Bile duct complications have a significant morbidity and mortality in living donor liver transplantation (LDLT) (1, 2). A Roux-en-Y hepaticojejunostomy with or without stent was once exclusively performed for bile duct reconstruction in the setting of LDLT using left or right lobe grafts. We first reported nine cases of duct-to-duct (DD) reconstruction for left lobe grafts demonstrating the feasibility of the method, even in patients receiving left lobe grafts (3). Recently, DD reconstruction has increasingly been performed and become the preferred choice in many centers. However, this method has been reported to be associated with a high incidence of biliary strictures (4–6). The causes of a higher incidence of biliary strictures in the setting of LDLT are not well defined but are believed to be attributable to the size of the bile duct of the graft, technical factors such as suture methods, and vascular integrity of the bile duct both in donor and recipient sides. Transplant surgeons might have their own particular dissection technique on how to preserve maximum blood supply to the bile duct; however, a standard technique has not yet been established. Here, we describe our simple bile duct dissection technique preserving maximum vascular integrity during total hepatectomy of the recipient, with the expectation of decreasing bile duct complications after LDLT.
We carried out the operations as follows. A hilar dissection was commenced with a normograde cholecystectomy. The cystic duct was cut between the ligatures. The left hepatic artery and the artery to segment four were identified, dissected, and divided between 3–0 Vicryl ties as high up as possible to secure the length of the vessels. The right anterior and posterior hepatic arteries were then identified, dissected, and divided between 3–0 Vicryl ties as high up as possible at the right side of the common bile duct without touching the connective tissue between the right hepatic artery and the common bile duct. The bile duct with the right hepatic artery was dissected off from the portal vein and was controlled with tape. The most important part of the dissection was to keep the dissection plane right on the portal vein. The connective tissue around the common bile duct including the bile duct vessels arising from the caudal side should not be dissected. The connective tissue around the portal vein trunk was further dissected off and the portal vein trunk was controlled with tape. The bifurcation of the portal vein was dissected up to the distal side and the hilar structure of the bile duct was dissected off from the portal vein, thus, completing the preparation (Figs. 1A and 2B).
A curved bull-dog clamp was applied to the common bile duct, which can include the right hepatic artery. An angle Potts clamp was put on the portal vein trunk temporally. The bile duct was then transected sharply using Metzenbaum scissors right on the hilar plate as high as possible, confirming the left and the right hepatic ducts were patent in a bloodless field (Fig. 1B). Small caudate branches were frequently encountered. After confirming the quality of the bile ducts, the hilar plate was closed with 3–0 Vicryl or 4–0 Prolene continuous sutures, thereby controlling the bleeding from the hilar plate (Fig. 2B). The proximal stump of the transected bile duct was left open. The clamp on the portal vein was released and additional bleeding points were further sutured with figure-of-eight stitches. Total hepatectomy preserving the retrohepatic inferior vena cava was performed after dissecting tissues around the liver.
Bile duct reconstruction was performed after the arterial reconstruction. The stump of the recipient bile duct was transected sharply again after releasing the bull-dog clamp to confirm a sufficient arterial blood supply from below. The bleeding points around the bile duct stump were closed with 6–0 Prolene figure-of-eight stitches. A DD reconstruction between the donor bile duct was performed usually over a 2.0 mm internal-external stent of the bile duct using 6–0 polydiaxanone suture (Ethicon, Somerville, NJ) interrupted sutures for the entire wall. The stent tube was exteriorized from the anterior wall of the common bile duct, where two 5–0 polydiaxanone suture purse-string sutures were placed to reinforce the exit. The leak test using indocyanine green solution followed by cholangiography with a C-arm was performed to confirm bile duct integrity.
Bile duct dissection and reconstruction in LDLT is more delicate or challenging than in deceased donor liver transplantation (DDLT). The size and length of the bile duct of partial grafts in LDLT are usually small and short, whereas those of DDLT are usually large and long enough. In DDLT, the bile duct of the recipient is cut at the level of the common bile duct or the hepatic duct during hilar dissection, thereby making a large and long bile duct. However, in the LDLT setting, the bile duct has to be preserved as long as possible to facilitate DD reconstruction because the bile duct of the donor graft may be multiple or too short or small. The conventional bile duct dissection technique in the setting of LDLT, where the common bile duct and the right hepatic artery are detached, is not different from that of DDLT. The transected stump of the bile duct is divided between ligatures, which may shorten the length of the bile duct. Therefore, a new technique such as “high hilar dissection” has been reported (7), where the hilar pedicle is left untouched and divided at the intrahepatic level.
The most important step of our technique is the dissection plane, where the bile duct structures, including the hepatic arteries, are dissected off from the portal vein.
When transecting the bile duct sharply on the hilar plate, a clamp on the portal vein is effective. Without the portal clamp, bleeding may be encountered when cutting the bile duct, leading to an inaccurate transection.
We have prospectively applied this technique to 39 adult cases with DD bile duct reconstruction since April 2006. There were six cases of multiple ducts in which only three required multiple bile duct reconstruction. To date, only 4 (10.2%) patients among these 39 (26.4%) patients have developed biliary strictures, which is an improvement from our previous series (8). The incidence of anastomotic bile leak was similar between the two studies, 0.9% (1/106) in the previous series and 2.6% (1/39) in the present series (P=NS). In conclusion, this simple, new bile duct dissection technique might facilitate DD bile duct reconstruction in both right and left lobe LDLT and, thus, contribute to reduce biliary complications such as biliary strictures.
1. Shah SA, Grant DR, McGilvray ID, et al. Biliary strictures in 130 consecutive right lobe living donor liver transplant recipients: Results of a Western center. Am J Transplant
2007; 7: 161.
2. Gondolesi GE, Varotti G, Florman SS, et al. Biliary complications in 96 consecutive right lobe living donor transplant recipients. Transplantation
2004; 77: 1842.
3. Soejima Y, Shimada M, Suehiro T, et al. Feasibility of duct-to-duct biliary reconstruction in left lobe adult living donor liver transplantation. Transplantation
2003; 75: 557.
4. Yi NJ, Suh KS, Cho JY, et al. In adult-to-adult living donor liver transplantation hepaticojejunostomy shows a better long-term outcome than duct-to-duct anastomosis. Transpl Int
2005; 18: 1240.
5. Hwang S, Lee SG, Sung KB, et al. Long-term incidence, risk factors, and management of biliary complications after adult living donor liver transplantation. Liver Transpl
2006; 12: 831.
6. Yazumi S, Yoshimoto T, Hisatsune H, et al. Endoscopic treatment of biliary complications after right-lobe living-donor liver transplantation with duct-to-duct biliary anastomosis. J Hepatobiliary Pancreat Surg
2006; 13: 502.
7. Lee KW, Joh JW, Kim SJ, et al. High hilar dissection
: New technique to reduce biliary complication in living donor liver transplantation. Liver Transpl
2004; 10: 1158.
8. Soejima Y, Taketomi A, Yoshizumi T, et al. Biliary strictures in living donor liver transplantation: Incidence, management and technical evolution. Liver Transpl
2006; 12: 979.