Liver transplantation techniques

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D[2]

Liver trasnsplantation Microchapters
Home
Patient Information
Overview
Historical Perspective
Indications
Pre-surgical management
Choice of donor
Epidemiology and Demographics
Techniques
Complications
Acute rejection
Immune therapy
Post-surgical infection
Prognosis

Overview

Liver transplantation techniques includes left lobe transplantation, right lobe transplantation, split-liver transplantation, and marginal liver grafts. In left lobe technique, the left and middle hepatic veins, left hepatic artery, and left portal vein are dissected. Small portal vein branches are ligated. The left bile duct is divided. In right lobe technique, the right lobe fits correctly into the right subphrenic space, making the vascular anastomoses easier to perform. Right lobe grafts are prone to a variety of technical complications. After cholecystectomy, intraoperative ultrasound may be used to mark the position of the hepatic veins and portal branches. The right hepatic artery and right portal vein are dissected, followed by the retrohepatic vena cava, isolating the origin of the right hepatic vein. Marginal graft means grafts from a higher risk group of donors based on demographic, clinical, laboratory, and histological data. Marginal liver grafts donors include those with any of the following characteristics: Liver donor age >70 years, livers from hepatitis C positive donors, livers with cold ischemia time >12 hours, livers from donation after cardiac death donors, livers with >30 percent steatosis, and livers split between two recipients.

Liver transplantation techniques

Left lobe transplantation

• The left and middle hepatic veins, left hepatic artery, and left portal vein are dissected.
• Small portal vein branches are ligated. The left bile duct is divided.
• Vascular and biliary structures entering segment 4 are divided or left intact.
• The parenchyma is transected and then the left hepatic artery and left portal vein are divided, releasing the graft.
• The middle hepatic vein is removed with the graft when a full lobectomy is performed.

Video shows left lobe transplantation steps

{{#ev:youtube|bVCJ5Fch2OU}}

Right lobe transplantation

• The right lobe fits correctly into the right subphrenic space, making the vascular anastomoses easier to perform.
• Right lobe grafts are prone to a variety of technical complications.
• After cholecystectomy, intraoperative ultrasound may be used to mark the position of the hepatic veins and portal branches.
• The right hepatic artery and right portal vein are dissected, followed by the retrohepatic vena cava, isolating the origin of the right hepatic vein.
• The right bile duct is isolated, completing mobilization of the right lobe.
• The liver parenchyma is transected using an ultrasonic scalpel.
• A portoportal anastomosis is then made between the donor right portal vein and the portal vein of the recipient.

Video shows right lobe transplantation steps

{{#ev:youtube|iNEcmYFRbfY}}

Split-liver transplantation

• Splitting donor livers into left lateral and extended right grafts for transplantation into a pediatric and an adult recipient.
• Splitting livers into right and left lobes for transplantation has been investigated as a way to increase the supply of donor organs.
• Approximately 20 percent of donors could be split.
• Five-year survival rates were 77 percent, with graft survival rates of 76 percent.
• For children, 5-year survival rates were 75 percent, with graft survival rates of 63 percent.

Marginal liver grafts

• The shortage of liver grafts has led to the relaxing of selection criteria for donors to ensure that as many potential recipients as possible are offered transplantation.
• Many donor organs which were previously not considered suitable are now used.
• The term marginal was originally applied to grafts from older donors, however, that definition has changed and now it is used to refer to grafts from a higher risk group of donors based on demographic, clinical, laboratory, and histological data.
• There is a balance that needs to be achieved between access to grafts, deaths on the waiting list, and survival after transplantation.
• Marginal liver grafts donors include those with any of the following characteristics:

• Liver donor age >70 years
• Livers from hepatitis C positive donors
• Livers with cold ischemia time >12 hours
• Livers from donation after cardiac death donors
• Livers with >30 percent steatosis
• Livers split between two recipients