Liver Transection First Approach for Living-Donor Hepatectomy with Complex Biliary and Vascular Anatomy

Abstract

Introduction: Aberrant donor anatomy is a challenge in living-donor liver transplantation (LDLT), potentially associated with recipient complications. The concept of minimal hilar dissection has been reported to avoid biliary ischemia and intimal damage to hepatic artery, which result in recipients' biliary complications and hepatic arterial thrombosis, respectively. However, complex donor anatomy forces extensive dissection and retraction when isolating vessels in the limited field at the liver hilum. Herein, we present the liver transection first approach (LTFA) for living-donor hepatectomy, which is beneficial especially in donors with complex anatomy to facilitate hilar dissection and prevent vascular/biliary damage. Methods: The graft-side Glissonean pedicle is first isolated en bloc at liver hilum, without dissecting each vessel, and cholangiography is performed to decide the division line of biliary ducts and liver parenchyma. Following graft liver mobilization, the graft-side hepatic vein is isolated and a hanging tape is placed onto the retrohepatic vena cava and above the Glissonean pedicle so that liver parenchyma is transected towards the tape. In the wide surgical field after completing parenchymal transection, graft-side hepatic arteries and portal veins are isolated with minimal dissection and the remining tissue within the Glissonean pedicle is divided concomitantly with graft-side bile ducts. Results: LTFA was used in 23 of 41 donor hepatectomy for adult-to-adult LDLT between 2017 and 2018. Biliary complication was observed in 9.8%, without any differences between donors with a single versus multiple bile ducts, and hepatic artery complications was zero. Conclusions: LTFA is helpful to decrease morbidity after LDLT.