Approach for outflow reconstruction and reperfusion in LDLT with a right lobe graft

Abstract

Presenter: Nicolas Goldaracena MD | University of Virginia Health System Background: Living donor liver transplantation (LDLT) emerged to overcome the organ shortage and reduce waitlist mortality. However, is a technically demanding operation that requires careful preoperative preparation, as well as a meticulous surgery. To reduce the risk of small for size syndrome, a balance between a sufficient graft size, the degree of the recipient’s portal hypertension and adequate outflow reconstruction to avoid venous congestion of the graft are mandatory. Different approaches are being utilized to perform an optimal outflow reconstruction during LDLT. However, proper graft positioning, enlarged outflow openings and reconstruction of venous outflow of all liver sectors are crucial to achieve a congestion-free graft. Methods: A video abstract is presented illustrating the approach used for venous outflow reconstruction and graft reperfusion during LDLT with a right lobe graft. Results: The living donor graft consisted of a right lobe without the middle hepatic vein (MHV). As venous outflow, the graft had a dominant right hepatic vein (RHV), an accessory segment 6/7 vein and a segment 8 vein that needed reconstruction for optimal graft venous drainage. The approach used consists of performing a total caval clamping that facilitates a wide opening of the recipient’s vena cava, as anastomosis sites, while ensuring an optimal graft positioning and orientation. Once the RHV and segment 6/7 vein are reconstructed, the outflow of the anterior sector (segment 8 vein) is temporarily clamped to be reconstructed sequentially to the MHV following graft reperfusion. Therefore, portal vein anastomosis is then performed and following the release of the caval clamps the graft is reperfused via the portal vein. Once the graft is reperfused, the anastomoses of the graft segment 8 vein to the recipient’s MHV is performed with an interposition cadaveric iliac vein that was previously anastomosed to the segment 8 vein of the graft in the backtable. Conclusion: In our opinion, total caval clamping in LDLT ensures the possibility of providing enlarged outflow openings without compromising graft positioning and orientation. Therefore, this approach allows an optimal venous outflow and a congestion free graft in LDLT. In addition, in order to shorten the total caval clamping time, sequential reconstruction of the anterior sector veins of right lobe grafts can be safely performed following reperfusion of the graft.