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Year : 2017  |  Volume : 11  |  Issue : 2  |  Page : 77-78

Hepatic venous outflow reconstruction in partial liver grafts: The middle path

1 Department of Gastroenterology and liver transplantation, Max Hospital, Saket, New Delhi, India
2 Department of Liver Transplantation Surgery, Indraprasta Apollo Hospital, New Delhi, India

Date of Web Publication12-Sep-2017

Correspondence Address:
Selvakumar Naganathan
101, Sangam Apartments, West Enclave, Pitampura, New Delhi - 110 034
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijot.ijot_18_17

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Background: Liver transplantation is the gold standard treatment in end-stage liver disease. Although organ donation is on the rise, living donor liver transplantation (LDLT) is still the bulk of all the transplantation procedures in our country (India). LDLT is a technically complex surgical procedure. In addition to known complications in the recipient donor morbidity and mortality are still fearsome complications, recipent complications includes multiple vasculo- biliary complications and graft dysfunctions. The surgical technique has evolved over the years to increase the recipient outcomes with negligible donor morbidities. One of them is shift from full middle hepatic vein grafts to modfied right lobe (MRL) grafts. Methods: MRL grafts were performed. In MRL grafts, drainage of the anterior sector is the critical step. Failure of this will lead to graft congestion and loss of functional graft volume. However, not all veins need to be drained. Results: In this article, we have described a simple and effective technique which we follow routinely in our institute to identify the intrahepatic veno-venous communications. Conclusion: MRL technique optimizes the drainage procedure with maximum yield.

Keywords: Hepatic venous outflow reconstruction, intrahepatic veno-venous communications, living donor liver transplantation, saline flush

How to cite this article:
Naganathan S, Gupta S. Hepatic venous outflow reconstruction in partial liver grafts: The middle path. Indian J Transplant 2017;11:77-8

How to cite this URL:
Naganathan S, Gupta S. Hepatic venous outflow reconstruction in partial liver grafts: The middle path. Indian J Transplant [serial online] 2017 [cited 2020 Jul 6];11:77-8. Available from: http://www.ijtonline.in/text.asp?2017/11/2/77/214381

  Introduction Top

In living donor liver transplantation (LDLT), the graft is marginal. This is because of multiple factors such as volume, cut surface, small pedicle structures, and multiple outflow veins. Hence, in LDLT, great care is taken to harvest and implant the best possible graft to achieve maximum donor safety and the best possible recipient outcome. Every milligram of graft is precious. Inflow-outflow mismatch has been found to be the most common cause of small-for-size syndrome. Hence, there are situations where, in spite of good graft volume, recipients end up with small-for-size features when the outflow is inadequate, on the contrary, with good outflows even smaller grafts (graft recipient weight ratio <0.8) have been seen to do well with comparable patient outcome.[1]

  Description of Technique Top


The principle of this technique is based on the concept that anatomical intra-parenchymal hepatic veno-venous communications exist in livers. The technique is devised to identify such communications and optimize the reconstruction procedure.

Anatomy of the outflow

Hepatic venous anatomy is variable. Full middle hepatic vein (MHV) grafts have been found to be unsafe for donors. Hence, more and more living-related liver transplantation (LRLT) centers are drifting toward modified right lobe (MRL) grafts in view of donor safety. With better understanding of LRLT, we also prefer MRL in majority of our adult recipients. Ideally, a MRL graft has one right hepatic vein, one segment 5 vein, and one segment 8 vein as outflows. Segment 5 and segment 8 veins are reconstructed to form a neo-MHV. However, more than 30% of grafts have multiple inferior hepatic veins (IHVs) and multiple segment 5 and segment 8 veins. Attempts are made to drain all the parenchymal volume to avoid graft congestion and functional small-for-size syndrome. Drainage is done with portal vein grafts retrieved from explant liver, polytetrafluoroethylene grafts, and cadaveric grafts. The goal of reconstruction in back bench is to keep minimum possible venous anastomosis and maximum drainage.[2]

Challenges in venous reconstruction in back bench

The challenges are multiple as follows:

  1. Availability of grafts - In patients with hepatocellular carcinoma and portal vein thrombosis, the native portal veins cannot be used. Synthetic or cadaveric grafts need to be used
  2. Alignment of veins into the grafts in cases of scattered sectoral veins - In cases where the sectoral veins are multiple and located in different alignment, extension cuffs have to be applied to bring them into common alignment. This increases the number of anastomoses and thereby time
  3. Multiple anastomoses - Multiple veins means multiple anastomoses which again increase cold ischemia time (CIT)
  4. Prolongation of CIT and warm ischemia time (WIT) - In cases with multiple IHVs, the implantation time also increases, thereby increasing the WIT.[3]

Which vein to drain?

The currently described practice is to drain significant veins, i.e., veins >6 mm. In our practice, we realized that it is not the ideal approach. This is because smaller veins may drain a sizeable parenchyma and the areas drained by larger veins can have intrahepatic venous communications [Figure 1].
Figure 1: Computed tomography angiography in hepatic venous phase showing intrahepatic veno-venous communications.

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How do we identify the communicating channels?

We have devised a simple technique to identify these communications. Cold saline is instilled into the vein under consideration. The drainage of saline through the neighboring veins is looked for. In case of intrahepatic veno-venous communication, the injected saline drains out through the neighboring vein. If there is no communication, then it flows out preferentially through the portal vein. The communicating veins were safely ligated [Figure 2].
Figure 2: Saline flushing of inferior hepatic vein in the back bench.

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By this technique, we were able to significantly reduce the number of anastomosis in the outflow of the graft which in turn reduced the outflow-related complications.

  Conclusion Top

With our experience of more than 2000 LRLTs, we have found this technique to be simple, safe, and effective. We recommend this technique for better outcomes in LRLT.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Jeng LB, Thorat A, Li PC, Li ML, Yang HR, Yeh CC, et al. Raising-flap technique for outflow reconstruction in living donor liver transplantation. Liver Transpl 2014;20:490-2.  Back to cited text no. 1
Hwang S, Lee SG, Ahn CS, Park KM, Kim KH, Moon DB, et al. Cryopreserved iliac artery is indispensable interposition graft material for middle hepatic vein reconstruction of right liver grafts. Liver Transpl 2005;11:644-9.  Back to cited text no. 2
Matsunami H, Makuuchi M, Kawasaki S, Hashikura Y, Ikegami T, Nakazawa Y, et al. Venous reconstruction using three recipient hepatic veins in living related liver transplantation. Transplantation 1995;59:917-9.  Back to cited text no. 3


  [Figure 1], [Figure 2]


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