Absence of the left portal vein: a difficulty for reduction of liver grafts?

Absence of the portal bifurcation is exceptional and characterized by an absent extrahepatic portal vein bifurcation, the right portal vein only being at the porta hepatis. There is no extraparenchymal left portal vein. This may represent a problem in liver splitting, reduction, and living related transplantation.

A case was encountered during reduction of a cadaveric liver allograft to a left lateral segmental graft from a 40-kg cadaveric donor to a 15-kg recipient. The portal venous inflow was reconstructed with a vein graft via a novel extrahilar approach to the left portal vein at the umbilical fissure.

This graft was used successfully in a 3-year-old child requiring transplantation for a failed Kasai operation for extrahepatic biliary atresia. The child is now well, 1 year posttransplant, after an uneventful postoperative course with good portal flow within the graft.

The situation of an absent left portal vein extrahepatic course should not preclude splitting or reduction procedures. The innovative technical solution, we propose, should add to the armamentarium of the liver transplant surgeon contemplating a left lateral segmental graft for the paediatric liver transplant recipient.