Graft outflow vein unification venoplasty with superficial left hepatic vein branch in pediatric living donor liver transplantation using a left lateral section graft

Abstract

Orifice size of the left hepatic vein trunk (LHV) in left lateral segment (LLS) grafts is often too small to perform direct anastomosis. A small superficial branch of LHV is encountered in approximately 30% of LLS grafts. Unification venoplasty of the LHV trunk and its superficial vein branch makes the orifice size of LLS outflow vein larger than the original size. We present refined surgical techniques for LHV unification venoplasty with a superficial LHV branch. The patient was a 5-month-old 9 kg-weighing girl with biliary atresia. Her general condition deteriorated, but there was low possibility of deceased donor liver allocation, thus living donor liver transplantation was performed using her mother's LLS. The graft hepatic vein was widened through unification venoplasty of LHV and its superficial branch. Recipient hepatic vein orifice was widened through unification of three hepatic veins. The graft and recipient hepatic vein orifices were well matched in size, and they were anastomosed with 5-0 continuous sutures. The portal vein was reconstructed with interposition of cold-preserved external iliac vein homograft. The graft left hepatic artery was reconstructed using the recipient right hepatic artery and hepaticojejunostomy was performed. This patient recovered uneventfully and is doing well for 3 months to date. The unification venoplasty with LHV trunk and its superficial vein branch makes the size of LLS outflow vein definitely larger than the original size, thus it can be a useful technical option to reduce the risk of hepatic vein outflow obstruction in pediatric liver transplantation using a LLS graft.

Pediatric liver transplantation with hyperreduced left lateral segment graft

“…To prevent such detrimental effect of extrinsic compression to the graft hepatic vein, customized unification venoplasty making a common channel is helpful to facilitate outflow vein drainage. 16 , 17 Since the amount of portal blood flow is small in small infant patients, there is a potential risk of portal hypoperfusion of the graft. Any anastomotic stenosis can interfere with the portal blood supply to the graft, so branch patch of the recipient portal vein was used for recipients with normal portal vein.…”

Third retransplantation using a whole liver graft for late graft failure from hepatic vein stent stenosis in a pediatric patient who underwent split liver retransplantation

“…for LDLT or split liver transplantation using a left lateral section graft in infant recipients. 7,8 In the present case, the graft hepatic vein stump with an internal wall stent was heavily adhered to the diaphragm, making its dissection impossible. Thus, we had to transect the graft hepatic vein stump and securely repair it at the level of the diaphragm.…”

“…We have developed customized hepatic vein reconstruction techniques suitable for LDLT or split liver transplantation using a left lateral section graft in infant recipients. 7 , 8 …”

Unification venoplasty of the outflow hepatic vein for laparoscopically harvested left liver grafts in pediatric living donor liver transplantation

“…A superficial branch of the LHV is identified in a considerable proportion of LL or left lateral section grafts [ 11 , 12 ]. Although this vein is small, it can be used for venoplasty, by which the actual cross-sectional area of the LHV anastomosis can be slightly increased, as shown in our case No.…”