Surgical management of anatomical variations of the right lobe in living donor liver transplantation

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 .