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High hilar dissection: new technique to reduce biliary complication in living donor liver transplantation
Kwang-Woong Lee1, Jae Won Joh, Sung Joo Kim
1Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
Insights
High hilar dissection (HHD) reduces biliary complications in living donor liver transplantation (LDLT). This technique involves intrahepatic Glissonian approach, leading to tension-free anastomosis and preserving bile duct blood supply, minimizing adverse outcomes.
Area of Science:
- Hepatobiliary Surgery
- Transplantation Surgery
- Surgical Techniques
Background:
- Biliary complications remain a significant challenge in living donor liver transplantation (LDLT).
- Current surgical approaches may not adequately address the prevention of these complications.
Purpose of the Study:
- To introduce and evaluate a novel surgical technique, high hilar dissection (HHD), for recipient hepatectomy in LDLT.
- To assess the efficacy of HHD in reducing biliary complications after LDLT.
Main Methods:
- The HHD technique involves an intrahepatic Glissonian approach, dividing Glissonia pedicles at the third level or beyond with total hepatoduodenal ligament occlusion.
- Unused bile ducts and bleeding were managed with continuous suture of the hilar plate following isolation of major vessels.
- The technique was applied in 31 LDLT recipients, with single or dual duct anastomosis performed.
Main Results:
- No bile leakage occurred at the biliary anastomosis site.
- Six biliary complications were observed in five patients (2 bile leaks from the cut liver surface, 4 biliary strictures).
- Conversion to hepaticojejunostomy was not required in any patient experiencing biliary complications.
Conclusions:
- The HHD technique may decrease biliary complications in duct-to-duct anastomosis during LDLT.
- HHD facilitates tension-free anastomosis and preserves critical blood supply to the bile duct.
- This approach simplifies multiple ductal anastomoses and reduces surgical complexity.
Abstract:
Biliary complications after living donor liver transplantation (LDLT) continue to be problematic. For reducing the biliary complications, the authors applied an intrahepatic Glissonian approach to the recipient hepatectomy. We called this Glissonian dissection technique at the high hilar level high hilar dissection (HHD). In this study, we introduced this HHD technique and evaluated its outcome in 31 recipients of a living donor liver transplant (LDLT). With total occlusion of hepatoduodenal ligament Glissonia pedicles were divided at the intrahepatic level at the third level of pedicles or beyond. After portal vein and hepatic artery were isolated from the hepatoduodenal ligament, unused bile ducts and bleeding were controlled with continuous suture of the hilar plate. Single duct anastomosis was performed in about 21 and dual duct anastomosis in 10 recipients. Bile leakage of the biliary anastomosis did not occur. There were 6 biliary complications in five patients; 2 bile leaks from the cut liver surface and 4 biliary strictures of which one of unknown etiology. In none of the patients with biliary complications, conversion to a hepaticojejunostomy was necessary. This new HHD technique during recipient hepatectomy may contribute to reduce the biliary complications in duct-to-duct anastomosis by allowing a tension free anastomosis and preserving adequate blood supply to the bile duct. Moreover, it facilitates multiple ductal anastomoses without difficult surgical manipulation.
