Download Living Donor Transplantation: Left Hemiliver Donor Procedure and

Living Donor Transplantation:
Left Hemiliver Donor Procedure and Implantation
Koichi Tanaka, Hiroto Egawa
For laparoscopic left hemiliver donor procedure see chapter by D. Cherqui.
Open Donor Procedure for Left Living Donor Liver Grafts
STEP 1
Access and mobilization
Access is gained through a bilateral subcostal incision with cranial extension. The falciform ligament is divided leaving enough length on the liver side as it needs to be fixed
in the recipient. Finally a retractor (e.g., Takasago retractor) is installed (A).
The lateral segment is lifted up and a towel is placed in front of the spleen for its
protection. A sponge is placed behind the left triangular ligament and the lateral
segment is placed back. The left liver is pulled downward and the left coronary
ligament and the left triangular ligament are divided by a cautery knife (B).
A
B
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SECTION 3
STEP 2
Approach to the left hepatic vein and the left side of the cava
Liver
The lateral segment is rotated to the right, and the ligamentum venosum is encircled,
ligated and divided near the inferior vena cava (A). The connective tissue is detached
from the superior aspect of the Spigelius lobe to expose the left side of the inferior vena
cava as well as the posterior surface of the left hepatic vein (B).
Living Related Liver Transplantation: Left Hemiliver Donor Procedure and Implantation
STEP 3
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Dissection of the hepatoduodenal ligament
The serous membrane on the ventral aspect of the hepatoduodenal ligament is detached
at the level of the cystic duct and the hepatic arteries are identified. The left and middle
hepatic arteries are dissected out at the hepatic hilum up to the bifurcation of the right
and left hepatic artery (A). The middle hepatic artery can be cut off when it is clearly
smaller than the left hepatic artery.
When the anterior aspect of the hepatoduodenal ligament is separated, the common
bile duct can be identified. After the left hepatic duct is identified a small vascular clip
is placed to the predetermined cut line on the bile duct. A 24-G puncture needle with
a trocar is inserted into the common bile duct and cholangiography is obtained (B).
In some cases, the left hepatic duct may be located inside the hepatic parenchyma
and it is difficult to be identified. In such cases, it can be identified during the dissection
of the parenchyma.
The cholangiography provides information of the biliary anatomy and allows to
determine the dissection line of the left hepatic duct (C). After the cholangiography,
the catheter is removed and the puncture site is closed by a 6-0 Prolene stitch. The left
hepatic duct can now be encircled at the point of predetermined cut line (D).
B
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STEP 4
Parenchymal dissection
For a Left Lateral Segment Graft (Sg2 and 3)
A cutting line is marked on the surface with a cautery knife approximately 1cm to
the right of the falciform ligament (A). Without any vascular obstruction during
parenchymal dissection, the liver surface is incised with a cautery knife and the
parenchyma is dissected with a Cavitron Ultrasonic Surgical Aspirator (CUSA)
in combination with a bipolar cautery with irrigation system for hemostasis.
Small vessels are dissected with the cautery knife while thicker vessels
(i.e., diameter >3mm) are ligated or clipped. Large vessels are clamped, dissected
and suture-ligated by 5-0 or 6-0 Prolene stitches.
A
Liver
Living Related Liver Transplantation: Left Hemiliver Donor Procedure and Implantation
STEP 4 (continued)
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Parenchymal dissection
For a Left Lateral Segment Graft (Sg2 and 3)
The left hepatic duct can be found where the parenchymal dissection line meets the
hepatic hilus region (right side of the left portal branch) (B). The left hepatic duct is cut
at the previously determined site. The hilar plate and the stiff fibrous tissue are dissected
with a cautery knife. The left hepatic duct is closed with 6-0 Prolene suture on the donor
side.
In the left lateral segment graft, reconstruction of the Sg4 hepatic duct is not
necessary and it can be closed after confirming the direction. The Sg4 duct can be
closed on the donor side too.
It is crucial to free the left portal vein branch completely through ligation and
isolation of the caudate branches. They extend from the horizontal part of the origin
of the branch.
For the parenchymal dissection, curved DeBakey forceps are used as a guide.
The tip of the forceps is inserted between the caudate lobe and the lateral segment
from the head direction of the portal vein. The forceps are lifted and fixed. The cutting
line of the parenchyma is made between the marked incision of the surface and the tip
of the forceps (C).
B
C
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STEP 4 (continued)
Parenchymal dissection
Liver
For a Full Left Hemiliver Graft without caudate lobe (Sg2–4)
The cutting line for left hemiliver graft is marked on the surface with electrocautery
starting from the right side of the middle hepatic vein to the liver bed of the gallbladder.
The location of the middle hepatic vein is confirmed with ultrasonography before
parenchymal dissection. The cutting line on the posterior side starts from the liver bed
and reaches to the right side of the predetermined cutting point of the left hepatic duct.
The parenchymal dissection follows the sagittal plane from the top surface until the
level of the middle hepatic vein (line 1). When the entire middle hepatic vein is included
in the graft side, the direction of the dissection is changed in an oblique plane (line 2).
To prevent injury of the middle hepatic vein and its small venous branches, some
parenchymal tissue should be left on the middle hepatic vein. After dissection of the left
hepatic duct, the direction is changed toward the space between the lateral segment and
the caudate lobe (line 3). The curved DeBarkey forceps are useful as a guide as in left
lateral segmentectomy.
STEP 5
Preparation of the hepatic veins
The tissue around the hepatic veins is separated and the confluence of the left hepatic
vein and the middle hepatic vein is exposed using the CUSA. Small branches around
the confluence should be stitched with 6-0 Prolene suture and divided. Do not use
hemostatic clips as they might interfere with the vascular clamp.
Living Related Liver Transplantation: Left Hemiliver Donor Procedure and Implantation
STEP 6
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Perfusion and removal of the graft
After accomplishing the parenchymal dissection, the donor is systemically administered
1,000units of heparin. The left hepatic artery is clamped with two clips and divided.
The anterior wall of the left portal vein is opened and the tip of the catheter for
perfusion is inserted into the lumen. Subsequently the left portal vein is divided (A-1).
The left hepatic veins is clamped with a spoon clamp and divided. Immediately after
dividing the left hepatic vein (A-2), the graft is perfused with preservation solution
[histidine-tryptophan-ketoglutarate (HTK) or University of Wisconsin [UW] solution]
(A-3). The artery is not rinsed. The hepatic duct is washed with the solution.
The donor hepatic vein is closed with 5-0 Prolene, the donor portal vein with 6-0
Prolene and the donor hepatic artery is closed with 6-0 Prolene suture or 3-0 silk double
ligation.
If the left hepatic vein has a septum close to the orifice, it is cut sharply with scissors
and sutured to make a single orifice with enough length of the cuff (B).
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SECTION 3
Liver
Implantation Procedure for Left Living Donor Liver Grafts
STEP 1
Access and hilar dissection
A bilateral subcostal incision with an upper midline extension to the xiphoid is the
preferred access. The most important point to consider during the hilar dissection in
living donor liver transplantation is to leave the pedicle of the vessels and bile duct with
the greatest possible length, because they are much shorter than those in a cadaveric
liver graft. The hepatic arteries are dissected carefully and transected close to the liver
to provide adequate length and enough options for arterial reconstruction. In children
suffering from biliary atresia the hepatic artery frequently has a larger size than
expected. In this particular situation, dissection of the hepatic artery inside the liver
of the recipient is required to adjust the size of hepatic artery between the graft and the
recipient. Double ties on the proximal side of the hepatic arteries are recommended to
prevent injury to the intima. The first ligation is done loosely just to occlude the lumen
with 4-0 silk. The second tie is placed tightly just distal to the first.
The portal pedicle is elongated by dissecting the tissue around the portal vein up to
the confluence of the superior mesenteric and splenic vein. Removal of the lymph nodes
around the portal vein is helpful as it provides the desired smooth curve of the portal
vein. The portal flow should be confirmed by unclamping the portal vein. The left gastric
vein is divided routinely to increase portal flow.
Living Related Liver Transplantation: Left Hemiliver Donor Procedure and Implantation
STEP 2
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Reconstruction of the hepatic vein
We have three standard procedures for hepatic vein reconstruction in left-sided graft
implantation: (a) one orifice using all of the hepatic veins, (b) the left and middle hepatic
vein orifices and an additional incision of the IVC, and (c) the right hepatic vein and an
additional incision of the IVC (A).
Preparation of a single orifice by using all of the hepatic veins is shown in the
following figures: The inferior vena cava is entirely clamped to include all hepatic
venous stumps (B-1). All septa are opened to create a single hole (B-2) and the size is
measured (B-3). If the hole is too large for the hepatic vein of the graft, the diameter is
adjusted by 5-0 Prolene suture at the left corner of the hole. Stitches with double armed
5-0 Prolene or PDS are placed on the right and left corners (B-4). The posterior anastomosis is made by the intraluminal method. After accomplishing the anastomosis,
another small vascular clamp is placed just proximal to the anastomosis and the large
one is removed to resume blood flow of the inferior vena cava.
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SECTION 3
STEP 2 (continued)
Reconstruction of the hepatic vein
Liver
Preparation of a single orifice by using all of the hepatic veins is shown in the following
figures: The inferior vena cava is entirely clamped to include all hepatic venous stumps
(B-1). All septa are opened to create a single hole (B-2) and the size is measured (B-3).
If the hole is too large for the hepatic vein of the graft, the diameter is adjusted by 5-0
Prolene suture at the left corner of the hole. Stitches with double armed 5-0 Prolene or
PDS are placed on the right and left corners (B-4). The posterior anastomosis is made
by the intraluminal method. After accomplishing the anastomosis, another small
vascular clamp is placed just proximal to the anastomosis and the large one is removed
to resume blood flow of the inferior vena cava.
Living Related Liver Transplantation: Left Hemiliver Donor Procedure and Implantation
STEP 3
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Portal vein anastomosis
Different techniques can be used for portal vein preparation (A), including: (a) with a
branch patch, (b) with an oblique incision, (c) graft interposition, and (d) a patch graft.
The first two are the simplest and most frequently used to adjust the graft size of the
portal vein. If the portal vein wall is damaged or narrow, it should be changed with a
venous graft. When the available venous graft is too small for interposition, the patch
graft technique using a patch made from a small venous graft which is longitudinally
opened is recommended.
Before the portal anastomosis is started, the portal vein should be briefly unclamped
and washed with heparinized saline to check the flow and to remove possible coagula.
The anastomosis is started by placing two double armed 6-0 Prolene or PDS sutures at
the right and left corner of the graft portal vein. Anastomosis of the posterior wall is first
carried out from the inside, in a running suture fashion. During the anastomosis, the
suturing stitch should be kept loose to prevent anastomotic stricture (B). When this
technique is used, creation of a growth factor is not required.
This continuous suture is our standard technique in most cases. However, interrupted
sutures are used for the anterior wall subsequent to a running suture for the posterior
wall in cases of a size mismatch or a small diameter using 7-0 Prolene or PDS.
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STEP 4
Arterial anastomosis
Liver
A surgical microscope and magnifying glasses should be used to perform the arterial
anastomosis. First, excellent front flow of the recipient artery needs to be confirmed.
Both arteries are clamped with fine vascular clips and are freed from the surrounding
connective tissue with microscissors until the smooth adventitial surface is reached.
The anastomosis is carried out with an interrupted 8-0 Prolene suture.
Size mismatch between the graft and recipient artery is frequently encountered.
In most cases it can be managed by simple mechanical dilatation of the smaller artery
using fine forceps. When the mismatch is significant, several techniques for adaptation
can be used. In cases of multiple arteries, a larger one is chosen for the first anastomosis.
When excellent arterial backflow is observed from the second artery after the first anastomosis, the second artery can be ligated.
Living Related Liver Transplantation: Left Hemiliver Donor Procedure and Implantation
STEP 5
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Biliary anastomosis
In patients with biliary atresia, pediatric patients with small-diameter bile ducts, or in
patients with primary sclerosing cholangitis and a sclerotic common bile duct, a
hepatico-jejunostomy should be performed. In other cases, a duct to duct anastomosis
can be performed in a similar way as for orthotopic or right living donor liver transplantation.
A small hole is made in the Roux-en-Y limb close to the proximal end. A 4-Fr
polyvinyl alcohol tube is inserted through the hole into the intestinal lumen as an
external stent and is led out of the intestinal wall again. Two double-armed 6-0 PDS
sutures are placed on the right and left corner of the graft hepatic duct. The stitch of the
right corner is pulled with a small clamp to open the hepatic duct. Anastomosis of the
posterior wall is made first with a running suture using the stitch of the left corner (A).
After completion of the posterior wall, the inside needle of the stitch of the right corner
of the graft is passed through the corner of the jejunum from inside to outside. After
insertion of the tip of the stent into the duct lumen, anastomosis of the anterior wall is
made using another needle of the left corner in running fashion (B). When the diameter
of the hepatic duct is small, an incision on the anterior wall along the axis can be used
to enlarge it.
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Liver
Tricks of the Senior Surgeon
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Preparation of the hepatic artery for a left lateral segment liver graft:
In case a small middle hepatic artery disturbs the hilar dissection, it can be cut
after confirmation of a sufficiently large left hepatic artery. By contrast, the left
hepatic artery should be kept even if it seems to be too small for anastomosis
until the anatomy of the left and middle hepatic artery is clarified.
Preparation of the hepatic duct for a left lateral segment liver graft:
When the left hepatic duct is cut above the B 4 bifurcation to preserve it for the
donor, this is likely to result in two separate bile ducts (B2 and B3), which would
complicate the biliary anastomosis. Therefore, we recommend the preparation of
a single biliary orifice even if B4 needs to be sacrificed for this purpose. Since the
inflow to Sg4 is usually limited it usually shrinks which leads to a compensatory
enlargement of the remnant liver. Hence, the occlusion of B4 will not be a
problem for the recipient.
“Monosegment grafts”:
In cases where the lateral segment is too large, the graft can be reduced by cutting
the lateral half or two thirds. If this reduced graft is still too large, the caudal 1/3
can be removed.
To prevent twisting of the hepatic vein secondary to dislocation of the graft into
the right subphrenic space, the falciform ligament should be reattached before
the abdomen is closed.