Functional venous anatomy for right-lobe grafting and techniques to optimize outflow

Right-lobe living donor liver transplantation has emerged as an alternative to cadaveric transplantation. An appreciation of the unique anatomy and be havior of the right lobe has emerged and has precipitated technical modific ations. Living donors underwent right lobectomy, including preservation of significant inferior hepatic veins. The parenchyma was divided following a plane approximating the right border of the posterior two thirds of the mid hepatic vein (MHV), but deviating anteriorly to include the distal one thir d of the MHV with the graft. Large venous tributaries from segment VIII wer e preserved. Anastomosis in the recipient was accomplished by means of comp lete cavoplasty. Significant inferior veins, tributaries to the MHV, and th e distal. portion of the MHV were reconstructed when technically possible. Forty-eight right-lobe resections and transplantations were performed in th e manner described. There were no donor complications attributable to the t echnique. Forty-six of the 48 recipients are alive, and 44 of the 46 surviv ing patients have their original graft. Venous tributaries from segment VII I and/or the distal portion of the MHV were reconstructed in only 3 patient s. Outflow obstruction was recognized intraoperatively in 2 patients; 1 pat ient had a caval web excised and the other patient required revision of the main anastomosis. Neither organ was lost. There were no other significant venous complications. The incidence of ascites was the same as that in reci pients of whole organs. These methods of parenchymal transection and venous reconstruction resulted in a low rate of complications. The wide anastomos is and collateral pathways between the MHV and right hepatic vein seem to b e more critical than reconstruction of tributaries from segment VIII or the distal MHV.