article
9. Zhang ZY, Jin L, Chen G, Su TH, Zhu ZJ, Sun LY, et al. 2017; Balloon dilatation for treatment of hepatic venous outflow obstruction following pediatric liver transplantation. World J Gastroenterol. 23:8227–34. DOI: 10.3748/wjg.v23.i46.8227. PMID: 29290659. PMCID: PMC5739929.
Article
10. Lu KT, Cheng YF, Chen TY, Tsang LC, Ou HY, Yu CY, et al. 2018; Efficiency of transluminal angioplasty of hepatic venous outflow obstruction in pediatric liver transplantation. Transplant Proc. 50:2715–7. DOI: 10.1016/j.transproceed.2018.04.022. PMID: 30401383.
Article
11. Yeh YT, Chen CY, Tseng HS, Wang HK, Tsai HL, Lin NC, et al. 2017; Enlarging vascular stents after pediatric liver transplantation. J Pediatr Surg. 52:1934–9. DOI: 10.1016/j.jpedsurg.2017.08.060. PMID: 28927979.
Article
12. Imamura H, Makuuchi M, Sakamoto Y, Sugawara Y, Sano K, Nakayama A, et al. 2000; Anatomical keys and pitfalls in living donor liver transplantation. J Hepatobiliary Pancreat Surg. 7:380–94. DOI: 10.1007/s005340070033. PMID: 11180859.
Article
13. Matsunami H, Makuuchi M, Kawasaki S, Hashikura Y, Ikegami T, Nakazawa Y, et al. 1995; Venous reconstruction using three recipient hepatic veins in living related liver transplantation. Transplantation. 59:917–9. DOI: 10.1097/00007890-199503270-00024. PMID: 7701594. PMCID: PMC3892747.
Article
14. Kwon H, Kwon H, Hong JP, Han Y, Park H, Song GW, et al. 2015; Use of cryopreserved cadaveric arterial allograft as a vascular conduit for peripheral arterial graft infection. Ann Surg Treat Res. 89:51–4. DOI: 10.4174/astr.2015.89.1.51. PMID: 26131446. PMCID: PMC4481033.
Article
Full Text Links
  • KJT
Actions
Cited
CITED
export Copy
Close
Share
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr