A secured technique for bile duct division during living donor right hepatectomy

Abstract

Although biliary complication is well recognized as a significant factor affecting patient/graft morbidity, and the procedure and outcome of bile duct reconstruction in the recipient has been fully discussed,1, 2 the technical details of bile duct division in living donor hepatectomy have not yet been described. Especially in the case of right lobe living donor liver transplantation, the incidence of multiple bile ducts in the graft is high, up to 80% in previous reports,3, 4 and several studies have indicated that multiple bile ducts in the graft is a risk factor for biliary complication in the recipient.5, 6 Accordingly, we should cut the bile duct as close as possible to the common hepatic duct, but biliary stricture in the remnant liver of the donor is a great concern. To overcome these problems, we describe our technical inventions for safe and accurate bile duct division during living donor right hepatectomy. During hilar dissection, the right hepatic artery and right portal vein are fully exposed and isolated from the hilar plate. At the final step of subsequent parenchymal transection, the right hilar plate is fully exposed and encircled with radiopaque marker filament, which is obtained from surgical gauze (Fig. 1). Intraoperative cholangiography is then performed via a catheter placed in the cystic duct (Fig. 2A). C-arm fluoroscopy is adapted during this procedure to enable us to check the optimal cutting point of the bile duct, which is made clear by pulling the filament and adjusting the accurate angle (Fig. 2B). The right hilar plate including the right hepatic duct is then sharply divided with scissors, and the stump of the remnant bile duct is closed with continuous 6-0 absorbable monofilament sutures ([Polydioxanone] Suture II, Ethicon, Somerville, NJ). Cholangiography with C-arm fluoroscopy is performed again to check the biliary leakage or stricture in the remnant bile duct (Fig. 2C). The right liver graft is then removed after the right hepatic artery, portal vein, and hepatic vein have been divided (Fig. 2D). Encirclement of the hilar plate with radiopaque marker filament. (A) Isolation of the hilar plate by Kelley clamp. (B) The hilar plate is then encircled with radiopaque marker filament, which is obtained from surgical gauze. (A) Intraoperative cholangiography with C-arm fluoroscopy. (B) The radiopaque marker filament is pulled to show the cutting point of the bile duct (arrow). In this case, the hilar plate was cut around 2 to 3 mm away from the filament, toward the common hepatic duct. (C) There was no biliary leakage/stricture in the remnant bile duct after division. (D) The graft bile duct is obtained as a single orifice with sufficient surrounding tissue. Of 54 living donor hepatectomies from August 1997 to December 2005, 38 underwent right hepatectomy, and the present procedure was adapted for use in the last 10 cases. Compared to the first 28 cases with ordinary cholangiography, the incidence of multiple ducts in the graft was significantly reduced (3/10 vs. 20/28, respectively; P < 0.05, Fisher exact test) without increasing donor morbidities. No biliary stricture developed in any of the donors. In regard to the incidence of biliary complications in the recipient, there were no significant differences between the 2 groups (30% vs. 29%, respectively). These technical inventions for bile duct division during living donor right hepatectomy have enabled us to obtain the good quality of the bile duct with a single orifice and sufficient surrounding tissue, which may lead to reduced recipient biliary complications with further experience.