Successfully in Situ Right-Left Split Liver Transplantation

Abstract

Introduction In-situ or ex-vivo left lateral segmentectomy and right trisegmentectomy split-liver transplantation had become and standard practice in Argentina. Over the last 10 years more than 150 split procedures has been performed, but until recently none in-situ right-left split was performed. We aim to report the first case done at a single institution. Material and Method Report of an in-situ right-left split liver procurement performed more than 1 thousand kilometers far from the transplant center. Follow by the engraftment into an adult recipient (54 years) with a non respectable metastatic NET and a pediatric recipient (14 years), with cystic fibrosis and severe portal hypertension (24 mmHg). Results After grafts allocations, our liver procurement team flew to the donor hospital, with the necessary devices to perform the in-situ liver parenchymal transection. Donor was hemodynamically stable without inotropic drugs. After midline incision, hiliar dissection was performed, to identify the right hepatic artery, right portal vein and bile duct; Intraoperative cholangiography showed normal billiary anatomy. A bulldog clamp was placed in the right portal and hepatic artery to delineate the transaction line. The cava and middle hepatic veins were left to left graft (LG). Billiary tree and common hepatic artery were left in the right graft (RG). HTK solution was used for preservation. Operative time for the procurement was 3.5 hours. Right graft weight 980 grs. and left graft 450 grs. The RG was used in an adult recipient and the LG in a pediatric recipient, CIT were: 475 min and 430 min respectevily. GRWR for the RG and LG were 1.53 and 1.67 respectively. The LG required re-exploration for intra-abdominal hemorrhage, and postop. ascitis was present and medically treated; in spite of a reduction in the portal pressure to 17 mmHg). Recipients were discharge on postop. day: 7 and 14 respectively. Conclusions Right and left split-liver transplantation should be considered as a source to expand the cadaveric donor liver pool. A trained committed surgical team is needed to successfully perform these procedures. The adequate donor and recipient selection will increase motivation to routinely use it for adolescents or adult recipients.