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Small right hepatic vein
Inf
hepatic
hepatic vein
8.6 (V) Short Hepatic Veins
Right
hepatic vein
Inferior right
hepatic vein
Middle
hepatic vein
Left
77
4. In about 10% of patients, there is a big right inferior
hepatic drain (Fig.8.17). If this vein is divided, part of the
right liver (mainly segment 6) can become congested
because of compromised outow drainage. On the other
hand, in the case of right side liver resection, even when
the right hepatic vein has to be resected, segment 6 can
still be preserved by preserving the inow blood supply
from the right hepatic pedicle and outow blood supply
by this vein.
Fig. 8.16 Belghiti’s avascular tunnel
a
erior right
vein
Big right inferior hepatic vein
Fig. 8.17 (a) Big right inferior hepatic vein. (b) Big right inferior hepatic vein
Middle hepatic vein
hepatic vein
b
Left
78
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8 Five Important Anatomical Structures inRight or Left Hepatectomy
8.7 Conclusion
In conclusion, an adequate understanding of the ve important anatomical structures helps surgeons to carry out safe
and better liver operations.
Further Reading
Blumgart LH, editor. Liver, biliary & pancreatic surgery. Video atlas.
Philadelphia, USA: Elsevier Saunders; 2011.
Jamieson G, Launois B. Chapter 2: Living liver resections and liver
transplantation: the anatomy of the liver and associated structures.
In: Jamieson GG, editor. The anatomy of general surgical operation.
2nd ed. Edinburgh: Elsevier Churchill Livingstone; 2006. p.8–23.
Anatomy Relevant toLiver
Transplantation
9
9.1 Types ofLiver Transplantation
There are many classications of liver transplantation. A
simple classication of the types of liver transplantation can
be seen in Table9.1.
9.2 Reconstruction ofAnatomical
Structures
In liver transplantation, there are four important anatomical
structures that need to be reconstructed: the hepatic artery, the
portal vein, the common hepatic duct and the hepatic veins (or
the inferior vena cava). Adequate knowledge of the extrahepatic and intrahepatic prevailing patterns (the most commonly
seen patterns) and their anomalies of these four important
Table 9.1 Types of liver transplantation
Classication of Liver Transplantation
(The donated liver can be the whole liver or part of the liver)
Source of Donated Liver:
Cadaveric (brain death, cardiac death)
– Whole liver
– Reduced size
– Split liver
Living (Living-related, living non-related):
– Extended right hemiliver
– Right hemiliver
– Left hemiliver
– Left lateral section
Recipient:
Orthotopic
– Conventional technique
– Piggyback technique
Auxillary
– Orthotopic
– Temporary
– Heterotopic
Domino liver transplantation
Dual graft liver transplantation
structures are important in liver transplantation operations as
anomalies can make the operation even more complicated.
9.3 Whole Liver Transplantation (in
Cadaveric Liver Donation Only)
As the whole liver is used in donation, intrahepatic anomalies of any of the four important anatomical structures have
no impact on the transplant operation. However, extrahepatic
anomalies will affect the operation to a varying degree,
depending on the type and the location of the anomaly.
9.3.1 Operative Steps ofWhole Liver
Transplantation (See Chap. 19)
The operative steps in whole liver transplantation are shown
in Fig.9.1. The steps involve reconstruction of the hepatic
Fig. 9.1 Diagrammatic representation of the steps in whole liver
transplantation
© Springer Nature Singapore Pte Ltd. and People’s Medical Publishing House Co. Ltd. 2021
W. Y. Lau, Applied Anatomy in Liver Resection and Liver Transplantation, https://doi.org/10.1007/978-981-16-0800-1_9
79
80
cd
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a b
(a)
(b)
9 Anatomy Relevant toLiver Transplantation
(c)
(d)
Fig. 9.2 Whole liver transplantation. (a) Anastomosis of supra- and infra-hepatic inferior vena cava. (b) Anastomosis of portal vein (slings c, d),
hepatic artery (sling a) and bile duct (sling b). (d) Reperfusion of liver
veins (or inferior vena cava), the portal vein, the common
hepatic artery (usually under a microscope) and nally the
common hepatic duct.
The actual operation is shown in Fig.9.2.
However, extrahepatic anomalies of the common hepatic
artery are common, and many anomalies have been described
(Fig.9.4).
It is very difcult to remember all these anomalies. For
practical reasons, these anomalies can be simplied into the
following two types:
9.4 The Prevailing Anatomical Structures
Are theStructures Commonly Seen
inanIndividual. TheLess Commonly
Seen Patterns Are Anomalies
9.4.1 Hepatic Artery
The prevailing pattern of the common hepatic artery is shown
in Fig.9.3.
(a) Anomalies arising from a single common hepatic artery
in origin (Fig.9.5)
(b) The right and the left hepatic arteries arising from two
separate arteries from two different origins (Fig.9.6)
Real examples of such anomalies are shown in Fig.9.7.
The management of these arterial anomalies is more
complicated. The approaches are either anastomosing two
ab
9.4 The Prevailing Anatomical Structures Are theStructures Commonly Seen inanIndividual. TheLess Commonly Seen Patterns…
81
d
c
Fig. 9.3 Extrahepatic hepatic artery. (a) Diagram. (b) Angiogram. (c) Operation. (d) 3D reconstruction
82
a
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9 Anatomy Relevant toLiver Transplantation
Fig. 9.4
Anomalies of extrahepatic common hepatic artery. RH right hepatic artery, LH left hepatic artery, C cystic artery, GD gastroduodenal
artery, RG right gastric artery, CA coeliac artery, LG left gastric artery, S splenic artery
9.4 The Prevailing Anatomical Structures Are theStructures Commonly Seen inanIndividual. TheLess Commonly Seen Patterns…
b
83
Fig. 9.4 (continued)
vessels into a single vessel, or using a carrel patch to do the
reconstruction (Fig.9.8).
9.4.2 Common Hepatic Duct
Anomalies affecting the extrahepatic biliary system are common (Fig.9.9).
However, these anomalies are not important provided that
enough care is taken to recognise these anomalies and to
divide the biliary system distal enough so that a single bile
duct can be used in biliary reconstruction, similar to the prevailing pattern with a single common hepatic duct.
9.4.3 Portal Vein
Anomalies of the extrahepatic portal system are rare.
However, in cirrhotic patients, portal vein thrombosis can
make liver transplantation technically more difcult. The
84
ab
and the superior mesenteric artery
ab
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9 Anatomy Relevant toLiver Transplantation
Common hepatic artery arises from superior
Fig. 9.5 Anomalies arising from a single hepatic artery. (a) Common hepatic artery arises from superior mesenteric artery. (b) Common hepatic
artery arises from the common Trunk together with the coeliac artery and the superior mesenteric artery
mesenteric artery
Common hepatic artery arises from the
common trunk together with the coeliac artery
Fig. 9.6 The right and the left arteries arise from two separate arteries
from two different origins. (a) Left hepatic artery from left gastric
artery. (b) Right hepatic artery from superior mesenteric artery. (c) Left
hepatic artery from left gastric artery, right hepatic artery from superior
mesenteric artery. (d) Right and left hepatic arteries from different origins of aorta. (e) Left hepatic artery from the aorta, right hepatic artery
from coeliac artery
9.4 The Prevailing Anatomical Structures Are theStructures Commonly Seen inanIndividual. TheLess Commonly Seen Patterns…
85
c
d
e
Fig. 9.6 (continued)
donor portal vein may have to be anastomosed to the superior mesenteric vein of the recipient, sometimes a graft is
required to bridge the gap.
9.4.4 Hepatic Veins
Extrahepatic anomalies of the hepatic vein are rare. In such
rare cases, a piggyback liver transplant can solve the technical problems (Fig.9.10).
9.4.5 Partial Liver Transplant
With the exception of reduced-size liver transplantation
which is seldom carried out nowadays, it is important to have
adequate liver volumes and function on the two sides of the
liver after the liver has been transected into two parts. In split
liver transplantation, the right and the left sides of the liver
will be used on two liver recipients. In living donor liver
transplantation, a part of the liver will be transplanted onto
the recipient and the remaining part of the liver remains in
86
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9 Anatomy Relevant toLiver Transplantation
ab
c
Fig. 9.7 Examples of anomalies
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