Split Liver: Surgical Techniques for Adult and Pediatric Recipients and for Two Adult Recipients

Abstract

Three different standard types of liver bipartition producing six different types of grafts can be created by following a plane directed on the right or the left line of the middle hepatic vein (MHV): a) splitting for adult and pediatric recipients with left lateral graft (LLG) and right extended graft (REG), b) splitting for two adults or for adult and pediatric recipients of large size with creation of left graft (LG) and right graft (RG), c) splitting for two adult recipients with creation of full left graft (FLG) and full right graft (FRG). The absence of an extrahepatic portal vein bifurcation is an absolute contraindication to liver splitting. Division of the portal branches to Segment I optimizes the freeing/lengthening of the left portal vein for the implantation. Identifying the portal tract entering the caudate process at its lower aspect is helpful in preparing for the division of the hilar plate. Early division of the Arantius remnant allows a safe encircling and control of the left hepatic vein. During in situ splitting technique for adult and pediatric recipients, a 1–2-min. selective clamping of the left hepatic vein (LHV) may provide assurance that the hepatic venous drainage of Segment IV is not jeopardized. Recognition of independent segment II and III suprahepatic venous outflow (<5 % of cases) is crucial in the adult and pediatric splitting procedure. Segment IV hypoperfusion is a potential pitfall during adult and pediatric liver splitting. During adult and pediatric split-liver procedure, parenchyma transection can be achieved according to the transhilar (TH) approach or transumbilical (TU) approach. In the liver-splitting technique for two adults, the “hanging manoeuvre” can be helpful to define the correct plane of transection from the bifurcation of the hepatic artery and portal vein to a point between the right and middle hepatic veins. In some case of MHV dominancy during split-liver procurement for two adults, the ex situ splitting of the vena cava and/or MHV can be considered possible options to avoid complex reimplantation of multiple tributaries of the MHV and the congestion of segments IV, V, and VIII.