Surgical techniques according to anatomic variations in living donor liver transplantation using the right lobe

In living donor liver transplantation, the right lobe has many anatomic variations in the vascular tree, which could lead to surgical complications. We need to define surgical technique according to anatomy.

From January 2000 to September 2007, 310 living donor liver transplantations using the right lobe were performed in patients with end-stage liver disease. The vascular trees were evaluated preoperatively with computed tomography and magnetic resonance angiography. We classified anatomic points for safe harvest in the hepatic artery, portal vein, and hepatic vein and described technical points based on anatomic variations.

There were many anatomic variations in the hepatic vasculature. Hepatic artery variations were observed in 16.8% of cases. Double hepatic artery was observed in 14 cases (4.5%). Of these 14 cases, reconstruction as a single artery was performed in 6 and dual reconstruction was performed in 8 cases. Portal vein variation was observed in 45 cases (14.5%): Dual anastomosis to right and left portal vein was performed in type III (n = 20; 6.4%) and type IV (n = 3; 1.0%) variations. There were 70 cases of portal vein thrombosis. In 8 of the 70, a jump or interposition graft with iliac vein was utilized. Of the middle hepatic vein variant, segment V vein only was reconstructed in 188 (60.6%) cases. In 21 (6.8%) cases, segment VIII vein only was reconstructed, and in 43 (13.9%) cases, both segment V and segment VIII veins were reconstructed using the recipient's portal vein, a cryopreserved iliac vein, or a prosthetic graft. The most common variation of right inferior hepatic vein was type II (n = 141; 45.5%), which has 1 right inferior hepatic vein.

Living donor liver transplantation using the right lobe can be performed safely, but there is a potential operative risk because of various anatomic variations. To minimize operative complications, anatomic variations should be kept in mind to ensure a safe and successful operation.