Lateral Sector Graft Research Articles

Pure laparoscopic left lateral graft procurement with removing segment 3 employing Glissonean approach, indocyanine green fluorescence imaging and in situ splitting for a small infant.

We report on a pure laparoscopic left lateral graft procurement with removing segment 3 that employs the Glissonean approach, indocyanine green (ICG) fluorescence imaging and in situ splitting. We first mobilised the liver and confirmed the root of the left hepatic vein (LHV). We then encircled the left Glissonean pedicle, and the segment 3 Glissonean pedicle (G3) was also individually encircled. We performed parenchymal transection of the left lateral segmentectomy using Pringle's manoeuvre. We clipped G3 and confirmed the demarcation line using ICG fluorescence imaging. The inflow in the S2 area was confirmed via intraoperative sonography, and we split segment 3 (S3) from the left lateral sector graft in situ. The left hepatic artery, left portal vein and left hepatic duct were also encircled and divided. The LHV was transected using a linear stapler, and the S2 monosegment liver graft and removed S3 were procured. Our technique reasonably prevents graft-related complications.

Dual graft living donor liver transplantation \u2013 a case report

BackgroundLiving donor liver transplantation (LDLT) has emerged as an equally viable option to deceased donor liver transplant for treating end stage liver disease patients. Optimising the recipient outcome without compromising donor safety is the primary goal of LDLT. Achieving the adequate graft to recipient weight ratio (GRWR) is important to prevent small for size syndrome which is an uncommon but potentially lethal complication of LDLT.Case presentationHere we describe a case of successful dual lobe liver transplant for a 32 years old patient with ethanol related end stage liver disease. A right lobe graft without middle hepatic vein and another left lateral sector graft were transplanted successfully. Recipient and both donors recovered uneventfully.ConclusionDual lobe liver transplant is a feasible strategy to achieve adequate GRWR without compromising donor safety.

A new surgical technique of living donor liver transplantation – use of extended right lateral sector graft combined with dorsal part of right paramedian sector.

A new surgical technique of living donor liver transplantation – use of extended right lateral sector graft combined with dorsal part of right paramedian sector.

Living donor liver transplantation: looking back at my 30years of experience.

Since I moved from the National Cancer Center to Shinshu University, I have been performing living donor liver transplantation (LDLT), which is the only way to save the life of patients with end-stage liver disease. In June 1990, we performed the first LDLT that case was the first successful case in Japan. The patient remains healthy and is enjoying a normal life still 28years after the transplant. In 1993, we successfully performed adult-to-adult LDLT, which was the first successful case in the world. The patient enjoyed a normal life for 17years until she died at 70years of age. For small children, the left liver of adult donors is too large to close the abdomen. However, in adolescents or adults, even when the whole right liver is used, the volume of the graft is too small. The concept of the standard liver volume (SLV) has proven very important for this procedure and is calculated as follows: 706.2 × body surface area + 2.4. We proposed a method for evaluating the congestion of the liver by Doppler ultrasound. In addition, we devised the right lateral sector graft. Over the years, we have contributed to LDLT in many ways and published many papers. We feel that our findings are quite useful not only for LDLT but also for other hepatectomy procedures.

Outflow Reconstruction Using Cryopreserved Homologous Venous Grafts in Living Donor Liver Transplantation

ObjectivesThe techniques and outcomes of outflow reconstruction in living donor liver transplantation (LDLT) using cryopreserved homologous veins at the University of Tokyo Hospital are presented. MethodsWe performed 540 LDLTs from January 1996 to March 2015. Graft types included right liver graft (n = 262), left liver graft (n = 196), left lateral sector graft (n = 53), and posterior sector graft (n = 28). We routinely use cryopreserved homologous vein grafts for the hepatic vein reconstructions to secure the large outflow of the graft. In addition to the presentation of our techniques, the cases with symptomatic outflow obstruction and the treatments were also investigated. ResultsThe 1-, 3-, and 5-year graft survival rates were 90.6%, 86.1%, and 83.5%, respectively. The incidence of severe complications (Clavien-Dindo grade IIIb and more) was 38%. The overall incidence of outflow obstruction requiring invasive treatment was 1.9% (10/540), including 3 left liver grafts (1.5%, 3/196) and 7 right liver grafts (2.7%, 7/262). Regarding the patency of the reconstructed veins, the left hepatic vein, middle hepatic vein, and right hepatic vein achieved nearly 100% patency. On the contrary, venous tributaries such as V5, V8, and inferior right hepatic vein were frequently occluded in the postoperative course. ConclusionsOutflow reconstruction is a key for the successful LDLT. Cryopreserved homologous vein graft is useful for the promising hepatic vein reconstruction.

Use of a Right Lateral Sector Graft in Living Donor Liver Transplantation Is Feasible, but Special Caution Is Needed With Respect to Liver Anatomy.

Right lateral sector (RLS) grafting has been introduced to enlarge the potential donor pool for living donor liver transplantation (LDLT); however, evidence of its feasibility is limited. Data from 437 LDLTs carried out between 2000 and 2013 were analyzed retrospectively. LDLTs using a right liver graft (n = 251) were compared with those using a RLS graft (RLSG; n = 28). No donor mortality occurred, and the major complication rates were similar between the two groups. Postoperative liver function preservation was better in the RLSG donors. Concerning the recipients, the mortality and overall survival rates were similar between the two groups. The complication rate for the recipients was higher when more than two arterial or biliary anastomoses were necessary. A systematic literature search identified four reports on LDLT using RLSGs. Among 66 LDLTs, including the present series, there were no cases of donor death, and the rates of major and minor complications in the donors were 6% and 29%, respectively. The major complication and overall mortality rates in the recipients were 29% and 6%, respectively. LDLT using an RLSG is feasible, with an acceptable survival rate among the recipients.

Pitfall of Right Lateral Sector Graft Procurement

Selection of a right lateral sector graft for adult-to-adult living donor liver transplantation (LDLT) has become feasible (1, 2). Herein, a case of right lateral sector graft procurement for liver transplantation is presented in which technical difficulties were encountered because of an anomaly of the right posterior hepatic artery. A 21-year-old male patient volunteered to serve as a live donor for liver transplantation for his brother who was suffering from fulminant hepatitis. A volumetric analysis revealed that only a right lateral sector graft would be suitable (3). Preoperative computed tomography revealed a supraportal right posterior hepatic artery, i.e., the right posterior hepatic artery running cranially over the right anterior portal vein (Fig. 1A, B), and the vascular anomaly was confirmed intraoperatively (Fig. 1C). Isolation of the right posterior hepatic artery was difficult during procurement of the graft because it ran between the right posterior portal vein and the posterior bile duct. Furthermore, the distal part of the right posterior hepatic artery was very thin, and the dissection between the perivascular tissue and the distal part of the right posterior hepatic artery was technically difficult, and had risk of injury by approach from the hepatic hilum.FIGURE 1: A, computed tomographic image showing the right posterior hepatic artery running cranially over the right anterior portal vein, i.e., supraportal right posterior hepatic artery (arrowhead). B, the three-dimensional reconstruction image of the computed tomography. The view is from the caudal side of the patient similar to the intraoperative view. The arrowhead indicates the supraportal right posterior hepatic artery. C, the intraoperative findings confirmed the preoperative imaging findings. The arrowhead indicates the supraportal right posterior hepatic artery. RHA, right hepatic artery; RAHA, right anterior hepatic artery; RPHA, right posterior hepatic artery; RPV, right portal vein; RAPV, right anterior portal vein; RPPV, right posterior portal vein.Therefore, after hilar dissection, the hepatic parenchymal transection was completed. At this stage, the right lateral sector was connected only via the posterior portal pedicle and the right hepatic vein. Under intraoperative cholangiography, the posterior duct was carefully divided. Probably because the dissection between the perivascular tissue and the distal part of the right posterior hepatic artery was insufficient, during division of the posterior duct, the distal part of the right posterior hepatic artery was injured. The right hepatic artery was temporarily clamped and the right lateral sector graft was procured by dividing the right posterior hepatic artery, the posterior portal vein, and the right hepatic vein, in that order. The right posterior hepatic artery was divided at the peripheral side after it had crossed the right anterior portal vein. Implantation of the right lateral sector graft was successfully carried out. The only problem was that the blood flow of the initial end-to-end anastomosis between the recipient hepatic artery and donor right posterior hepatic artery was insufficient. Therefore, a re-anastomosis was performed after trimming the anastomosis line and finally sufficient blood flow was obtained. The postoperative course was uneventful in both the donor and the recipient. Five hundred eleven LDLTs were performed at the institution between January 1996 and August 2013. During this period, a right lateral sector graft was procured in 27 cases (5.3%). The case presented herein was the only one with this type of vascular anomaly. Yoshioka et al. have reported encountering this type of anomaly during extended left hepatectomy for cholangiocarcinoma (4). The reported incidence of supraportal right posterior hepatic artery is 5.4%. The reported incidence of infraportal hepatic artery for segment 6 and supraportal hepatic artery for segment 7, i.e., the combined type of anomaly, is 6.4%. Because the right anterior portal vein cannot be cut during a donor operation, the difficulty posed by this anomaly is even greater during right lateral sector graft procurement than during surgery for cholangiocarcinoma. In cases with the combined type of anomaly, reconstruction of the right posterior hepatic artery is necessary. This case underscores the importance of paying attention to the course of the right posterior hepatic artery during right lateral sector graft procurement. Because supraportal right posterior hepatic artery can cause accidental arterial injury, complete transection before cutting of the posterior portal pedicle is recommended. Takashi Kokudo 1 Kiyoshi Hasegawa1 Yasuhiko Sugawara1 Norihiro Kokudo1,2 1Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division Department of Surgery Graduate School of Medicine The University of Tokyo Tokyo, Japan

Biliary Reconstruction in Living Donor Liver Transplantation: Technical Invention and Risk Factor Analysis for Anastomotic Stricture

Bile duct complications especially biliary stricture remains a major cause of morbidity influencing the postoperative course in living donor liver transplantation (LDLT). The objectives of this study were to investigate the outcome of biliary reconstruction using "open-up" anastomotic technique and to clarify the risk factors for biliary stricture after LDLT. We retrospectively analyzed data of 83 consecutive adult patients who underwent LDLT between 1999 and 2007. Hepaticojejunostomy was conducted in 22 patients and duct-to-duct anastomosis in 61 patients. The "open-up" anastomotic technique was applied uniformly for biliary reconstruction. The mean follow-up period after LDLT was 2.7+/-2.1 years (range, 0.01-7.52). Of the 83 recipients, six (7.2%) developed biliary strictures (four at anastomotic site and two at multiple intrahepatic sites), and one (1.2%) developed biliary leakage after hepaticojejunostomy. Risk factor analysis identified the diameter of donor bile duct and the use of right lateral sector as significant risk factors for biliary stricture at the anastomosis. Care should be taken when anastomosing a small bile duct of the donor graft or right lateral sector graft in LDLT because of the associated high incidence of biliary stenosis. Our technique, including the "open-up" procedure, ensures quality control for bile duct reconstruction and a better outcome after LDLT.

3D Anatomical Variations of Hepatic Vasculature and Bile Duct for Right Lateral Sector of Liver with Special Reference to Transplantation

To achieve a safer living related liver transplantation (LRLT) using the right lateral sector, anatomical variations of the portal vein, hepatic artery and bile duct for the right lateral sector and their three dimentional (3D) relationship were assessed by integrated 3D-CT images. 52 patients who underwent contrast enhanced multi-detector row CT (MD-CT) and MD-CT cholangiography were enrolled. Data from contrast enhanced MD-CT were used to reconstruct the 3D images of the hepatic artery and portal vein. 3D images reconstructed from MD-CT data of the hepatic artery, portal vein and bile duct were integrated into a single image. The dual branching of the right lateral portal vein was observed in 22 (42.3%) patients. Three (5.8%) had dual right lateral ducts and 14 (26.9%) had dual right lateral arteries. Among them, "south-turning" artery and "north-turning" bile duct was observed in 22 (42.3%). "South-turning" artery and "south-turning" bile duct were 3 (5.8%). "North-turning" artery and "north-turning" bile duct were 2 (7.4%). Only 27 (51.9%) had single portal vein, bile duct and artery for the right lateral sector, those were preferable as candidates for right lateral sector graft transplantation. 3D anatomical variations of portal vein, artery and bile duct for the right lateral sector were complexed, and only half of the donor candidates had preferable hepatic structures for right lateral sector graft transplantation. Understanding of the 3D hepatic structures by 3D-CT may contribute to a better definition of anatomical contraindications for LRLT which may further results in more safe and widely applied right lateral sector graft LRLT.

Biliary complications in right lateral sector graft live donor liver transplantation

Biliary complications remain the most challenging issue in adult living donor liver transplantation (LDLT) and to the best of our knowledge, no study has focused on the biliary complications in LDLT with right lateral sector graft (RLSG), a graft consisting of segments VI and VII according to Couinaud's nomenclature for liver segmentation. Between January 1996 and October 2006, 310 LDLTs were performed for adult recipients at our institution. Among them, 20 patients received RLSG. The incidence of biliary complications during follow-up in these patients with RLSG was retrospectively analyzed. Follow-up period after transplantation ranged from 1 to 87 months (median 58 months). The 3-year and 5-year graft survival rates following the use of RLSGs in LDLT were 90% and 90%, respectively. Biliary complications were encountered in altogether nine patients. Two patients (10%) were complicated with bile leakage requiring surgical intervention. Seven patients (35%) were complicated with bile duct stenosis, which occurred with a median interval of 26 months (range: 6-51 months) after LDLT. Four were treated surgically and the other three were treated by endoscopic approach. Outcomes of the interventions were satisfactory in all cases. The incidence and severity of biliary complications after LDLT using RLSG was within an acceptable range with excellent graft survival. Accordingly, it is concluded that RLSG is a technically feasible option that may effectively expand the donor pool. Further application of RLSG is warranted.

Preoperative Estimation of Right Lateral Sector Graft by Three-Dimensional Computed Tomography

The right lateral sector is an alternative graft for living donor liver transplantation. Three-dimensional image reconstruction of right lateral sector grafts was performed to reveal vascular anatomy and volume using three-dimensional computed tomography software in three donors. There was a correlation between actual and estimated volume ( r = .93), although actual graft volume tended to be larger than the preoperative estimated volume. In one donor, a portal branch of the right lateral sector was independently ramified. The branch was sacrificed in the operation because its territory volume was only 44 cm 3. Three-dimensional images matched the shape of the right lateral sector graft. Three-dimensional computed tomography might be useful before donor hepatectomy, providing important information for decisions regarding the operative procedure.

Tailoring the Type of Donor Hepatectomy for Adult Living Donor Liver Transplantation

Donor hepatectomies for adult living donor liver transplantations were performed in 200 consecutive donors to harvest a left liver (LL) graft (n = 5), a LL plus caudate lobe (LL + CL) graft (n = 63), a right liver (RL) graft (n = 86), a RL and middle hepatic vein (RL + MHV) graft (n = 28) or a right lateral sector (RLS) graft (n = 18). The graft type was selected so that at least 40% of the recipient's standard liver volume was harvested. No donor deaths occurred, and no significant differences in the morbidity rates among either donors or recipients were observed when the outcomes were stratified according to the graft type. Donors who donated RL exhibited higher values of serum total bilirubin and prothrombin time than those who donated non-RL (LL, LL + CL, RLS) grafts. The time taken for hilar dissection and parenchymal transection increased in the following order: RLS graft, LL graft and RL graft harvesting. In conclusion, non-RL grafting was more time consuming, but the hepatic functional loss in the donors was smaller. Our graft selection criteria were useful for reducing the use of RL grafts with acceptable morbidity in both donors and recipients.

Reconstruction of the middle hepatic vein tributary in a right lateral sector graft

A right lateral sector graft (RLSG) was devised to overcome graft-size disparity in living donor liver transplantation (LDLT). When the RLSG has a middle hepatic vein (MHV) tributary, which drains a significant part of segment VI, the MHV tributary (V6) should be reconstructed to avoid congestion of the RLSG. In the donor operation, congestive area of segment VI was identified by 5 minutes of simultaneous clamping of V6 and the hepatic artery to the right lateral sector. An RLSG was harvested, preserving the V6 orifice. After plastic surgery of outflow veins including V6 using venous grafts, the RLSG was implanted into the recipient. In 19 patients who received RLSG in our institution, 2 RLSGs required V6 reconstruction. The postoperative courses of these two recipients and donors were uneventful. In conclusion, the present technique might be useful to avoid complications due to congestion and poor function of the relevant graft area and might help to expand the indications for RLSG.

Right lateral sector graft as a feasible option for partial liver transplantation

Right lateral sector graft as a feasible option for partial liver transplantation

The surgical approach to HCC: our progress and results in Japan.

Due to the prevalence of hepatitis virus infection, the incidence of hepatocellular carcinoma (HCC) is very high in Japan. Many techniques have been devised by Japanese surgeons to reduce the mortality rate after hepatectomy for HCC: preoperative precise evaluation of hepatic functional reserve, portal venous embolization as preoperative preparation, anatomical and nonanatomical limited resections using intraoperative ultrasonography, and intermittent inflow occlusion during liver transection. Several challenging surgical procedures are also being tried for advanced HCC: HCC with portal and hepatic venous tumor thrombus, multiple and/or recurrent HCC, and HCC in the caudate lobe. As a result, the latest national survey of HCC revealed that operative mortality was 0.9% and the 5-year survival rate after surgery was 52%. Living-donor liver transplantation for adult patients with HCC is another surgical treatment developed in Japan. After the success of adult-to-adult living donor liver transplant using a left liver graft in 1993, a right liver graft, a left liver graft with caudate lobe, and a right lateral sector graft were developed. Indications for reconstructing the middle hepatic vein tributaries in right liver grafts were also proposed. Consequently, in our series of 36 patients with HCC who underwent living-donor liver transplantation, operative mortality was 3%, and the 2-year survival rate was 84%.

RIGHT LATERAL SECTOR GRAFT IN ADULT LIVING-RELATED LIVER TRANSPLANTATION1

A major concern regarding adult living-related liver transplantation (LRLT) is graft-size disparity. The authors report their experience with LRLT using the right lateral sector. Between January 2000 and April 2001, 32 adult-to-adult LRLTs were performed at our institution. Of these, six patients received a right lateral sector (RLS, segments VI and VII according to Couinaud's nomenclature for liver segmentation) graft. The right liver was over 70% of the estimated volume of the whole donor liver. The estimated RLS volume was greater than that of the left liver, which was over 40% of the recipient's standard liver volume. The postoperative course was uneventful in all donors. All of the patients survived the operation. Three patients were complicated with bile leakage from the dissection plane of the graft. Four patients suffered from acute rejection. RLS graft obtained by this procedure may be useful for overcoming borderline graft-recipient size differences and expanding the donor pool.