Laparoscopic Donor Right Hepatectomy with Reconstruction of Segment V and VIII Tributaries of the Middle Hepatic Vein Using a Cadaveric Iliac Artery Allograft
Living donor liver transplantation (LDLT) has become a pivotal strategy to address the shortage of deceased donor organs. Despite its benefits, up to 40% of living donors experience postoperative complications, primarily linked to the morbidity of right subcostal laparotomy wounds. The advent of pure laparoscopic techniques has revolutionized donor hepatectomy by minimizing surgical trauma, enhancing recovery, and reducing hospital stays. This case report details a pioneering application of pure laparoscopic living donor right hepatectomy (PLDRH) combined with vascular reconstruction to address middle hepatic vein (MHV) variations, demonstrating the feasibility of expanding donor selection criteria in specialized centers.
Case Presentation
A 46-year-old female donor (48 kg, 160 cm, BMI 18.8 kg/m²) volunteered to donate her right liver lobe to her 40-year-old brother, who suffered from decompensated biliary cirrhosis, severe portal hypertension, and recurrent variceal bleeding. The recipient’s clinical status was classified as Child-Pugh B-9 with a Model for End-Stage Liver Disease (MELD) score of 14. Preoperative imaging, including contrast-enhanced computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP), revealed a donor liver anatomy suitable for right hepatectomy. The estimated right liver volume, excluding the MHV, was 512 g, yielding a graft-to-recipient weight ratio (GRWR) of 0.98% and a remnant liver volume of 50%. The MHV exhibited two dominant tributaries draining segments V and VIII (Figure 1A), necessitating venous outflow reconstruction to prevent graft congestion.
Surgical Technique
The donor was positioned in a 30° reverse Trendelenburg orientation with abducted arms. Five laparoscopic trocars were strategically placed (Figure 1B). Initial steps included cholecystectomy, mobilization of the right liver by dividing ligaments and short hepatic veins, and dissection of the right hepatic vein (RHV). A hanging maneuver was established using a tube passed through the tunnel between the RHV, MHV, and retrohepatic inferior vena cava (IVC). The right hepatic artery (RHA) and right portal vein (RPV) were isolated, and transient clamping delineated the ischemic transection line.
Parenchymal transection employed a Thunderbeat scalpel and ultrasonic aspirator (CUSA Excel+). The segment V and VIII tributaries of the MHV were identified, divided between Hem-o-Lok clips (Figures 1C, 1D), and reconstructed post-resection. A laparoscopic hanging maneuver facilitated deep parenchymal division (Figure 1E). Intraoperative cholangiography confirmed biliary anatomy before transecting the right hepatic duct. After heparinization, the RHA, RPV, and RHV were sequentially divided using vascular staplers. The graft, weighing 500 g (GRWR 0.96%), was extracted via a subumbilical incision.
Vascular Reconstruction
Back-table perfusion with 2 L of histidine-tryptophan-ketoglutarate (HTK) solution preceded vascular reconstruction. The MHV tributaries (segment V: 0.8 cm; segment VIII: 0.5 cm in diameter) were anastomosed to a cadaveric iliac artery allograft. The external and internal iliac artery branches were sutured to the segment V and VIII tributaries, respectively, using 5-0 polypropylene. The common iliac artery conduit was then anastomosed to the recipient’s IVC (Figure 1F), ensuring adequate venous outflow.
Outcomes
The donor’s operative time was 515 minutes, with warm ischemia limited to 5 minutes and blood loss under 300 mL (no transfusion required). The donor recovered uneventfully, discharged on postoperative day 7. The recipient’s course was similarly favorable, with a 23-day hospitalization and no complications.
Discussion
Laparoscopic donor hepatectomy, initially limited to left lateral sectionectomies in pediatric LDLT, has evolved to include major resections in adults. However, PLDRH remains technically demanding due to challenges in vascular control, deep parenchymal transection, and biliary dissection. This case underscores the importance of meticulous preoperative planning, including 3D CT volumetry and MRCP, to assess vascular and biliary anatomy.
The decision to preserve the MHV in the donor prioritizes donor safety but mandates venous reconstruction in the graft. At the authors’ institution, 46 of 285 right lobe grafts (15.4%) without the MHV required reconstruction of segment V/VIII tributaries using cryopreserved vessels. The use of a cadaveric iliac artery allograft in this case highlights its versatility as a conduit, offering structural integrity and compatibility for complex venous reconstructions.
Laparoscopic techniques reduce parietal trauma, potentially lowering incisional hernia rates and accelerating recovery. However, the steep learning curve and need for advanced laparoscopic skills limit widespread adoption. The authors emphasize strict donor selection criteria, including normal vascular anatomy and adequate remnant liver volume (>30%), to ensure safety.
Conclusion
This case illustrates the feasibility of PLDRH with MHV tributary reconstruction in donors with venous anatomical variations. By integrating advanced laparoscopic skills and innovative vascular reconstruction techniques, this approach expands the donor pool while prioritizing donor safety. The procedure’s success in a high-volume center underscores its potential for broader application, provided stringent patient selection and surgical expertise are maintained.
doi.org/10.1097/CM9.0000000000000167
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