Extended right liver graft and outflow reconstruction

Abstract

‘‘Extended right liver graft’’ was the term we used at the beginningof our right lobe living donor liver transplant (LDLT) programbecause the liver transection line was about 1 cm on the left side ofthe middle hepatic vein (MHV). The inclusion of the liver wasthought to be necessary for protection of the MHV. We subse-quently recognized that inclusion of the liver on the left side of theMHV was not necessary and actually dangerous. It predisposed toinfection on the transection surface. Nowadays, the liver transectionline is exactly on the Cantlie line and the MHV is exposed from thejunction where it receives the segment 4a (distal portion of segment4) hepatic vein to the junction with the left hepatic vein or inferiorvena cava. The major branch of the segment 4b hepatic vein ispreserved with the donor. Such a graft design is now called a rightliver graft containing the MHV. Before implantation, the MHV isjoined to the right hepatic vein to form a triangular orifice. In the recipient, the inferior vena cava is crossclamped and a matched-sizetriangular opening is made for anastomosis with the MHV/righthepatic vein of the graft. The outcome of the anastomosis is assessedby Doppler ultrasonography. A triphasic pulsatility wave form is anindication of successful reconstruction. With this technique, a large,non-redundant, and completely patent hepatic vein anastomosisand, thus, liver function are ensured. The 5-year survival rate forright liver LDLT recipients (82.2%) is comparable to that for whole-graft deceased donor liver transplant recipients (83.7%), whether therecipients suffered from cirrhosis, acute deterioration of cirrhosis,acute on chronic hepatitis B infection, or fulminant hepatic failure.