231.2: Advantages of extrahepatic Glissonean approach in the donor operation in living donor liver transplantation.

Abstract

Background: In the donor operation for living donor liver transplantation (LDLT), it is required to preserve the appropriate length and sufficient blood supply of bile ducts for both the remnant liver and the graft. We introduced the extrahepatic Glissonean approach combined with liver hanging maneuver in the living donor operation since 2016 to preserve blood supply of the hilar plate and secure the maximum length of the bile duct. We report the beneficial effect of the technique comparing the outcomes before and after the introduction. Methods: Surgical procedures are as follow. The first step is extrahepatic Glissonean pedicle isolation and the second one is liver transection with liver hanging maneuver. Prior to liver transection, we secure the extrahepatic Glissonean pedicle at the donation side approaching the gap between the Glissonean pedicle and Laennec’s capsule. Then, we introduce a hanging tape from the encircle point of Glissonean pedicle to the groove between the middle hepatic vein and right hepatic vein. Liver transection was initiated from the demarcation line and performed with the hanging maneuver. After the completion of transection, hepatic artery and portal vein of the donation side were isolated in the hilar part. The encircled pedicle without hepatic artery and portal vein was recognized as bile ducts. We compared surgical and clinical outcomes (operation time, intraoperative bleeding volume, postoperative stay, incidences of bile duct leakage and bile duct stenosis in donors and 1-year survival in recipients) of Glissonean approach group (2016-) with those of conventional technique group (2005-2015). Results: We performed 149 (lateral segment graft in 36, left lobe graft in 72, and right lobe graft in 41) and 42 (lat. seg. in 7, left in 24, and right in 11) of living donor operations before and after the introduction, respectively. There were no statistically significant differences in operation time, bleeding amount, postoperative stay between the groups. Bile duct stenosis was observed in 2 cases (1.3%) in conventional technique group but was not observed in Glissonean approach group. In conventional technique group, the incidence of bile leakage was higher in the left lobe graft than in right lobe graft (0.7% vs 6.0%). The incidence of bile leakage did not differ between the groups in lateral segment donor (0% vs 0%) and right lobe graft donor (0.7% vs 0%), but was markedly reduced in Glissonean approach group compared to conventional technique group in left lobe graft donor (4.2% vs 13.0%). One-year survival of recipients did not differ between the groups (90.6% vs 87.2%). Conclusions: The proposed procedures with extrahepatic Glissonean approach and pedicle guided liver transection enable minimum dissection of hilar part, preservation of blood supply for bile ducts, and dissection of bile ducts at the ideal point. The introduction was beneficial for reducing the incidence of bile duct complications.