Split liver transplantation

Abstract

Split liver transplantation offers an attractive way to increase the number of cadaveric grafts. In the past 10 years, it has enabled clinicians to minimise paediatric waiting list mortality. Two major concepts are applied in liver splitting. The more widely accepted approach provides a left lateral and a right extended liver graft to be transplanted into one child and one adult, respectively. To date the results from this technique are comparable to whole organ techniques for both the paediatric and the adult recipient. The second principle of splitting the liver provides two 'full' hemi-grafts-the left side for a small adult or big child and the right for a medium-sized adult patient. Full right/full left splitting is an important means of expanding the adult liver graft pool; however, it is a complex variant of liver transplantation that requires a high level of technical skill and a comprehensive knowledge of possible anatomic variations. Splitting for two adults should be performed in centres with a significant annual volume of liver transplantations, experience with left lateral splitting and an active program of hepatobiliary surgery. This brief review discusses anatomical and technical aspects and summarises the experience of both approaches to split liver transplantation to date.

Figure 1.

Anatomic situation after dissection of the portal branches to segment IV in the course of left lateral splitting. The left hilar plate behind the left portal vein is exposed. In most cases the bile duct(s) within the hilar plate can be seen. Sharp transection of the hilar plate (dashed line) should yield a short stump of the bile duct(s) from segments II and III (see text).

Figure 2.

Different strategies to optimise venous drainage of segments V and VIII subsequent to full right/full left splitting. Beyond right and segment VIII vein from cut surface re-anastomoses, outflow via short retrohepatic veins is assured by utilising the right cava patch subsequent to the cava split technique (a). Venous branches that lead in the parenchymal transection plane should, if >5 mm in diameter, be reconstructed via the recipients own middle hepatic vein without (b) or with (c) interpositioning graft Alternatively, a graft can be interposed between the stump of segments V and VIII veins and the recipient's cava (d).