Surgical technique for right lobe adult living donor liver transplantation without venovenous bypass or portocaval shunting and with duct-to-duct biliary reconstruction

Abstract

Objective: To report the authors' experience with adult living donor liver transplantation (ALDLT) without venovenous bypass and to describe modifications that will allow for a direct duct-to-duct biliary reconstruction.

Summary background data: Adult living donor liver transplantation is being evaluated as a method to alleviate the organ shortage. Descriptions of the procedure have emphasized the use of venovenous bypass, portocaval decompression, and the mandatory use of a Roux-en-Y biliary enteric anastomosis. The authors describe a technique for ALDLT without venovenous bypass, portocaval decompression, or caval clamping in 11 recipients and describe the modifications to the procedure that may allow a duct-to-duct biliary reconstruction in certain cases.

Methods: Between March 1999 and March 2000, 11 ALDLTs were performed at the authors' institution. All procedures were performed without venovenous bypass, portocaval decompression, or caval clamping. After a modification to the procedure, five of the last six recipients underwent biliary reconstruction with a direct duct-to-duct anastomosis. Data regarding donor, recipient, and graft survival, complications, and graft function were collected.

Results: Recipients comprised five women and six men, mean age 48 years. Donors comprised five women and six men, mean age 36.5 years. Donor to recipient relationships included sibling, spouse, son, and daughter. Indications for transplantation were hepatitis C, hepatitis C with hepatocellular carcinoma, primary biliary cirrhosis, primary sclerosing cholangitis, ethanol, and cryptogenic. No case required venovenous bypass or portocaval shunting. The right hepatic vein of the donor graft was anastomosed to the confluence of the left and middle hepatic veins in all cases. All donors are alive and well, with no adverse complications reported. Recipient and graft survival rates were 91% and 82%, respectively, for ALDLT versus 92% and 92% for recipients of cadaveric organs during the same time period. One recipient died of multiple organ failure and sepsis. Biliary reconstruction was performed by Roux-en-Y hepaticojejunostomy in the six cases. In five of the last six recipients, direct duct-to-duct biliary reconstruction with a T tube was used. No anastomotic leaks or strictures occurred in the patients undergoing duct-to-duct reconstruction.

Conclusions: Adult living donor liver transplantation can be performed safely and may help alleviate the organ shortage. Neither venovenous bypass nor portocaval shunting is necessary to perform the procedure, and modifications to both the donor and recipient hepatectomy procedures may allow biliary reconstruction to be performed by a direct duct-to-duct anastomosis in selected cases.

Figure 1. Magnetic resonance angiogram showing the relevant hepatic vasculature in a potential right lobe donor. This patient represents an ideal situation for right lobe donation. A replaced right hepatic artery (RHA) is seen to arise from the superior mesenteric artery, and a single right portal vein (RPV) is present. LPV, left portal vein; LHA, left hepatic artery.

Figure 2. Magnetic resonance cholangiogram showing normal biliary anatomy with a single right hepatic duct draining the right lobe.

Figure 3. Dissection of the right hepatic artery (RHA) in the donor is performed to the right side of the common bile duct (CBD). Dissection is avoided between the right hepatic artery and bile duct to prevent devascularization. PV, portal vein.

Figure 4. The donor right lobe is mobilized from the inferior vena cava (IVC). The right hepatic vein (RHV) can be seen clearly.

Figure 5. Postoperative T-tube cholangiogram in a recipient who received a direct duct-to-duct anastomosis for biliary reconstruction. This is made possible by preserving the blood supply to the bile duct from the right hepatic artery and gastroduodenal artery of the recipient.

Figure 6. HIDA scan performed on postoperative day 7 in a recipient of a right lobe with a biliary enteric anastomosis. Excellent uptake and excretion are noted from the right lobe graft.