A. Marcos et al., Surgical management of anatomical variations of the right lobe in living donor liver transplantation, ANN SURG, 231(6), 2000, pp. 824-829
Objective To review the anatomical variations of the right lobe encountered
in 40 living liver donors, describe the surgical management of these varia
tions, and summarize the results of these procedures.
Summary Background Data Anatomical variability is the rule rather than the
exception in liver and biliary surgery. To make effective use of liver segm
ents from living donors for transplantation, surgical techniques must be ad
apted to the anomalies.
Methods Donor evaluation included celiac and mesenteric angiography with po
rtal phase, magnetic resonance angiography, and intraoperative ultrasonogra
phy and cholangiography. Arterial anastomoses were generally between the do
nor right hepatic artery and the recipient main hepatic artery. Jump-grafts
were constructed for recipients with hepatic artery thrombosis, and double
donor arteries were joined to the bifurcation of the recipient hepatic art
ery. The branches of a trifurcated donor portal vein were isolated during t
he parenchymal transection, joined in a common cuff, and anastomosed to the
recipient main portal vein. Significant accessory hepatic veins were prese
rved, brought together in a common cuff if multiple, and anastomosed to the
recipient cava. The bile ducts were individually drained through a Roux-en
-Y limb. and stents were placed in most patients.
Results Forty right lobe liver transplants were performed between adults. N
o donor was excluded because of prohibitive anatomy. Seven recipients had a
prior transplant and five had a transjugular intrahepatic portosystemic sh
unt (TIPS), Arterial anomalies were noted in six donors and portal anomalie
s in four. Arterial jump-grafts were required in three. Sixteen had at leas
t one significant accessory hepatic vein, and one had a double right hepati
c vein. There were no vascular complications. Multiple bile ducts were foun
d in 27 donors. Biliary complications occurred in 33% of patients without s
tents and 4% with stents.
Conclusions Anatomical variations of the right robe can be accommodated wit
hout donor complications or complex reconstruction. Previous transplantatio
n and TIPS do not significantly complicate right lobe transplantation. Micr
ovascular arterial anastomosis is not necessary, and vascular complications
should be infrequent. Biliary complications can be minimized with stenting
.