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The "carving" liver partitioning technique for graft hepatectomy in live donor liver transplantation: A single-center experience

: Radtke, A.; Sgourakis, G.; Molmenti, E.P.; Schroeder, T.; Cicinnati, V.R.; Beckebaum, S.; Peitgen, H.-O.; Broelsch, C.E.; Malagó, M.


Surgery 153 (2013), Nr.2, S.189-199
ISSN: 0039-6060
ISSN: 1532-7361
Fraunhofer MEVIS ()

In adult live donor liver transplantation, postoperative venous congestion of graft and remnant livers can lead to life-threatening complications. The purpose of this study was to evaluate the safety and benefits of our 3-dimensional, computed tomographic, computer-assisted donor hepatectomy using the "carving" partitioning technique.
Eighty-three consecutive adult live donor liver transplantations were performed based on data obtained from individualized preoperative 3-dimensional, computed tomographic reconstructions and virtual graft hepatectomies.
There were 71 right and 12 left grafts. Small grafts (graft volume body weight ratio, <1.0) were used in 20 cases. We observed no clinically important differences in postoperative function between right and left grafts. Four recipients developed lethal small-for-size syndrome. Reversible small-for-size syndrome was observed in a right graft recipient and in 2 right graft donors.
Preoperative 3-dimensional, computed tomographic, computer-assisted planning using virtual liver partitioning allowed for: (1) an individualized carving technique based on specific donor anatomic characteristics, (2) donor safety based on individualized patterns of venous outflow, and (3) optimized drainage of the medial area of the graft based on the preferential inclusion of the middle hepatic vein.
Hepatic venous outflow is of equal or even greater importance than portal inflow in assuring optimal graft outcome in cases of adult live donor liver transplantation (ALDLT). Impaired outflow in cases of small grafts in recipients with prominent portal hypertension can turn an otherwise controllable, small-for-size (SFS) situation into lethal graft failure.
Venous outflow of the grafts can be optimized by inclusion of the middle hepatic vein (MHV). In the case of right grafts, this approach carries the potential risk of liver failure in the donor remnant liver secondary to venous congestion of the medial sector, which is drained by the detached MHV 4A and 4B tributaries.
Our experience (inclusive of a learning curve) led us to establish the "carving" technique, in which the donor MHV is procured with the graft. As opposed to the standard Pringle/Cantlie line division that entails the detachment of tributaries from the MHV trunk, our "carving" technique transects small branches exactly at the MHV trunk. The preservation of subterritorial microveins seems to provide marginal zones with "bridge" drainage from the time of resection to the spontaneous opening of venous shunts into the left hepatic vein (LHV) or right hepatic vein (RHV).
The aims of the present study were (1) to provide a step-by-step description of the "carving" liver parenchyma transection technique based on donor-individualized, 3-dimensional, computed tomographic, computer-assisted surgery planning (3D-CASP) and (2) to evaluate the outcomes of this technique.