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Annals of Surgery:
Advances in Surgical Technique

Vein Reconstruction in Modified Right Liver Graft for Living Donor Liver Transplantation

Sugawara, Yasuhiko MD; Makuuchi, Masatoshi MD; Sano, Keiji MD; Imamura, Hiroshi MD; Kaneko, Junichi MD; Ohkubo, Takao MD; Matsui, Yuichi MD; Kokudo, Norihiro MD

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Abstract

Objective: To report the authors’ experience with hepatic vein reconstruction and plasty in living donor liver transplantation for adult patients.

Summary Background Data: A right liver graft without the middle hepatic vein (MHV) trunk (modified right liver graft) can cause severe congestion of the right paramedian sector. However, the need for MHV reconstruction has not been fully recognized.

Methods: From June 2000 to December 2001, 30 adult patients received a modified right liver graft. Major MHV tributaries were preserved and reconstructed under the authors’ criteria. Plasty of recipient hepatic veins for a wide outflow orifice was performed when necessitated. The regeneration of paramedian and lateral sectors of the grafts was examined by computed tomography 1 and 3 months after the operation.

Results: MHV tributaries were reconstructed in 18 grafts. Plasty of recipient hepatic veins was performed in 15 patients. All patients survived the operation. The regeneration of paramedian and lateral sectors was equivalent.

Conclusions: A modified right liver graft can provide satisfactory surgical results if hepatic vein reconstruction and plasty are performed using the present techniques.

Living donor liver transplantation (LDLT) was originally developed as a solution for the organ shortage with pediatric recipients 1,2 and has recently been extended to adult recipients. An extended right liver graft, 3 which includes the trunk of the middle hepatic vein (MHV), was devised to alleviate the problem of graft size disparity. However, this graft increases the extent of the donor operation and might raise an important ethical issue in LDLT. 4

A right liver graft without the MHV trunk (modified right liver graft) is now commonly used but can cause severe congestion of the right paramedian sector (corresponding to Couinaud segments 5 and 8 5). Such congestion can lead to severe graft dysfunction and septic complications 6 because hepatic venous outflow of the right paramedian sector is drained mostly into the MHV. 7

MHV drainage into the recipient’s venous system can be reconstructed using vein grafts. This provides a functioning liver mass comparable to an extended right liver graft. We previously proposed reconstruction criteria and have performed LDLT using the graft under these criteria. 8 A wide outflow orifice seems to be another crucial issue. We present here our surgical indications, techniques, and results for hepatic vein reconstruction in modified right liver graft.

© 2003 Lippincott Williams & Wilkins, Inc.

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