Combination splitting using both in situ and ex situ techniques in triple split liver transplantation in pigs

In situ splitting of cadaver livers has been reported to reduce cold ischemic damage, to avoid biliary complications, and to result in improved graft survival. In this study, which involved a wider application of split liver transplantation (SLT), we examined the effects of a technique combining both ex situ and in situ splittings in triple SLT in pigs and compared it to ex situ splitting alone. In the combination splitting group, the splitting between the right and left lobes was done in situ with perfusion of the left lobe with cold, lactated Ringer's solution; that between the lateral and medical right lobes was done ex situ in backtable surgery. The time required for in situ splitting was 28 +/- 5 min. The time for backtable surgery and the total ischemia time were significantly shorter in the combination splitting group than that in the ex situ splitting group (P < 0.05). One day after triple SLT, the elevations in both serum AST and LDH in the ex situ splitting group were significantly greater than those in the combination splitting group (P < 0.05). We conclude that combination splitting may provide a technical improvement and have a beneficial effect on the clinical application of triple SLT.