Laparoscopic Anatomic Segment III Procurement in Pediatric Living Donor Liver Transplantation Using Real-Time ICG Fluorescence In Situ Reduction by the Glissonean Approach

Abstract

Nowadays, anatomic hepatectomy has been widely accepted and acknowledged as a feasible practice during laparoscopic procedure. We herein report the first case of laparoscopic anatomic segment III (S3) procurement in pediatric living donor liver transplantation using real-time indocyanine green (ICG) fluorescence in situ reduction by Glissonean approach. A 36-year-old father volunteered for living donation to his daughter who was diagnosed with liver cirrhosis and portal hypertension due to biliary atresia. Preoperative liver function was normal with mild fatty liver. Liver dynamic computed tomography showed a left lateral graft volume of 379.43 cm3 with a graft to recipient weight ratio (GRWR) of 4.77%. The ratio of the maximum thickness of the left lateral segment to the anteroposterior diameter of the recipient's abdominal cavity was 1.20. Hepatic veins of segment II (S2) and S3 separately flowed into the middle hepatic vein. The estimated S3 volume was 173.16 cm3 and GRWR was 2.18%. The estimated S2 volume was 118.54 cm3 and GRWR was 1.49%. Laparoscopic anatomic S3 procurement was scheduled. Liver parenchyma transection was divided into 2 steps. Step I: Anatomic in situ reduction of S2 by using real-time ICG fluorescence. Step II: Separating the S3 along the right side of sickle ligament. The left bile duct was identified and divided by ICG fluorescence cholangiography. The total operation time was 318 minutes without transfusion. The final graft weight was 208 g with GRWR of 2.62%. The donor was discharged uneventfully on postoperative day 4, and the graft function recovered to normal in the recipient without any graft related complication. Laparoscopic anatomic S3 procurement with in situ reduction is a feasible and safe procedure in selected donors in pediatric living donor liver transplantation.