Living Donor Hepatectomy Technique

Updated: Dec 17, 2013
  • Author: Antonios Arvelakis, MD; Chief Editor: Ron Shapiro, MD  more...
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Technique

Approach Considerations

There are 3 different types of donor hepatectomies for living donor liver transplantation (LDLT), as follows:

  • Left lateral hepatectomy, in which the graft consists of segments II and III, with or without segment I
  • Left hepatectomy, in which the graft consists of the whole left lobe, segments I, II, III, and IV
  • Right hepatectomy, in which the graft consists of the right lobe, segments V, VI, VII, and VIII
Next:

Left Lateral Hepatectomy

The patient is placed in a regular supine position with arms on extension. Care is taken to avoid pressure sores and brachial plexus injury. Devices to prevent hypothermia and deep vein thrombosis are installed.

The incision for left lateral hepatectomy is the classic hepatectomy bilateral subcostal incision with upward midline extension. In cases of thin donors, a midline incision can also be used (see image below).

Incision for living donor hepatectomy. The left la Incision for living donor hepatectomy. The left lateral subcostal extension can be avoided depending on the donor body habitus.

The xiphoid is excised so exposure of the suprahepatic vena cava can be achieved after the application of the retractors.

Self-retaining retractors are used.

The liver is carefully inspected to evaluate any abnormalities that may have been missed on preoperative imaging. At this point, many surgeons prefer to perform intraoperative ultrasonography to delineate the arrangement of segments II, III, and IV and the hepatic veins.

The round ligament is divided and double-ligated, and the falciform ligament is taken down with cautery. The left triangle ligament is also divided with cautery. The lesser omentum is then opened and palpated to evaluate for the presence of an accessory or replaced left hepatic artery (LHA) and eventually opened if such an artery is absent. If there is a replaced LHA, it will be preserved with the graft.

At this point, some surgeons proceed with cholecystectomy and intraoperative cholangiography. The aim of intraoperative cholangiography is to identify possible biliary anatomic variations that were missed on preoperative imaging and to delineate the point of safe division of the bile duct. Not all surgeons perform cholecystectomy and intraoperative cholangiography as part of left lateral hepatectomy, since preoperative imaging offers high-quality images of the anatomy and the possible variations of this region.

The left lateral sector is detached from the undersurface of the diaphragm by dividing the left triangular ligament. The loose tissue overlying the suprahepatic inferior vena cava (IVC) is divided to expose the common trunk of the left hepatic vein (LHV) and middle hepatic vein (MHV) and its junction with the IVC.

The next step is to identify and dissect the left branch of the portal vein and the hepatic artery (see image below).

The left branch of the portal vein and the left he The left branch of the portal vein and the left hepatic artery have been dissected free from surrounding tissue. Notice that in this donor there are two separate arteries supplying the segment II and III.

During dissection of the left portal vein (LPV), care should be taken to recognize and double-ligate small portal tributaries from the caudate lobe. This is important in order to safely carry out the parenchymal transection at that level. The dissection of the LPV continues with ligation of the portal branches of segment IV. Once the dissection of the hilar structures is complete, the left lateral sector is elevated to expose the fissure of ductus venosum (ligament of Arantius).

The ductus venosum is dissected and ligated at its junction with the IVC, exposing the lateral wall of the LHV. If the junction of the LHV and MHV is extrahepatic, at this point, gentle dissection can be carried out around the LHV and extended cephalad to create a plane between the LHV and MHV. Many surgeons avoid to attempt to encircle the LHV at this point, since such a maneuver may induce severe bleeding if the junction between the LHV and MHV is intrahepatic. The liver capsule just underneath the fissure of ductus venosum is removed with cautery or the ultrasonic dissector (CUSA). This line will be the plane of dissection between the caudate lobe and the left lateral graft.

The next step is to mark the plane of resection on the anterior surface with cautery. The line will be on the left of the falciform ligament. After the marking, transection of the liver parenchyma is started.

There are multiple ways to transect the liver (eg, clamp fracture, cautery, double-ligation); the preferred method for LDLT is with an ultrasonic dissector (CUSA) (see image below).

Ultrasonic aspirator and dissector. Ultrasonic aspirator and dissector.

The advantages of the ultrasonic dissector are that it can coagulate structures less than 1 mm safely but preserve larger ones that need to be double-ligated or clipped, minimizing blood loss and making larger structures more easily recognized and ligated safely. The hepatic parenchyma is transected without obstructing the blood inflow to the liver (Pringle maneuver).

Usually, the dissector is set at 60% of maximum amplitude, irrigation with normal saline at about 4-6 mL/minute, and the suction power at 20% of maximum. A fine-tip handpiece with incorporated electrocautery is preferred for precise dissection. The parenchyma is transected on the anterior surface of the liver until the hilar plate is reached (see image below).

After the parenchmymal dissection reaches the hila After the parenchmymal dissection reaches the hilar plate, a right angle clamp is passed behind the bile duct.

At this point, many surgeons prefer to perform a second cholangiogram to confirm the exact point of the left hepatic duct (LHD) division. This cholangiogram allows the surgeon to dissect the LHD safely before the branching to the segment II and III ducts, thus avoiding two bile duct orifices in the graft. Also, in some cases, the duct confluence of segments II and III is in very close proximity to the right hepatic duct (RHD), and cholangiography helps to avoid injury to the right duct.

Once the point of LHD division is determined, the hilar plate, along with the LHD, are divided slowly with a knife (see image below).

The bile duct is divided with a knife for precise The bile duct is divided with a knife for precise transection and preservation of its vascular supply.

Brisk arterial and venous bleeding from the hilar plate and the ductal wall is common (see image below).

Brisk bleeding after the division of bile duct. Brisk bleeding after the division of bile duct.

Bleeding should be controlled (usually with 6-0 Prolene suture) immediately as it is encountered before proceeding with further division to reduce blood loss and to provide a clear field. The hilar plate is completely divided, and any hilar plate vessels are then encircled and divided. The orifice of the common hepatic duct is then sutured with 6-0 PDS suture. If the right bile duct is in very close proximity to the confluence of segments II and III ducts, a third cholangiogram may be performed to rule out injury or narrowing of the common duct.

After division of the hilar plate and LHD, hilar plate cut edges should be carefully inspected to identify any small caudate lobe bile ducts that may have been transected. If any are found, they should be suture ligated to avoid bile leakage.

The parenchymal division is then continued toward the fissure of ductus venosum. Lifting up the fissure with umbilical tape, clamp, or even the assistant’s fingers will help the surgeon keep the proper orientation and expedite the liver transection. Great care should be taken at this point to avoid forceful retraction of the graft, causing avulsion and bleeding from the LHA (see image below).

The parenchyma and the bile duct have been divided The parenchyma and the bile duct have been divided.

The parenchymal transection continues cephalad and finishes at the junction of the MHV and LHV. In certain cases, a large segment IV hepatic vein may drain directly to the LHV, which will be encountered in this area and will need to be divided and tied or suture-ligated in order to complete the hepatectomy.

If the recipient needs a larger liver graft but not a formal whole left lobe, part of the segment IV parenchyma may be included with segments II and III. In this case, the transection plane moves farther toward the midplane of the liver, and the MHV may be encountered. In this setting, the MHV should be followed carefully to the junction with the LHV, and the liver transection plane is then shifted horizontally toward the fissure of the ductus venosum.

After the parenchymal transection is complete, retrieval of the left lateral graft starts with division of the LHA. A bulldog clamp is placed on the LHA, and a 2-0 silk tie is placed close to the junction with the main hepatic artery. The LHA is then divided with a knife. The LPV follows in the same manner. Some surgeons prefer to use a vascular clamp on the LPV close to the junction with the right, to divide the LPV, and to oversew the remaining stump with 6-0 Prolene. Using a 2-0 silk tie on the stamp is also very common. When the tie is placed, sufficient length of the LPV should be left above the tie for subsequent suturing while also avoiding occlusion of the bifurcation of the portal vein.

After the LHA and LPV, the LHV is the one left to be divided. The division can be carried out with a vascular stapler (TA30, V3 [2.5 mm], USA Surgical) or with a vascular clamp and oversewing the remaining stump with 5-0 Prolene suture.

The liver graft is transferred to a basin that contains ice sludge. The bulldog clamps are removed, and the graft is flushed with histidine-tryptophan-ketoglutarate (HTK) solution . A cannula is placed in the LPV, and at least 1000 mL of solution is flushed through the graft. The hepatic artery is then cannulated, usually with a 23-gauge angiocatheter and flushed with 500 mL of solution. The flushing continues until the effluent is clear solution without any blood. The bile duct is also rinsed with HTK upon conclusion.

The graft is then inspected for quality and any missed injuries. The LHV orifice is inspected for the need of any reconstruction. Finally, the graft is weighed, stored in the plastic bag, and transferred to the room of the recipient operation.

After the graft has been removed and the vascular stumps have been sutured/ligated, the donor is carefully inspected to identify any areas of bleeding or bile leak. Some surgeons infuse dilute methylene blue into the common bile duct via the cystic duct cannula to check for bile leaks. The likely sites for bile leaks include the LHD stump, the hilar plate, and the entire cut surface. If any bile leak is found, it is sutured with 6-0 PDS.

The abdominal wound is closed. Most surgeons choose not to leave any abdominal drains in the donor.

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Left Lobe Hepatectomy

The donor is placed in a supine position with care to avoid pressure sores and brachial plexus injury. Devices to prevent hypothermia and deep vein thrombosis are used. The incision, as in the case of left lateral hepatectomy, is bilateral subcostal with midline extension. A hockey-stick incision with avoidance of the left subcostal part is also an option in certain patients.

After the liver is exposed with appropriate retractors, it is inspected for quality and size. If the liver appears normal, cholecystectomy and intraoperative cholangiography are then performed (see image below). This is a mandatory step during left hepatectomy, since biliary duct variations that may have been missed on preoperative imaging are possible.

The cholangiogram catheter has been inserted in th The cholangiogram catheter has been inserted in the cystic duct stump for the performance of the cholangiogram.

In addition, cholangiography helps the surgeon accurately identify the exact point of division of the left bile duct (see image below).

Intraoperative cholangiogram reveals normal bile d Intraoperative cholangiogram reveals normal bile duct anatomy.

Once the bile ducts are clearly visualized, the surgeon can place a bulldog vascular clamp at the point of intended dissection of the bile duct and repeat the cholangiography. Under cholangiographic guidance, the bulldog clamp can be repositioned several times until it is in the desired point for safe bile duct division.

Hilum dissection then begins. The LHA is carefully dissected to the junction with the main hepatic artery. Care should be taken to avoid injury of a segment IV artery, which may arise from the left artery at any level. Once the LHA is dissected, the LPV follows. Small caudate lobe branches that originate from the LPV close to the junction with the right should be carefully double-ligated and divided. The rest of the caudate branches that are connected directly with the LPV are left intact, since the caudate lobe will follow the graft.

The lesser omentum is then exposed and divided all the way to the diaphragm. If there is a replaced or accessory LHA, it should be preserved with the graft. Afterward, the left lobe is mobilized with the division of the left triangular ligament. Care should be taken not to injure the diaphragmatic vein that drains into the LHV. The diaphragmatic vein can be safely ligated and divided for better exposure of the LHV.

The caudate lobe is then mobilized from the IVC. All the small caudate lobe veins that drain directly to the IVC are carefully double-ligated and divided. If a larger caudate vein is present, it should be preserved and anastomosed in the IVC of the recipient to avoid congestion of the caudate lobe. The ductus venosum is then dissected and ligated to expose the lateral part of the LHV. The anterior surface of the LHV and MHV are then cleared from the surrounding tissue, and the junction of the MHV with the right hepatic vein (RHV) is identified (see image below).

Hepatic veins exposed. Hepatic veins exposed.

The junction of the MHV and LHV is seen from the posterior side, and the common trunk of the LHV and MHV may be encircled at this point (see image below).

A right ankle clamp inserted in the groove between A right ankle clamp inserted in the groove between the left and middle hepatic veins.

The next step is to define the parenchymal transection line by temporarily clamping the LPV and LHA and following the demarcation line with monopolar diathermy (see image below).

After clamping the left hepatic artery and the lef After clamping the left hepatic artery and the left portal vein the left lobe of the liver becomes dusky and the demarcation line is visible.

Typically, this line connects the junction of the MHV and RHV with the gallbladder bed anteriorly and continues in the middle of the gallbladder bed inferiorly to the point of division of the LHD in the hilar plate and to the posterior junction of the RHV and MHV (see images below).

The line of parenchymal dissection has been marked The line of parenchymal dissection has been marked with the cautery on the anterior/cephalad surface of the liver.
The line of dissection as it is marked at the post The line of dissection as it is marked at the posterior surface of the liver.

The parenchymal transection is performed with an ultrasonic dissector. The MHV is included with the graft, and the left wall of this vein is the guide of the transection. Care should be taken to double-ligate the branches of segment V and VIII hepatic veins that drain in the MHV in order to avoid severe bleeding (see image below).

Segment V vein draining in the middle hepatic vein Segment V vein draining in the middle hepatic vein is double ligated.

Once the plane of transection reaches the hilar plate, the bile duct is divided with a knife, and bile duct vessel bleeding is controlled with 7-0 Prolene sutures. The bile duct stump on the right side of the liver is closed with 6-0 running PDS sutures.

After the liver transection is complete, the LHA and LPV are clamped with bulldog vascular clamps toward the donor graft while ligated toward the remaining right lobe and divided. The common stump of the MHV and LHV is clamped toward the IVC and divided (see image below).

The stump of the left and middle hepatic vein is c The stump of the left and middle hepatic vein is clamped with a German clamp.

The graft is taken to the backbench container and flushed with preservation solution (see image below). In the donor, the stump of MHV and LHV is closed with 3-0 or 4-0 running Prolene suture.

The left lobe graft in the preservation solution b The left lobe graft in the preservation solution basin.

The cut surface of the remaining liver is then carefully inspected for bleeding or bile leaks (see image below).

The remaining right lobe inspected for signs of bl The remaining right lobe inspected for signs of bleeding or bile leak.

Some surgeons repeat cholangiography through the cystic duct stump to rule out any bile duct injuries or leaks. Some also use methylene blue though the cystic duct for the same purpose. If no bleeding points or bile leaks are identified, the surgeon may decide to leave a surgical drain, and the abdomen is closed.

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Right Lobe Hepatectomy

The donor is placed supine on the operating table. Attention is paid to avoid pressure sores, and devices are used to prevent deep vein thrombosis. Warming devices are also applied over the lower and upper limbs. The incision is bilateral subcostal with midline upward extension. If the donor is slim, the left subcostal extension may be avoided.

After the peritoneal cavity is entered, the liver is inspected for any abnormality that may have been missed on preoperative radiographic tests.

The falciform ligament is dissected to the suprahepatic vena cava.

Cholecystectomy is then performed, followed by intraoperative cholangiography. During cholangiography, the anatomy of the intrahepatic and extrahepatic bile tree is carefully inspected to evaluate any anatomic variations that may exclude a safe hepatectomy. If no such variations are present, the surgeon places a surgical clip or a bulldog clamp at the hilar area where he or she feels the bile duct transection should be performed and obtains another cholangiogram to verify the position of the transection (see image below).

Intraoperative cholangiogram. The bulldog clamp ha Intraoperative cholangiogram. The bulldog clamp has been placed to facilitate the evaluation of the division point.

Under cholangiographic guidance, a surgical clip is placed at the point where the division of the bile duct is appropriate.

The cystic artery is then followed to its junction to the right hepatic artery (RHA). After the RHA is identified, it is dissected free from surrounding tissue. Care should be taken not to dissect the RHA beyond the left side of the common hepatic duct and into the space between the RHD and the RHA to avoid jeopardizing the blood supply to the common hepatic duct and RHD, respectively. In addition, if a segment IV hepatic artery arises from the RHA, their junction is at the right side of the common bile duct in most cases.

The segment IV artery should be preserved to prevent ischemic necrosis of segment IV. If there is uncertainty about a branch arising from the RHA, it can be temporarily clamped and Doppler scan used to evaluate the arterial flow in segment IV. In some cases, the arterial branches of segment IV communicate with segments II and III, which should have been identified on preoperative imaging. In this case, if the segment IV artery arises from the RHA, it can be sacrificed.

Next, the right portal vein (RPV) is dissected free. In order to obtain sufficient RPV length, certain branches that enter the caudate lobe should be divided.

The right liver is then mobilized. The right triangular ligament is divided, and all the bare area of the right lobe is freed from its diaphragmatic attachment. The assistant rotates the liver to the left, and the surgeon continues the mobilization of the right lobe downward to the IVC. The right adrenal gland will be encountered, and caution needs to be taken in order to dissect it free from the liver without injury and bleeding. Monopolar cautery is the preferred method for this dissection.

The surgeon then begins mobilizing the posterior surface of the right lobe from the IVC. The numerous small accessory hepatic veins, which drain directly into the IVC, have to be carefully divided and double-ligated. This dissection continues until most of the anterior surface of the IVC is freed in order to facilitate subsequent liver transection. If an accessory vein is 5 mm or more, it should be preserved in the graft and reimplanted in the recipient IVC (see image below).

Large middle right accessory vein. Large middle right accessory vein.

In most cases, there are two such larger accessory veins, the right middle and right inferior hepatic vein.

The MHV and RHV are dissected free from the surrounding tissue in their junction with the suprahepatic IVC. If the junction of the middle and/or LHV is deep inside the liver parenchyma, the surgeon should avoid further dissection at this stage and leave it for the end of the liver transection.

The RHA and RPV are then occluded temporarily to produce the demarcation line between the right and left liver (see image below).

After clamping of the right hepatic artery and rig After clamping of the right hepatic artery and right portal vein, the right lobe becomes dusky and the demarcation line is visible.

The line is marked with cautery, and the transection begins. Liver transection is performed with the ultrasonic dissector (CUSA).

At this point, the surgeon can divide the liver parenchyma, including or excluding the MHV with the right graft.

The issue of whether to include the MHV in the right liver graft is controversial. The authors’ institution routinely does not include the MHV, so the transection takes place on the right side of the MHV. The rationale is that the MHV drains segment IV, and, by taking it with the right graft, it will cause significant congestion in the remaining liver for the donor.

On the other hand, advocates of including the MHV recognize that, by not including it, there is congestion of segments V and VIII in the right graft.

In order to minimize this congestion, any big branches of segment V and VIII that are draining into the MHV need to be preserved and anastomosed individually with the IVC or RHV of the recipient. Nonetheless, there is some congestion of those segments in the recipient for the first postoperative days until all the communicating collaterals between the anterior and posterior sectors grow and the venous drainage of segments V and VIII is restored, explaining why the size of the right liver graft should be adequate and the recipient should not be critically ill in order to sustain impaired graft function in the immediate postoperative period.

If the MHV is included in the right graft, care should be used to recognize the segment IVb large vein that drains in the MHV and to preserve it in the donor by avoiding dissection of the MHV farther than that point. In the authors’ center, the MHV is always left with the remaining left lobe (see image below).

The middle hepatic vein is preserved with the rema The middle hepatic vein is preserved with the remaining left lobe in the donor.

When the parenchymal transection reaches the hilar plate, the bile duct is divided with a knife and the bleeding vessels tied with 7-0 Prolene. The opening in the main bile duct in the donor is closed with running 6-0 PDS. The RPV and RHA are then tied at the side of the donor and clamped with bulldog vascular clamps at the side of the graft and divided. The RHV (and MHV when it is included) is clamped at the side of the IVC, and the donor side is cut with scissors (see image below).

The liver parenchyma and the bile duct have been t The liver parenchyma and the bile duct have been transected. The right hepatic artery and right portal vein have been dissected up to the bifurcation of the main hepatic artery and portal vein.

The right liver graft is placed into an ice-cold preservation solution basin and flushed (see image below).

The right lobe graft. The right lobe graft.

The cut surface of the left lobe is inspected for signs of bleeding and bile leaks. Some surgeons perform another cholangiogram at this point through the cystic duct stump to rule out any leaks or damage in the remaining bile tree.

After placement of the surgical drain, the abdomen is closed.

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