Right lobe graft in living donor liver transplantation

For the sake of donor safety in living donor liver transplantation (LDLT), the left lobe is currently being used most often for the graft. However, size mismatch has been a major obstacle for an expansion of the indication for LDLT to larger-size recipients, because a left lobe graft is not safe enough for them.

In 1998, LDLT using a right lobe graft was introduced and performed on 26 recipients to overcome the small-for-size problem. The right lobe, which does not include the middle hepatic vein of the donor, was used. Initially, indication for right lobe LDLT was basically defined as an estimated left lobe graft volume/recipient body weight ratio (GRWR) of <0.8%, which was later raised to <1.0%.

All the donors recovered from the operation without persistent complications. Two donors with transient bile leakage were successfully treated with a conservative approach. A right lobectomy resulted in more blood loss (337+/-175 ml), and a longer operative time (6.67+/-0.85 hr) than a lateral segmentectomy, but not a left lobectomy. Grafts with a GRWR >0.8% were implanted in all recipients, except for two, who received relatively smaller right lobes (GRWR of 0.68% and 0.66%). In one of these two, the right lobe from the donor was used as the orthotopic auxiliary graft. Postoperative transitory increases in total bilirubin and aspartate transaminoferase for right lobe donors were higher than those for the left lateral segmentectomy. Nineteen recipients (73.1%) were successfully treated with this procedure. The causes of death were not specific for right lobe LDLT, except for one patient with a graft that had multiple hepatic venous orifices. These multiple and separate anastomoses of the hepatic veins caused an outflow block as a result of a positional shift of the graft, which finally led to graft loss.

Our experience suggests that right lobe grafting is a safe and effective procedure, resulting in the expansion of the indication for LDLT to large-size recipients. How to deal with the possible variation in the anatomy of the right lobe graft should be given attention throughout the procedure.