The Role of Microsurgery in Living Donor Liver Transplantation

Liver transplantation (LT) is an accepted curative therapy to save select patients with end-stage liver failure, congenital liver diseases affecting the liver or bile duct, and hepatocellular carcinoma. Living donor liver transplantation is an indispensable and alternative choice to manage the scarcity of deceased liver grafts and to provide a quick way to access a healthy graft. Successful hepatic artery reconstruction for liver transplantation is crucial for outcomes. Difficult hepatic artery reconstructions (HAR) are not uncommon in LT, especially in living donor liver transplantation (LDLT). They are defined as graft or recipient hepatic arteries smaller than 2 mm in diameter, size discrepancy greater than 2 to 1, and also include cases with multiple hepatic arteries, suboptimal quality, or those that require immediate redo HAR during transplantation. Technique refinements include selection of the appropriate recipient HA, precise HA dissection, early recognition of vessel injury under the microscope, meticulous use of clips for branch ligations whenever needed, deliberate oblique cut of the artery, and the use of a modified funneling technique, or shifting to an alternative artery to replace a pathologic HA. Reconstruction of an additional HA for dual arterial supply can also contribute to the improved result and minimize complications. Complex biliary anatomies are also commonly encountered in living donor liver transplantation. Reconstruction using microsurgical techniques and specific surgical strategies can lead to a significant reduction of biliary complications, as seen in our experience from an average of 10.35% between 2006 and 2021, to 6.5% in the year 2022. These techniques and approaches include using the ipsilateral bile duct as the first choice for duct anastomosis, an additional figure-of-8 suture over the anastomosis site, centralization of duct anastomosis when size discrepancy is greater than 2 to 1, and thoughtful selective biliary stent insertion in select cases. In conclusion, the application of microsurgical techniques and refined surgical strategies has tremendously improved the results of hepatic artery and biliary reconstructions in living donor liver transplantation, leading to lower complication rates and better outcomes.