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Split-liver transplants for two adult recipients:

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  • Shshonee (Alley)
    Images in Liver Transplantation Split-liver transplants for two adult recipients: Technique of preservation of the vena cava with the right lobe graft Abhinav
    Message 1 of 1 , Nov 6, 2004
      Images in Liver Transplantation

      Split-liver transplants for two adult recipients: Technique of preservation of the vena cava with the right lobe graft
      Abhinav Humar *, Khalid Khwaja, Timothy D. Sielaff, John R. Lake, William D. Payne
      Department of Surgery, University of Minnesota, Minneapolis, MN

      email: Abhinav Humar (humar001@...)

      *Correspondence to Abhinav Humar, University of Minnesota Department of Surgery, MMC 195, 420 Delaware St. SE, Minneapolis, MN 55455

      Telephone: 612-624-1927; FAX: 612-624-7168

      Abstract

      No abstract.



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      Digital Object Identifier (DOI)


      Article Text



      Split-liver transplants for two adult recipients have been developing slowly over the last few years. Numerous transplant centers have now initiated programs for splitting livers from ideal cadaver donors to use for two adult recipients. No standard operative technique yet exists for such splitting; each center has developed its own technique, with subtle variations. The majority of these techniques involve dividing the liver in its midplane, thereby generating two grafts consisting of the anatomic right lobe (segments 5, 6, 7, 8) and the anatomic left lobe (segments 1, 2, 3, 4). Previously, we described splitting the liver in this fashion, with preservation of the middle hepatic vein, inferior vena cava (IVC), and main hilar structures with the left lobe.[1] That technique is similar to the one commonly described for adult-to-adult living-donor liver transplants using the right lobe.

      Recently, we have modified the splitting procedure such that the IVC is preserved with the right lobe (Fig. 1). Doing so, we feel, offers several advantages over our previously described technique. If the IVC is preserved with the left lobe, the right lobe is implanted in the recipient by anastomosing the right hepatic vein directly to the recipient's IVC. In such cases, the right lobe may sometimes be compromised by poor outflow. To prevent this, it is important to reimplant all large (>5 mm) accessory or short hepatic veins and to reconstruct any major segment 5 or 8 hepatic veins that were draining into the middle hepatic vein (usually with a vein graft). But those reimplantation and reconstruction steps add to the warm ischemic time.


      Figure 1. Diagram of split showing that the IVC was preserved with the right lobe, followed by bench reconstruction of a segment 5 hepatic vein with a saphenous vein graft.
      [Normal View 18K | Magnified View 85K]


      By preserving the donor IVC with the right lobe, all short hepatic veins (small and large) draining the right lobe are kept intact. Also, major hepatic vein tributaries to the middle hepatic vein tributaries can be reconstructed on the back table in cold University of Wisconsin solution (Fig. 2). Doing so maximizes outflow from the right lobe, minimizes warm ischemic time, and simplifies the implantation of the right lobe.


      Figure 2. View after bench reconstruction of the right lobe graft showing the vein graft draining segment 5.
      [Normal View 45K | Magnified View 253K]



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      Abbreviations:
      SLTs, split-liver transplants; IVC, inferior vena cava.

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      Donor Surgery


      The vascular dissection is carried out as previously described by isolating the right hepatic artery and right portal vein.[1] The right lobe is not mobilized, and all short hepatic veins draining the posterior aspect of the right lobe into the IVC are thus preserved. The left lobe (including the caudate lobe) is completely mobilized away from the underlying IVC. The confluence of the left and middle hepatic veins is encircled with an umbilical tape. The liver parenchyma is then split in situ, staying just to the right of the middle hepatic vein; this vessel is therefore preserved with the left lobe. Large right-lobe tributaries to the middle hepatic vein (usually draining segment 5 or 8) are marked as they are transected, so that they can be reconstructed on the back table.

      After flushing, the liver is fully separated into the right lobe and left lobe on the back table. The left and middle hepatic vein confluence is divided at its junction with the IVC; the outflow for the left lobe will therefore consist of these two veins, which have a common orifice (Fig. 3). The hilar structures are divided, keeping the full length of the vessels with the left lobe. The right lobe is prepared by oversewing the opening that was created by the division of the middle and left hepatic veins. Major tributaries of the middle hepatic vein are reconstructed by anastomosing them to the IVC using a reversed segment of saphenous vein from the deceased donor (Fig. 1 and 2).


      Figure 3. Outflow for the left lobe, based on the common junction of the middle and left hepatic veins.
      [Normal View 38K | Magnified View 201K]


      Recipient Surgery


      The left lobe is implanted in a standard piggyback fashion, preserving the recipient's IVC. The donor hepatic veins can be anastomosed to the recipient's left and middle hepatic vein confluence with good size match. The remainder of the vascular connections are done in a standard fashion. The left and middle hepatic veins will allow for adequate drainage of the left lobe. One possible concern is that the caudate lobe may not drain adequately, especially if the short hepatic veins, which drain the caudate lobe into the IVC, are divided at the time of procurement. However, we have not seen this to be a problem: the caudate lobe seems to drain well through other venous channels. Figure 4 clearly demonstrates good perfusion of the caudate lobe posttransplant in a left-lobe recipient.


      Figure 4. CT scan at 3 months posttransplant, demonstrating good perfusion of the caudate lobe.
      [Normal View 54K | Magnified View 276K]

      The right lobe can be implanted either with complete replacement of the recipient's IVC or in a standard piggyback fashion, anastomosing the donor's suprahepatic cava to the confluence of the recipient's three main hepatic veins. The donor's hepatic artery and portal vein are anastomosed to the corresponding vessels in the recipient.

      Conclusion


      In summary, the surgical technique for split-liver transplants for two adult recipients continues to undergo refinements. Preservation of the IVC with the right lobe followed by bench reconstruction of middle hepatic vein tributaries offers several advantages for these recipients, including improved outflow, decreased warm ischemic time, and a less technically involved procedure. The left lobe is not compromised by performing the split in this fashion.

      References

      1 Humar A, Khwaja K, Sielaff TD, Lake JR, Payne WD. Technique of split-liver transplant for two adult recipients. Liver Transpl 2002; 8: 725-729. Links



      http://www3.interscience.wiley.com/cgi-bin/fulltext/106599711/HTMLSTART

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