clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

Implantation of the Left Graft in a Pediatric Recipient (Sg2 and 3)

As in this situation the cava stays with the right graft, the left hepatic vein is anastomosed directly on the inferior vena cava of the recipient. It is fundamental to keep the hepatic vein short as too long a vein can lead to kinking of the caval anastomosis. End- to-end anastomosis of the portal vein between the donor’s left portal vein and the recipient common trunk is performed. Finally, the celiac axis of the left graft is anastomosed to the hepatic artery of the recipient at the level of the gastroduodenal artery and biliary continuity is reconstituted by a Roux-en-Y biliodigestive anastomosis.

outflow is of great importance to safeguard a maximal parenchymal integrity. In principle the same venous reconstructions and anastomoses are made as in right liver donation, including reanastomosis of segment 6 veins and reconstruction of larger segment 5 or 8 veins as shown. Additionally two techniques, not usable in living donation, can be applied to make the implantation easier while maintaining optimal venous outflow.

Splitting of the Inferior Vena Cava

This technique can be used in the in-situ as well as in the ex-situ technique. The frontand backwall of the vena cava are cut longitudinally, thus obtaining a caval patch on both grafts containing the respective hepatic veins as well as a possible segment 6 vein on the right side and Sg1 veins on the left side. At implantation the caval patches are sewn into the front wall of the preserved recipient vena cava.

Splitting of the Middle Hepatic Vein

This technique can only be performed in ex-situ splitting. During parenchymal transection the middle hepatic vein is cut through the middle, in continuity with its orifice in the vena cava (A). On both sides it is reconstructed using donor iliac vein patches. In this way larger segment 5 or 8 veins are drained without the need for any further reconstructions or anastomoses (B-1, B-2).

Postoperative Complications

■Biliary leaks from the raw surface, which usually resolve with percutaneous drainage

■Other complications are the same as for orthotopic liver transplantation or living donor transplantations and should be treated accordingly

Tricks of the Senior Surgeon

■Sharp transection of the parenchyma is preferred as it leaves a flat surface allowing for most efficient hemostasis.

■Clips have a propensity to drop off during the implantation procedure. Therefore, every individual vessel seen on the cut surface is closed with stitches. During this step, care is taken to avoid liver rewarming by applying cold towels, leaving only the cut surface exposed.

Right Living Donor Hemihepatectomy

Zakiyah Kadry, Pierre-Alain Clavien

Indications and Contraindications

Right Lobe Living Donor Workup

■Psychological evaluation and clinical examination

■Laboratory tests for undiagnosed liver disease

■Non-invasive tests for the assessment of liver volume and anatomy:

–CT scan or MRI for volumetry and vascular reconstruction

–Magnetic resonance cholangiopancreatography (MRCP) or CT cholangiography for biliary anatomy (center dependent)

■Invasive tests:

–Liver biopsy (center dependent)

–ERCP (center dependent)

form ligament should be cut at a distance from the liver as it will be sutured to the diaphragm at the end of the procedure. The left triangular ligament is also preserved to fix the remnant left liver. Guided by intraoperative ultrasound (A-1), the position of the middle hepatic vein is marked by electrocautery (A-2) and any intrahepatic lesions missed on the preoperative workup are excluded.

If a portal vein trifurcation is present, the anterior and posterior branches should be individually identified and separately encircled.

The point of transection of the right hepatic duct as decided by intraoperative cholangiography is marked either with a metallic clip or a fine suture. The division of the right hepatic duct is started on its anterior wall at 2–3mm from the confluence with the left hepatic duct. Then, the posterior wall of the right hepatic duct is divided, leaving an adequate cuff to close the remaining donor side using a continuous suture of 5-0 or 6-0 resorbable PDS or Maxon without causing a stricture of either the common or left hepatic ducts. If there are an additional one or two bile ducts draining segments of the right liver into the left hepatic duct, they are identified and divided during the parenchymal dissection.

The line of hepatic transection should be approximately 1cm to the right of the middle hepatic vein, identified and demarcated at the start of the procedure by intraoperative ultrasound. The line of demarcation can also be checked by placing a vascular or bulldog clamp on the right hepatic artery and right portal vein.

Alternatively, a partial Pringle maneuver involving the left hemiliver by temporarily occluding the left hepatic artery and portal vein using an umbilical tape is also possible. This allows demarcation of the line of transection, which can be marked using electrocautery. Next, two stay sutures (2-0 silk) are placed on either side of the line of demarcation on the inferior border of the liver as for a conventional right hemihepatectomy.

The anesthesiologist is asked to maintain a low central venous pressure below 3mmHg. In case the hanging maneuver (see chapter “Hanging Maneuver for Right Hepatectomy”) is used, it is prepared at this stage. Although different techniques for liver dissection can be used, Hydrojet or CUSA without inflow occlusion is preferred in most centers.

In a standard right donor hepatectomy, the middle hepatic vein is conserved and remains with the donor left liver. When V5 and/or V8 are significant and have to be preserved, they are carefully identified during the dissection and divided between a vascular metal clip on the right side and a ligature of 2-0 silk on the left side close to the middle hepatic vein. This preserves the V5 and V8 veins for venous drainage reconstruction in the recipient.

On completion of the parenchymal transection, time is taken to re-check for hemostasis and any potential bile leakage on both the graft and donor side.