Reconstruction of a rare variant of the left hepatic vein in a left lateral segment liver graft from a living donor: Technical notes

Abstract

Reconstruction of hepatic veins in living donor liver transplantation (LDLT) is often technically challenging and a good venous outflow is essential for survival of the graft and patient. We describe a quadrangular patch venoplasty technique used for the reconstruction of a rare variant of the left hepatic vein (LHV) in a pediatric LDLT with left lateral segment (LLS) graft. Segment II vein in the graft was draining directly into the inferior vena cava (IVC) and segment III vein was draining into the middle hepatic vein (MHV) after receiving a tributary from segment IV so that there were two widely separated ostia at the cut surface. This is one of the rarest variations of the LHV and is so called type 3 variant; it is usually reconstructed using interposition tubular conduits necessitating two separate anastomoses at the IVC.

Hepatic venous reconstruction of the left lateral segment with emphasis on anomalous hepatic vein in pediatric liver transplantation

“…[27] The large caliber formed by venoplasty between the HVG conduit and V2 allows a wide anastomosis; despite this, the higher GHV/RHV correlation in type IIIB LLS grafts did not determine the need for IVC clamping during implantation, as shown in Table 1. In the situation of extreme mismatching, this can be solved by communicating the 3 recipient's HV, with triangulation and enlargement of the common ostium toward the IVC, thus enabling the compatibility of the very small recipient Dar et al [28] HAG interposition a 3 HV venoplasty Case report 6 mo Patent graft HV Sakamoto et al [12] No BTVR−Dual HV anastomosis in recipient V2G: LHV + V3G: MHV or V2G: LHV/MHV + V3G: RHV 10 Median 7.9 y 1 HVOO (10%)-BV Hwang et al [8] HVG interposition b 3 HV venoplasty Case report 6 mo Patent graft HV Veerankutty et al [29] QVP anchored to V2G ± V3G Anteromedial IVC venotomy Case report 3 mo Patent graft HV Hou et al [26] No BTVR−Dual HV anastomosis in recipient V2G: LHV ± MHV V3G: Anteromedial IVC venotomy 08 Mean 15.6 mo…”

“…The literature related to outflow reconstruction of LLS grafts with AHV is scarce, and the published studies, [8,12,[25][26][27][28][29] represented with small samples or case reports, generally describe the use of different surgical strategies (Table 3) and miscellaneous outcomes. In short, the techniques are summarized in the use of conduits and dual independent anastomosis.…”

Outflow vein venoplasty of left lateral section graft for living donor liver transplantation in infant recipients

“…Very rarely, only the segment II vein drains into the LHV and the segment III vein separately drains into the MHV. In this variant anatomy, unification venoplasty requires a special design that includes an interposition vein conduit 14,15 . Because the incidence of this variant is very low, we did not include it in the classification of types of hepatic vein reconstruction for LLS grafts.…”

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

“…By contrast, in some variant liver anatomy, an aberrant segment III vein can drain into the middle hepatic vein trunk directly, which requires a customized design for the use of interposition procedure of graft hepatic vein reconstruction. 3 , 9 Notably, the size of single LHV trunk in LLS grafts is usually small because only small-sized LLS grafts are intentionally selected for use with infant recipients. In those cases, such a small graft hepatic vein orifice is closely associated with the development of an anastomotic stenosis, thus it is important to make the graft hepatic vein orifices large enough to match with the recipient IVC orifice.…”