Living Donor Hepatectomy



The history of liver surgery stretches back to ancient times, when battle surgeons introduced debridement of damaged liver segments from open wounds. However, formal entry into the abdominal cavity to treat a liver tumor or to drain an abscess began with the advent of general anesthesia and antisepsis in the late 1800s.

With a better understanding of hepatic anatomy and the segmental structure of the liver, surgeons started performing partial liver resections. The first successful resection of a liver tumor was performed in 1887 in Germany by Langenbuch, the same surgeon who performed the first successful cholecystectomy 5 years earlier.

The lessons learned during World War II concerning liver trauma, blood supply to the liver, and bleeding control spurred the confidence of liver surgeons and marked the beginning of the modern era of liver operations. [1Two landmarks of paramount importance have marked this period. The first was Cuinaud’s detailed description of the segmental anatomy of the liver based on blood supply (see image below). [2The second, and probably brightest landmark of this period, was the first whole-liver transplantation by Thomas Starzl in 1963. [3]

Couinaud's segmental liver anatomy. Couinaud's segmental liver anatomy.

As experience with liver resections increased dramatically while the supply of cadaveric liver grafts became increasingly inadequate to meet the needs for liver transplants, the concept of resecting a healthy person’s liver to use for support of another person’s life was raised.

The concept of living donor liver transplantation (LDLT) emerged originally for pediatric patients because of the high mortality rate among children awaiting a cadaveric graft [4and the fact that a child needs only a small allograft, so an adult donor would not need to undergo major hepatectomy. [5]

Raia et al [6from Brazil described the first attempt of LDLT in children in 1989. Although the recipient did not survive, other centers followed, and the first successful pediatric LDLT, from a mother to her son, was performed by Strong in Australia that same year. [7]

In the United States, the first successful LDLT from a parent to a child was performed the same year at the University of Chicago. [8Before this first procedure, the physicians involved published a manuscript describing the protocol for donor and recipient selection, risks and benefits, and the use of the donor advocacy panel. [9A few years later, reports first showed that the introduction of LDLT dramatically decreased the mortality of children on the waiting list. [10]

With the success of the LDLT in the pediatric population, transplant centers started to embrace the idea of using LDLT in adult recipients. The first successful cases were reported in Japan, where cadaveric grafts are extremely scarce owing to cultural constrains to organ donation. [11 Japanese transplant teams reported excellent results with the use of left- and right-lobe grafts. [12]

The initial results from the LDLT experience in the United States were not as encouraging, [13so the first decade of adult-to-adult LDLT developed very slowly, with only 34 such procedures performed between 1991 and 1998. [8Many of the failures resulted from the underappreciated importance of donor graft size to recipient size. In the pediatric population, this issue was absent, since the size of the recipient was always much smaller than that of the donor. In adult patients, the graft was often too small, the posttransplant function was poor, and, in some cases, there was primary nonfunction. [1415]

After surgeons realized this concept and avoided smaller grafts for larger recipients, the success of adult-to-adult LDLT increased, along with the number of such transplantations performed. Thus, from 1998-2003, 1374 adult recipients underwent LDLT in the United States. [16Enthusiasm for adult-to-adult LDLT in the United States peaked in 2000, with 49 centers performing this operation. However, the enthusiasm fell sharply after a donor death in 2001, which changed the climate for living donation. [17]

From 2001-2006, the number of centers performing adult LDLT and the number of operations performed declined and then stabilized at around 250 cases per year, or 5% of the total number of liver transplantations in adults, approximately half of the peak in 2001. [18After the donor death, numerous position papers, conferences, and review boards took place. [19New York State created a review committee and document that mandated guidelines for transplant centers and physicians who perform LDLT. [1820Additionally, the National Institute of Health (NIH) sponsored a multicenter prospective study of adult-to-adult LDLT, which includes 9 centers in the United States. The Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL) has published outcomes and suggestions concerning LDLT in adult patients. [2122]


To be considered eligible for LDLT, a patient should be able to fulfill the minimal listing criteria for deceased donor (DD) transplantation. All potential LDLT recipients must first be listed on the regular liver transplant waiting list with the United Network for Organ Sharing (UNOS). [23Any contraindication for DD transplant applies to living donor recipients, which is why, in all centers, the evaluation of a potential donor does not start until the recipient is listed.

In the pediatric population, eligibility  for LDLT comes with the listing of the patient for DD transplant. Because procurement surgery for a pediatric LDLT is associated with fewer complications than that for an adult recipient and outcomes in the pediatric population are generally better, ethical issues to determine the eligibility of the recipient are uncommon. [24]

However, in the adult population, such issues play an important role in determining eligibility for LDLT. [25Because living donation involves a healthy individual placed at surgical risk for the benefit of a transplant recipient, the general concept is that LDLT should be performed in recipients who would not receive a DD transplant as soon as they need it, based on the severity of their illness. In other words, the shortage of DD organs is the paramount principle of living donation. However, for this to be ethically justified, the anticipated survival of the recipient should be sufficient to support such an act.

To justify the risk to the donor, the outcome after LDLT should at least equal the outcome after deceased donor liver transplantation (DDLT) and the ability to decrease death among potential recipients on the waiting list. LDLT graft survival  average 87% at 90 days and 81% at 1 year, and improve as the center volume increases. [26]

Just as important as posttransplant survival rate is the effect of LDLT on the risk of death among those on the waitlist. In a 2007 report, LDLT was associated with a lower mortality rate than the alternative of waiting for a DDLT, with an adjusted mortality hazard ratio of 0.56 for LDLT. [21]

Posttransplant outcomes depend partly on the severity of the recipient’s disease. With the implementation of the model for end-stage liver disease (MELD) system for allocation of liver allografts, the sickest patients are prioritized for transplantation (see the MELD Score calculator). [27The postoperative mortality rate after liver transplantation is higher in patients with a high MELD score, regardless of whether DDLT or LDLT is performed, with higher mortality rates with the latter than the former. [28]

The explanation of the increased mortality rates following LDLT among sicker patients is that a partial graft is unable to meet the needs of a patient experiencing severe and prolonged illness. Therefore, many transplantation centers and the New York State of Health Department have recommended that LDLT should not be offered to patients with a MELD score above 25. [29 With the application of that principle, the 1-year patient survival for LDLT has improved to 86%. [3031]

Ideal candidates for living donor liver transplantation

Two groups of recipients are considered ideal candidates for LDLT.

The first group includes patients with hepatocellular carcinoma confined to the liver and without liver decompensation. [32These patients are not sick enough to be placed high on the list based on their MELD score, but their cancer may soon render them unsuitable for transplantation if they develop extrahepatic disease. Data from Japan demonstrate that LDLT for hepatocellular carcinoma yields results that are comparable to LDLT performed in patients without hepatocellular carcinoma. [33]

The second group includes patients whose MELD score does not reflect the severity of their illness. These are patients with complicated cholestatic liver disease, severe encephalopathy, ascites, or cachexia whose illness is much worse than suggested by their MELD score. They are very low on the priority list, and their likelihood of receiving a DDLT is very low, while their risk of death while on the waiting list is very high. [34]

The selection of the donor has ethical and medical considerations.

Ethical considerations center on the 3 healthcare ethics principles [35:

  • Autonomy,
  • Beneficence/nonmaleficence
  • Justice

Autonomy for the donor involves the respect for his or her right to act intentionally and without coercion. The donor has the right to choose what may be a high-risk donation, provided that consent is fully informed. The principle of informed consent goes beyond explanation of the surgical procedure. All the information about the risks and benefits of the living donation, as well as all national and center data, should be included in the consent discussion.

The principles of beneficence (doing good) and nonmaleficence (not inflicting harm) are, at times, in competition in the cases of living organ donations, since healthy individuals are undergoing a potentially harmful procedure to help someone else.

Justice weighs the fairness of treatments for individuals and the larger society. [8]

Donor advocacy panels are an integral part of all centers that perform LDLT. Their main task is to ensure that all the above principles are strongly present and are followed in the evaluation of every donor.

Medical considerations of the living donor are that (1) the donor must be in excellent health in order to be able to undergo the operation and the postoperative and recovery period with minimal physical and psychological distress and that (2) the liver of the donor is of such quality and size that it can be divided in a way that can support both the donor and recipient. These are two separate issues for which testing criteria often overlap but that are at times in conflict. In such cases, donor safety is the priority.

In brief, most potential donors are excluded based on initial studies to rule out underlying conditions that represent increased surgical risk, such as hypertension; diabetes; and hepatic, cardiac, renal, and pulmonary problems. In addition, donors who are younger than 18 years or older than 55 years, as well as pregnant women, are excluded. [36Chronic infections, especially hepatitis and HIV, are traditionally exclusion criteria in most centers. Hypercoagulable states are relative contraindications depending on the severity of the disorder, given the risk of increased donor mortality due to embolic episodes and increased recipient mortality due to portal vein thrombosis. [37]

The potential donor liver is evaluated thoroughly with laboratory and radiology tests. Liver function test results should be perfect in order to proceed to the radiologic evaluation of the liver. High-resolution CT scanning with angiography and cholangiography or MRI are the most common modalities used in most centers. [38The examination of liver quality is very important. Relevant steatosis must be excluded, as it lowers the functional liver mass. Any other parenchymal abnormalities (eg, iron deposits, tumors) should also be ruled out.

Liver volumetry is paramount. Modern CT (eg, MeVis Liver Analyzer and LiverView) and MRI software produce virtual 3-dimensional liver models that enable volume measurements (total liver and graft volumes) and permit virtual hepatectomy as part of presurgical planning. Accurate size matching of the donor and recipient is essential to ensure that functional hepatic mass is available both to sustain metabolic demands and to permit volume regeneration. Inadequate liver volume in the donor will lead to liver failure; inadequate liver volume in the recipient will lead to small-for-size syndrome (SFSS) and primary nonfunction. [39The critical threshold of the remnant liver volume in most centers is 35%, although many centers use 40%; the lowest limit has reported to be 27%. [40]

SFSS in adult-to-adult LDLT remains the greatest limiting factor for the expansion of segmental liver transplantation. SFSS develops in the first 1-2 weeks after transplantation and is characterized by prolonged cholestasis with elevated serum bilirubin levels, coagulopathy, elevated liver enzyme levels, ascites, and, in severe cases, gastrointestinal bleeding and primary nonfunction with encephalopathy, acidosis, renal failure, and shock. [4142]

Portal hyperperfusion, venous pathology, and the arterial buffer response are considered the main contributors to the clinical and histological manifestations of the syndrome. [43Data have suggested that the exposure of a small graft to persisting hyperdynamic circulation and high portal blood inflow results in sinusoidal congestion and hemorrhage, inducing impairment of liver regeneration and hepatic dysfunction. [4442 

Furthermore, the high portal blood inflow causes a compensatory decrease in arterial blood flow. This phenomenon, known as the buffering response, results from a reciprocal compensatory regulation between portal vein and hepatic artery inflow and might contribute to worsening of the graft injury. [45]

Earlier data suggested that a graft-to-recipient weight ratio (GRWR) of less than 0.8% or a graft liver volume of less than 30% of standard estimated volume is a risk factor for the development of SFSS. Most centers do not accept grafts smaller than that, especially when the recipient has portal hypertension. [46]

Finally, a comprehensive vascular and biliary roadmap facilitates detailed surgical planning and reduces postoperative complications in both donor and recipient. [47All the potential anatomical variations should be clearly demonstrated and identified, as this will provide the surgeon with the ability to plan the surgical technique and to identify grafts that would be inappropriate because of anatomical variations.


Contraindications to LDLT in the donor include the following:

  • Age younger than 18 years or older than 55 years

  • Any type of liver disease

  • Anatomical contraindications such as insufficient liver volume or vascular and/or biliary variations that preclude a safe liver resection

  • Obesity with body mass index (BMI) greater than 35 kg/m2

  • Any type of severe comorbidities such as coronary artery disease, cerebrovascular disease, severe uncontrolled diabetes, or hypertension

  • Psychosocial problems that may compromise an uneventful recovery and restoration of physical and social function

Contraindications to LDLT in the recipient include the following:

  • All contraindications for liver transplantation (eg, active infection, active extrahepatic malignancy)

  • Severely decompensated liver failure (MELD score >25 in most cases is a contraindication to LDLT)

  • Cholangiocarcinoma

  • Previous graft failure due to recurrent hepatitis C

  • Acute alcoholic hepatitis

  • Need for combined liver-kidney transplantation


Early postoperative complications may include the following:

  • Liver failure
  • Vascular problems (eg, portal vein thrombosis) [48]
  • Intra-abdominal bleeding
  • Bile leak
  • Wound infection/dehiscence
  • Pulmonary complications (pneumonia, embolus)
  • Pain
  • Other (eg, phlebitis, brachial plexus injury)

Late postoperative complications may include the following:

  • Chronic pain
  • Psychological impact of poor recipient outcome
  • Late bile duct strictures
  • Other (eg, adhesions and associated intestinal obstruction)

Living Donor Hepatectomy Periprocedural Care

Monitoring & Follow-up

The donor is transferred to the surgical intensive care unit (SICU) after the operation. In most cases, the donor stays in the SICU for 48 hours and is then transferred to the regular transplant floor. Most donors can be discharged 1 week after the surgery. Weekly follow-up in the transplant clinic is mandated for the first months after the surgery.

Living Donor Hepatectomy Technique

Approach Considerations

Three different types of donor hepatectomies are used for living donor liver transplantation (LDLT), as follows:

  • Left lateral hepatectomy, in which the graft consists of segments II and III, with or without segment I

  • Left hepatectomy, in which the graft consists of the whole left lobe, segments I, II, III, and IV

  • Right hepatectomy, in which the graft consists of the right lobe, segments V, VI, VII, and VIII

Left Lateral Hepatectomy

The patient is placed in a regular supine position with arms on extension. Care is taken to avoid pressure sores and brachial plexus injury. Devices to prevent hypothermia and deep vein thrombosis are installed.

The incision for left lateral hepatectomy is the classic hepatectomy bilateral subcostal incision with upward midline extension. In cases of thin donors, a midline incision can also be used (see image below).

Incision for living donor hepatectomy. The left laIncision for living donor hepatectomy. The left lateral subcostal extension can be avoided depending on the donor body habitus.

The xiphoid is excised so exposure of the suprahepatic vena cava can be achieved after the application of the retractors.

Self-retaining retractors are used.

The liver is carefully inspected to evaluate any abnormalities that may have been missed on preoperative imaging. At this point, many surgeons prefer to perform intraoperative ultrasonography to delineate the arrangement of segments II, III, and IV and the hepatic veins.

The round ligament is divided and double-ligated, and the falciform ligament is taken down with cautery. The left triangular ligament is also divided with cautery. The lesser omentum is then palpated to evaluate for the presence of an accessory or replaced left hepatic artery (LHA), and is eventually opened if such an artery is absent. If there is a replaced LHA, it will be preserved with the graft.

At this point, some surgeons proceed with cholecystectomy and intraoperative cholangiography. The aim of intraoperative cholangiography is to identify possible biliary anatomic variations that were missed on preoperative imaging and to delineate the point of safe division of the bile duct. Not all surgeons perform cholecystectomy and intraoperative cholangiography as part of left lateral hepatectomy, since preoperative imaging offers high-quality images of the anatomy and the possible variations of this region.

The left lateral sector is detached from the undersurface of the diaphragm by dividing the left triangular ligament. The loose tissue overlying the suprahepatic inferior vena cava (IVC) is divided to expose the common trunk of the left hepatic vein (LHV) and middle hepatic vein (MHV) and its junction with the IVC.

The next step is to identify and dissect the left branch of the portal vein and the hepatic artery (see image below).

The left branch of the portal vein and the left heThe left branch of the portal vein and the left hepatic artery have been dissected free from surrounding tissue. Notice that in this donor there are two separate arteries supplying the segment II and III.

During dissection of the left portal vein (LPV), care should be taken to recognize and double-ligate small portal tributaries from the caudate lobe. This is important in order to safely carry out the parenchymal transection at that level. The dissection of the LPV continues with ligation of the portal branches of segment IV. Once the dissection of the hilar structures is complete, the left lateral sector is elevated to expose the fissure of ductus venosum (ligament of Arantius).

The ductus venosum is dissected and ligated at its junction with the IVC, exposing the lateral wall of the LHV. If the junction of the LHV and MHV is extrahepatic, at this point, gentle dissection can be carried out around the LHV and extended cephalad to create a plane between the LHV and MHV. Many surgeons avoid the attempt to encircle the LHV at this point, since such a maneuver may induce severe bleeding if the junction between the LHV and MHV is intrahepatic.

The liver capsule just underneath the fissure of ductus venosum is removed with cautery or the ultrasonic dissector (CUSA). This line will be the plane of dissection between the caudate lobe and the left lateral graft.

The next step is to mark the plane of resection on the anterior surface with cautery. The line will be on the left of the falciform ligament. After the marking, transection of the liver parenchyma is started.

There are multiple ways to transect the liver (eg, clamp fracture, cautery, double-ligation); the preferred method for LDLT is with a CUSA (see image below).

Ultrasonic aspirator and dissector. Ultrasonic aspirator and dissector.

The advantages of the ultrasonic dissector are that it can coagulate structures less than 1 mm safely but preserve larger ones that need to be double-ligated or clipped, minimizing blood loss and making larger structures more easily recognized and ligated safely. The hepatic parenchyma is transected without obstructing the blood inflow to the liver (Pringle maneuver).

Usual settings for the dissector are as follows:

  • Amplitude 60% of maximum
  • Irrigation with normal saline at about 4-6 mL/minute
  • Suction power at 20% of maximum

A fine-tip handpiece with incorporated electrocautery is preferred for precise dissection. The parenchyma is transected on the anterior surface of the liver until the hilar plate is reached (see image below).

After the parenchmymal dissection reaches the hilaAfter the parenchmymal dissection reaches the hilar plate, a right angle clamp is passed behind the bile duct.

At this point, many surgeons prefer to perform a second cholangiogram to confirm the exact point of the left hepatic duct (LHD) division. This cholangiogram allows the surgeon to dissect the LHD safely before the branching to the segment II and III ducts, thus avoiding two bile duct orifices in the graft. Also, in some cases, the duct confluence of segments II and III is in very close proximity to the right hepatic duct (RHD), and cholangiography helps to avoid injury to the right duct.

Once the point of LHD division is determined, the hilar plate, along with the LHD, are divided slowly with a knife (see image below).

The bile duct is divided with a knife for precise The bile duct is divided with a knife for precise transection and preservation of its vascular supply.

Brisk arterial and venous bleeding from the hilar plate and the ductal wall is common (see image below).

Brisk bleeding after the division of bile duct. Brisk bleeding after the division of bile duct.

Bleeding should be controlled (usually with 6-0 Prolene suture) immediately as it is encountered before proceeding with further division, to reduce blood loss and to provide a clear field. The hilar plate is completely divided, and any hilar plate vessels are then encircled and divided. The orifice of the common hepatic duct is then sutured with 6-0 PDS suture. If the right bile duct is in very close proximity to the confluence of segments II and III ducts, a third cholangiogram may be performed to rule out injury or narrowing of the common duct.

After division of the hilar plate and LHD, hilar plate cut edges should be carefully inspected to identify any small caudate lobe bile ducts that may have been transected. If any are found, they should be suture ligated to avoid bile leakage.

The parenchymal division is then continued toward the fissure of ductus venosum. Lifting up the fissure with umbilical tape, clamp, or even the assistant’s fingers will help the surgeon keep the proper orientation and expedite the liver transection. Great care should be taken at this point to avoid forceful retraction of the graft, causing avulsion and bleeding from the LHA (see image below).

The parenchyma and the bile duct have been dividedThe parenchyma and the bile duct have been divided.

The parenchymal transection continues cephalad and finishes at the junction of the MHV and LHV. In certain cases, a large segment IV hepatic vein that drains directly to the LHV will be encountered in this area and will need to be divided and tied or suture-ligated in order to complete the hepatectomy.

If the recipient needs a larger liver graft but not a formal whole left lobe, part of the segment IV parenchyma may be included with segments II and III. In this case, the transection plane moves farther toward the midplane of the liver, and the MHV may be encountered. In this setting, the MHV should be followed carefully to the junction with the LHV, and the liver transection plane is then shifted horizontally toward the fissure of the ductus venosum.

After the parenchymal transection is complete, retrieval of the left lateral graft starts with division of the LHA. A bulldog clamp is placed on the LHA, and a 2-0 silk tie is placed close to the junction with the main hepatic artery. The LHA is then divided with a knife. The LPV follows in the same manner. Some surgeons prefer to use a vascular clamp on the LPV close to the junction with the right, to divide the LPV, and to oversew the remaining stump with 6-0 Prolene. Using a 2-0 silk tie on the stump is also very common. When the tie is placed, sufficient length of the LPV should be left above the tie for subsequent suturing while also avoiding occlusion of the bifurcation of the portal vein.

After the LHA and LPV, the LHV is divided. The division can be carried out with a vascular stapler (TA30, V3 [2.5 mm], USA Surgical) or with a vascular clamp and oversewing the remaining stump with 5-0 Prolene suture.

The liver graft is transferred to a basin that contains ice sludge. The bulldog clamps are removed, and the graft is flushed with histidine-tryptophan-ketoglutarate (HTK) solution . A cannula is placed in the LPV, and at least 1000 mL of solution is flushed through the graft. The hepatic artery is then cannulated, usually with a 23-gauge angiocatheter, and flushed with 500 mL of solution. The flushing continues until the effluent is clear solution without any blood. The bile duct is also rinsed with HTK upon conclusion.

The graft is then inspected for quality and any missed injuries. The LHV orifice is inspected for the need of any reconstruction. Finally, the graft is weighed, stored in the plastic bag, and transferred to the room of the recipient operation.

After the graft has been removed and the vascular stumps have been sutured/ligated, the donor is carefully inspected to identify any areas of bleeding or bile leak. Some surgeons infuse dilute methylene blue into the common bile duct via the cystic duct cannula to check for bile leaks. Likely sites for bile leaks include the LHD stump, the hilar plate, and the entire cut surface. If any bile leak is found, it is sutured with 6-0 PDS.

The abdominal wound is closed. Most surgeons choose not to leave any abdominal drains in the donor.

Left Lobe Hepatectomy

The donor is placed in a supine position with care to avoid pressure sores and brachial plexus injury. Devices to prevent hypothermia and deep vein thrombosis are used. The incision, as in the case of left lateral hepatectomy, is bilateral subcostal with midline extension. A hockey-stick incision with avoidance of the left subcostal part is also an option in certain patients.

After the liver is exposed with appropriate retractors, it is inspected for quality and size. If the liver appears normal, cholecystectomy and intraoperative cholangiography are then performed (see image below). This is a mandatory step during left hepatectomy, since biliary duct variations that may have been missed on preoperative imaging are possible.

The cholangiogram catheter has been inserted in thThe cholangiogram catheter has been inserted in the cystic duct stump for the performance of the cholangiogram.

In addition, cholangiography helps the surgeon accurately identify the exact point of division of the left bile duct (see image below).

Intraoperative cholangiogram reveals normal bile dIntraoperative cholangiogram reveals normal bile duct anatomy.

Once the bile ducts are clearly visualized, the surgeon can place a bulldog vascular clamp at the point of intended dissection of the bile duct and repeat the cholangiography. Under cholangiographic guidance, the bulldog clamp can be repositioned several times until it is in the desired point for safe bile duct division.

Hilum dissection then begins. The LHA is carefully dissected to the junction with the main hepatic artery. Care should be taken to avoid injury of a segment IV artery, which may arise from the left artery at any level. Once the LHA is dissected, dissection of the LPV follows. Small caudate lobe branches that originate from the LPV close to the junction with the right should be carefully double-ligated and divided. The rest of the caudate branches that are connected directly with the LPV are left intact, since the caudate lobe will follow the graft.

The lesser omentum is then exposed and divided all the way to the diaphragm. If there is a replaced or accessory LHA, it should be preserved with the graft.

Afterward, the left lobe is mobilized with the division of the left triangular ligament. Care should be taken not to injure the diaphragmatic vein that drains into the LHV. The diaphragmatic vein can be safely ligated and divided for better exposure of the LHV.

The caudate lobe is then mobilized from the IVC. All the small caudate lobe veins that drain directly to the IVC are carefully double-ligated and divided. If a larger caudate vein is present, it should be preserved and anastomosed in the IVC of the recipient to avoid congestion of the caudate lobe. The ductus venosum is then dissected and ligated to expose the lateral part of the LHV. The anterior surface of the LHV and MHV are then cleared from the surrounding tissue, and the junction of the MHV with the right hepatic vein (RHV) is identified (see image below).

Hepatic veins exposed. Hepatic veins exposed.

The junction of the MHV and LHV is seen from the posterior side, and the common trunk of the LHV and MHV may be encircled at this point (see image below).

A right angle clamp inserted in the groove betweenA right angle clamp inserted in the groove between the left and middle hepatic veins.

The next step is to define the parenchymal transection line by temporarily clamping the LPV and LHA and following the demarcation line with monopolar diathermy (see image below).

After clamping the left hepatic artery and the lefAfter clamping the left hepatic artery and the left portal vein the left lobe of the liver becomes dusky and the demarcation line is visible.

Typically, this line connects the junction of the MHV and RHV with the gallbladder bed anteriorly and continues in the middle of the gallbladder bed inferiorly to the point of division of the LHD in the hilar plate and to the posterior junction of the RHV and MHV (see images below).

The line of parenchymal dissection has been markedThe line of parenchymal dissection has been marked with the cautery on the anterior/cephalad surface of the liver.
The line of dissection as it is marked at the postThe line of dissection as it is marked at the posterior surface of the liver.

The parenchymal transection is performed with an ultrasonic dissector. The MHV is included with the graft, and the left wall of this vein is the guide of the transection. Care should be taken to double-ligate the branches of segment V and VIII hepatic veins that drain in the MHV in order to avoid severe bleeding (see image below).

Segment V vein draining in the middle hepatic veinSegment V vein draining in the middle hepatic vein is double ligated.

Once the plane of transection reaches the hilar plate, the bile duct is divided with a knife, and bile duct vessel bleeding is controlled with 7-0 Prolene sutures. The bile duct stump on the right side of the liver is closed with 6-0 running PDS sutures.

After the liver transection is complete, the LHA and LPV are clamped with bulldog vascular clamps toward the donor graft while ligated toward the remaining right lobe and divided. The common stump of the MHV and LHV is clamped toward the IVC and divided (see image below).

The stump of the left and middle hepatic vein is cThe stump of the left and middle hepatic vein is clamped with a German clamp.

The graft is taken to the backbench container and flushed with preservation solution (see image below). In the donor, the stump of MHV and LHV is closed with 3-0 or 4-0 running Prolene suture.

The left lobe graft in the preservation solution bThe left lobe graft in the preservation solution basin.

The cut surface of the remaining liver is then carefully inspected for bleeding or bile leaks (see image below).

The remaining right lobe inspected for signs of blThe remaining right lobe inspected for signs of bleeding or bile leak.

Some surgeons repeat cholangiography through the cystic duct stump to rule out any bile duct injuries or leaks. Some also use methylene blue through the cystic duct for the same purpose. If no bleeding points or bile leaks are identified, the surgeon may decide to leave a surgical drain, and the abdomen is closed.

Right Lobe Hepatectomy

The donor is placed supine on the operating table. Attention is paid to avoid pressure sores, and devices are used to prevent deep vein thrombosis. Warming devices are also applied over the lower and upper limbs. The incision is bilateral subcostal with midline upward extension. If the donor is slim, the left subcostal extension may be avoided.

After the peritoneal cavity is entered, the liver is inspected for any abnormality that may have been missed on preoperative radiographic tests.

The falciform ligament is dissected to the suprahepatic vena cava.

Cholecystectomy is then performed, followed by intraoperative cholangiography. During cholangiography, the anatomy of the intrahepatic and extrahepatic bile tree is carefully inspected to evaluate any anatomic variations that may exclude a safe hepatectomy. If no such variations are present, the surgeon places a surgical clip or a bulldog clamp at the hilar area where the bile duct transection will be performed and obtains another cholangiogram to verify the position of the transection (see image below).

Intraoperative cholangiogram. The bulldog clamp haIntraoperative cholangiogram. The bulldog clamp has been placed to facilitate the evaluation of the division point.

Under cholangiographic guidance, a surgical clip is placed at the point where the division of the bile duct is appropriate.

The cystic artery is then followed to its junction to the right hepatic artery (RHA). After the RHA is identified, it is dissected free from surrounding tissue. Care should be taken not to dissect the RHA beyond the left side of the common hepatic duct and into the space between the RHD and the RHA to avoid jeopardizing the blood supply to the common hepatic duct and RHD, respectively. In addition, if a segment IV hepatic artery arises from the RHA, their junction is at the right side of the common bile duct in most cases.

The segment IV artery should be preserved to prevent ischemic necrosis of segment IV. If there is uncertainty about a branch arising from the RHA, it can be temporarily clamped and Doppler scan used to evaluate the arterial flow in segment IV. In some cases, the arterial branches of segment IV communicate with segments II and III, which should have been identified on preoperative imaging. In this case, if the segment IV artery arises from the RHA, it can be sacrificed.

Next, the right portal vein (RPV) is dissected free. In order to obtain sufficient RPV length, certain branches that enter the caudate lobe should be divided.

The right liver is then mobilized. The right triangular ligament is divided, and all the bare area of the right lobe is freed from its diaphragmatic attachment. The assistant rotates the liver to the left, and the surgeon continues the mobilization of the right lobe downward to the IVC. The right adrenal gland will be encountered, and caution needs to be taken in order to dissect it free from the liver without injury and bleeding. Monopolar cautery is the preferred method for this dissection.

The surgeon then begins mobilizing the posterior surface of the right lobe from the IVC. The numerous small accessory hepatic veins, which drain directly into the IVC, have to be carefully divided and double-ligated. This dissection continues until most of the anterior surface of the IVC is freed in order to facilitate subsequent liver transection. If an accessory vein is 5 mm or more, it should be preserved in the graft and reimplanted in the recipient IVC (see image below).

Large middle right accessory vein. Large middle right accessory vein.

In most cases, there are two such larger accessory veins, the right middle and right inferior hepatic vein.

The MHV and RHV are dissected free from the surrounding tissue in their junction with the suprahepatic IVC. If the junction of the middle and/or LHV is deep inside the liver parenchyma, the surgeon should avoid further dissection at this stage and leave it for the end of the liver transection.

The RHA and RPV are then occluded temporarily to produce the demarcation line between the right and left liver (see image below).

After clamping of the right hepatic artery and rigAfter clamping of the right hepatic artery and right portal vein, the right lobe becomes dusky and the demarcation line is visible.

The line is marked with cautery, and the transection begins. Liver transection is performed with the ultrasonic dissector (CUSA).

At this point, the surgeon can divide the liver parenchyma, including or excluding the MHV with the right graft.

The issue of whether to include the MHV in the right liver graft is controversial. The authors’ institution routinely does not include the MHV, so the transection takes place on the right side of the MHV. The rationale is that the MHV drains segment IV, so taking it with the right graft will cause significant congestion in the donor's remaining liver.

On the other hand, advocates of including the MHV recognize that not including it can result in congestion of segments V and VIII in the right graft. In order to minimize this congestion, any large branches of segment V and VIII that are draining into the MHV need to be preserved and anastomosed individually with the IVC or RHV of the recipient.

Nonetheless, some congestion of those segments will occur in the recipient for the first postoperative days, until all the communicating collaterals between the anterior and posterior sectors grow and the venous drainage of segments V and VIII is restored. This is why the right liver graft needs to be of adequate size and the recipient's overall health should be  adequate to withstand impaired graft function in the immediate postoperative period.

If the MHV is included in the right graft, care should be taken to recognize the segment IVb large vein that drains into the MHV and to preserve it in the donor by avoiding dissection of the MHV farther than that point. In the authors’ center, the MHV is always left with the remaining left lobe (see image below).

The middle hepatic vein is preserved with the remaThe middle hepatic vein is preserved with the remaining left lobe in the donor.

When the parenchymal transection reaches the hilar plate, the bile duct is divided with a knife and the bleeding vessels tied with 7-0 Prolene. The opening in the main bile duct in the donor is closed with running 6-0 PDS. The RPV and RHA are then tied at the side of the donor and clamped with bulldog vascular clamps at the side of the graft and divided. The RHV (and MHV when it is included) is clamped at the side of the IVC, and the donor side is cut with scissors (see image below).

The liver parenchyma and the bile duct have been tThe liver parenchyma and the bile duct have been transected. The right hepatic artery and right portal vein have been dissected up to the bifurcation of the main hepatic artery and portal vein.

The right liver graft is placed into an ice-cold preservation solution basin and flushed (see image below).

The right lobe graft. The right lobe graft.

The cut surface of the left lobe is inspected for signs of bleeding and bile leaks. Some surgeons perform another cholangiogram at this point through the cystic duct stump to rule out any leaks or damage in the remaining bile tree.

After placement of the surgical drain, the abdomen is closed.