Drainage of segments V and VIII venous tributaries usually is mandatory to avoid congestion of the anterior segment of right lobe during a living-donor liver transplant. Extension of the venous tributaries to the vena cava can be done with several vascular materials. Here, we describe using an 8 × 3 cm vascular patch from the peritoneum over the venous conduit (which had become kinked) that drained segments V and VIII veins. Peritoneal reconstruction worked well during the early postoperative period and avoided congestion of the right anterior liver segment. During the late postoperative period, the conduit became occluded as do other grafts used to extend tributaries; however, the collaterals that developed prevented congestion of the anterior liver segment. Using part of the peritoneum as a venous graft during living-donor liver transplant can be a good alternative to the other vascular grafting options. Peritoneal grafting provides temporary drainage of the liver lobe, prevents congestion of the anterior section, and saves time creating venous collaterals.
Key words : Liver transplant, Living donor, Peritoneum, Hepatic vein, Surgical technique
Liver transplant is the only treatment for the end-stage liver disease. A paucity of donations has led patients and clinicians to use live donations. Living-donor liver transplants have some technical difficulties compared with deceased-donor liver transplant (eg, shorter and narrower vascular stumps and multiple biliary orifices of the grafts). Hepatic reconstruction of the outflow of the right lobe using graft from a live donor is more difficult than using the graft of a deceased donor. To reach the vena cava, right lobe liver grafts usually require extending the venous tributaries at the cut surface. Here, we described a method that solves the technical outflow problem of the venous conduit during right lobe living-donor liver transplant.
The recipient was a 56-year-old woman with no history of surgery. She was referred from another center for decompensated liver cirrhosis secondary hepatitis C with minimal ascites of 5 years’ duration. There was no history of abdominal pain, hema-tochezia, or encephalopathy. Results of her laboratory tests included hemoglobin, 82 g/L; white blood count, 3.3 × 109/L; albumin, 29.0 g/L; interna-tional normalized ratio 2.2; bilirubin, 35.92 μmol/L; and creatinine, 47.74 μmol/L. Her Child-Pugh score was 9 and her Model for End-Stage Liver Disease score was 18. Computed tomography scan showed minimal ascites, splenomegaly, and nodular appearance on the liver.
She was a candidate for a liver transplant and her 32-year-old daughter was the donor. We decided to recover the right lobe without the middle hepatic vein; still, extension of venous outflow tributaries was required. We reconstructed segment V and VIII venous tributaries at the back table with an autologous cryopreserved vein graft. The autologous vein was first anastomosed to segment V vein via an end-to-end manner; later, segment VIII vein was anastomosed to the same conduit from the lateral view (end-to-side, Figure 1). Venous tributaries then were combined, and a large common orifice was created by suturing another venous fence around the orifices for easier drainage of the liver (ie, an all-in-one technique). This large single orifice of the hepatic veins was anastomosed directly to the vena cava by enlarging the orifice of the right hepatic vein. After completing the portal vein anastomosis, the liver was reperfused as usual. However, there was an outflow problem in segment V because of the narrowness of the autologous venous graft at the end-to-side level of the anastomosis of segment VIII vein (Figure 1). The anterior section of the graft became immediately occluded. The section became darker and harder, and bleeding began at the surface. This was due to bending (or kinking) the venous conduit at the end-to side anastomosis. Liver inflow and outflow occlusions result in graft ischemia; therefore, only proximal, distal, and side connections of the kinked vessels were clamped, keeping the portal venous inflow and right hepatic venous outflows protected.
We relaxed the kinked conduit by longitudinally opening the venous conduit. We cleaned the inner part of the vein because it was filled with clots. By releasing the clamps, we ensured that the proximal, distal, and side connections were not occluded by the clots. The peritoneum that we recovered from the patient’s abdominal wall (right subcostal area including some muscles) was fashioned into an 8 × 3 oval patch, and the defect on the lateral part of the conduit was covered, using a patch made with continuous 6-0 polypropylene sutures. After releasing the clamps, there was no suture line bleeding, and the conduit was not occluded and congestion of the anterior section disappeared (Figure 2).
No venous outflow or any other problem took place during surgery. On postoperative days 1, 3, and 7, we examined the liver vascularity by Doppler ultrasound, and patency of the hepatic veins and conduit were excellent. On postoperative day 10, Doppler ultrasound demonstrated no-flow in the conduit (confirmed by contrast-enhanced computed tomography). Additionally, there was no congestion in the anterior portion or at any other part of the liver. As shown in Figures 3 and 4, postoperative results of the patient’s alanine transaminase, aspartate transaminase, international normalized ratio, and total bilirubin did not worsen. The patient was discharged to her home, and at the time of this writing, she is doing well.
When right lobe grafts are used in living-donor liver transplant, re-establishing venous outflow of segments V and VIII are mandatory (particularly if they are larger than 5 mm). If the venous outflow of the anterior section is not well established, the congested anterior section can result in dysfunction leading to a small-for-size syndrome or liver failure. The risk of liver dysfunction increases with small right lobe grafts or with fatty grafts. A perfect hepatic venous outflow is required in an adult-to-adult right lobe liver transplant, especially when the grafts are marginal. The posterior section of the right lobe graft (segments VI and VII) drain mainly via the right hepatic vein, which is directly anastomosed to the vena cava. However, hepatic venous drainage of the right anterior section can be provided by extending its venous tributaries (segments V and VIII) to the vena cava, or by including the middle hepatic vein with the graft. Both methods (including middle hepatic vein or not including the middle hepatic vein) have their good and bad points, and there is no unequivocal method for every donor and every graft. We prefer using both techniques, according to the anatomy of the hepatic veins and the remnant volume of the donors. In the current case, the remnant volume of the donor’s liver was 34%. It would have been less than 30%, if the middle hepatic vein had been included, but we preferred a right lobe graft without a middle hepatic vein. Segment V and VIII tributaries were both larger than 5 mm and each required drainage to the vena cava.
Hepatic venous tributaries can be anastomosed to the vena cava separately or by conjoining them in an all-in-one orifice. Separate anastomoses of all extensions to the vena cava result in multiple anastomoses with small orifices on the vena cava. This method increases time in performing the anastomoses and the warm ischemia. Using an all-in-one technique conjoins all the tributaries to each other and makes a common cuff before the caval anastomosis. We usually prefer the all-in-one technique whenever possible. Using this technique, vascular reconstruction is prepared at the back table, and the warm ischemia time is reduced by a single large anastomosis. However, there is a risk of blocking venous outflow because of angulation, thrombosis, narrowing, and torsion of the extended veins to the common cuff. The risk of these complications increases with small caliber vascular extensions and by increasing several vascular tributaries. To prevent undesired outflow, severe angles should be avoided. Large vascular grafts are preferred. And precision at the bench and during transplant is necessary. In the current case, using a narrow vein graft (cryopreserved deceased-donor iliac vein), with a right angulation, were the main factors contributing to venous tributaries outflow occlusion.
Fresh cryopreserved or synthetic vascular grafts can be used as hepatic venous conduits. A fresh vascular graft may be recovered from the recipient, the donor, or from the explanted diseased liver. An inferior mesenteric, saphenous, internal iliac, renal, ovarian, portal, middle hepatic, or umbilical vein may be used as a fresh vascular conduit.1,2
In principle (for safety), we do not prefer vascular grafting from the donors. In the current case, the donor operation had been completed when we needed a vascular graft. We required a long, wide, vascular patch (one at least 8 × 3 cm), but because we were dealing with the peritoneum, we had no chance of removing a vascular graft of this size from the recipient. In centers like ours where deceased donation is rare, the chance of finding a cryopreserved vein from a deceased donor is limited. We considered using a synthetic vascular graft as a patch, but it was difficult to use over the kinked vein. We had a previous experience using the peritoneum as a vascular graft in a donor with a successful outcome.3 Therefore, we preferred using the peritoneum, and we removed a peritoneal patch with suitable dimensions. We had no problem handling the peritoneum during or after the anastomosis.
The patency rates of all these venous conduits is a matter of debate and only some have long-term patency. Almost all those conduits are occluded without respect to conduit material. Studies demonstrate temporary drainage of the congested anterior segment may be enough to recover the damaged sinusoids by developing intrahepatic collaterals by 7 days after transplant.4 We conclude that the peritoneum, as a vascular patch, can restore drainage of the hepatic venous tributaries when there is a blockage during a living-donor liver transplant.
Volume : 13
Issue : 4
Pages : 365 - 368
DOI : 10.6002/ect.2013.0266
From the 1Liver Transplantation Institute, Inonu University,
Malatya, Turkey; the 2Department of Surgery, Azerbaijan Medical
University, Baku, Azerbaijan; the 3Department of Surgery, Suleyman
Demirel University; and the 4Department of Surgery Kabul, Rabia
Balkhi Hospital, Afghanistan
Acknowledgements: The authors have no conflicts of interest to disclose, and there was no funding for this study.
Corresponding author: Cuneyt Kayaalp, MD, Prof, Liver Transplantation Institute, Department of General Surgery, Staff Surgeon of Gastrointestinal Surgery, Turgut Ozal Medical Center, Inonu University, Malatya, Turkey, 44315
Phone: +90 422 341 0660/3706
Fax: +90 422 341 0229
E-mail: firstname.lastname@example.org or email@example.com
Figure 1. Occluded Venous Conduit of the Right Lobe Graft Owing to Kinking (Bending) in the Middle Anastomosis (End-to-Side) of the Conduit
Figure 2. Peritoneal Patch Over the Conduit
Figure 3. Postoperative Aspartate Transaminase and Alanine Transaminase Levels Between Days 1 and 16
Figure 4. Postoperative Total Bilirubin and International Normalized Ratio Levels Between Days 1 and 16