One-step venous reconstruction for a right lobe graft with multiple venous orifices in living donor liver transplantation

In living donor liver transplantation (LDLT) using the right lobe (RL) without the middle hepatic vein (MHV), reconstruction of the MHV tributaries, such as hepatic vein draining segment 5 (V5) and hepatic vein draining segment 8 (V8) of the liver, is often essential to avoid congestion of the associated area.1 However, ideal vascular grafts to reconstruct such tributaries are scarce, especially in the setting of LDLT. Various reconstruction techniques have been reported using autologous vein grafts such as the greater saphenous vein,2 the left portal vein (PV),3 or the paraumbilical vein.4 Moreover, some techniques have been reported using cryopreserved veins5 or arteries6; however, the availability of such vascular grafts is extremely limited. APV, anterior portal vein; GV, graft volume; HA, hepatic artery; HV, hepatic vein; IJV, internal jugular vein; LDLT, living donor liver transplantation; LHV, left hepatic vein; LIJV, left internal jugular vein; MHV, middle hepatic vein; PDS, polydioxanone suture; PPV, posterior portal vein; PV, portal vein; RHV, right hepatic vein; RIHV, right inferior hepatic vein; RL, right lobe; SHV, short hepatic vein; V5, hepatic vein draining segment 5 of the liver; V8, hepatic vein draining segment 8 of the liver. Here, we present a 1-step venous reconstruction technique for an RL graft with multiple and complex hepatic vein (HV) orifices, using the recipient's internal jugular vein (IJV) and an entire length of the PV procured from the explanted liver. The recipient was a 58-year-old Japanese male who had liver cirrhosis due to hepatitis C and multiple hepatocellular carcinomas within the Milan criteria. His liver function was Child-Pugh Class B, his total bilirubin levels were 1.1 mg/dL, his albumin levels were 3.0 g/dL, and his prothrombin time was 68% (international normalized ratio of 1.26). The Model for End-Stage Liver Disease score was 9. Imaging studies revealed severe liver cirrhosis with 3 hypervascular nodules (maximum size, 2.3 cm) in segments 8, 6, and 7 of the liver, which were compatible with hepatocellular carcinomas. An LDLT was indicated because of the expected poor prognosis with conventional therapeutic modality. The donor was the recipient's healthy 48-year-old wife, whose blood type was identical to that of the recipient. The estimated graft volume (GV) of the RL, calculated by a 3-dimensional computed tomography scan, was 567 mL, corresponding to 47% of the recipient's standard liver volume. The donor remnant liver volume was 306 mL or 35% of the whole liver volume, which was acceptable for the RL donation according to our criteria (the remnant liver volume was ≥35% of the whole liver volume). The vascular anatomy of the RL revealed the separated right anterior portal vein (APV) and posterior portal vein (PPV) with a single right hepatic artery (HA). The anatomy of the HV was complex. There were 5 major HVs draining the RL, including the right hepatic vein (RHV), 2 large short hepatic veins (SHVs), a large V5, and a V8 (Fig. 1A). The calculated total drainage area of the 4 HVs, except for the RHV, was 445 mL, which amounted to 66.5% of the total GV. Therefore, we decided to reconstruct all of these HVs. (A) A preoperative 3-dimensional image of the hepatic veins. Note that there are 5 major hepatic veins draining the right lobe of the liver. (B) A right lobe graft after completion of reconstruction at the back table. Abbreviations: LHV, left hepatic vein; LIJV, left internal jugular vein; MHV, middle hepatic vein; PV, portal vein; RHV, right hepatic vein; RIHV, right inferior hepatic vein; SHV, short hepatic vein; V5, hepatic vein draining segment 5 of the liver; V8, hepatic vein draining segment 8 of the liver. The donor procedure was performed with the usual method preserving all of the significant HVs. The MHV was not procured with the graft. The actuarial graft weight was 565 g, which accounted for 46.9% of the recipient standard liver volume. As expected, there were 5 significant HV orifices seen on the graft. The diameters of the RHV, 2 SHVs, V5, and V8 were 25, 16 and 10, 13, and 7 mm, respectively. In the recipient, the left IJV, which was 8 cm in length, was procured and stored in sterile heparinized saline before the abdomen was opened. A total hepatectomy was performed as usual under the venovenous bypass. The PV was divided at the level of the main PV trunk. After completion of the total hepatectomy, the entire length of the recipient's PV, from the umbilical portion to the distal end of the right APV and PPV, was procured from the explanted liver by ligation of all the branches in a bloodless field. At the back table, the APV and PPV of the RL graft were anastomosed to the explant APV and PPV vascular grafts, respectively, with 6-0 polydioxanone suture (PDS) continuous sutures (Ethicon, Somerville, NJ); in this way, a single PV orifice was made. The V5 and V8 were anastomosed to the umbilical portion and the PV of the vascular graft, respectively, with 7-0 PDS continuous sutures. The other side of the PV graft was anastomosed to the RHV of the graft, as shown in Fig. 1B. The left IJV graft was horizontally cut open, and this made a wide venous patch. One corner of the patch was sutured to the common orifice of the RHV and the PV graft (Fig. 1B). The 2 SHVs of the RL graft were connected together with continuous 6-0 PDS sutures. A 2 × 2 cm2 hole was then opened on the venous patch to fit the common orifice of the SHVs and sutured with 6-0 PDS continuous sutures. Thus, a large venous patch incorporating the RHV, the PV graft, and 2 large SHVs together was prepared (Fig. 1B) for a 1-step venous reconstruction. The left and middle HV conduit of the recipient was suture-closed with 5-0 PDS continuous sutures. A cavoplasty was performed by the extension of the orifice of the RHV to the dorsal side and to the left side. The implantation of the RL graft was performed as follows: the venous patch of the RL graft was anastomosed face-to-face to the inferior vena cava with 5-0 PDS continuous sutures. The PV anastomosis was performed with 6-0 PDS continuous sutures with a growth factor. Reperfusion of the graft was prompt and smooth. The graft was soft on palpation, and there was no discolored area noted on the surface of the whole graft; this suggested excellent venous drainage without congestion. The arterial reconstruction was performed under a microscope between the right HA of the graft and the left HA of the recipient with 8-0 Prolene interrupted sutures (Ethicon). A duct-to-duct bile duct reconstruction was carried out with 6-0 PDS interrupted sutures over a 2.0-mm tube (retrograde transhepatic biliary drainage tube; Sumitomo Bakelite Co., Ltd., Tokyo, Japan). The retrograde transhepatic biliary drainage tube was exteriorized from the anterior wall of the common bile duct. The immediate graft function was excellent. We performed serial Doppler ultrasound examinations of each HV before closing the abdomen on postoperative days 1 through 14, and the results were excellent. The patient was discharged on postoperative day 54 without complications, while pegylated interferon alpha and ribavirin were started preemptively. Reconstruction of the MHV tributaries is a controversial issue in RL-LDLT. The anterior segment of the RL graft may be congested and lead to a graft loss if those vessels are not reconstructed. However, there is not yet consensus regarding the criteria of MHV reconstruction. Our previous study using a 3-dimensional computed tomography scan demonstrated that the MHV tributaries or SHVs should be reconstructed if the calculated area of congestion is more than 20%.7 Other studies have suggested that the MHV tributaries should be reconstructed when the graft is small or the associated PV flow is regurgitated after clamping of the drainage veins.8 In this case, the total calculated drainage area of the V5, V8, and 2 SHVs was as large as 58% of the total GV, for which reconstruction of all these tributaries was justified. There have been many reports regarding the technique of reconstructing these tributaries with autologous and artificial9 vascular grafts with acceptable results. However, the reconstruction of such multiple drainage veins, as in the current case, poses a particular challenge in the setting of LDLT because the availability of the appropriate vascular grafts is severely limited. We have used the explant PV as an interposition graft since 2005 for 23 cases, and we believe that this is the best vascular graft in terms of length, wall thickness, and availability.10 However, in some situations such as cases with preexisting PV thrombosis or hypoplastic PV, the use of this vascular graft may not be possible. The procurement of the left IJV can be performed easily and quickly, requiring approximately 30 minutes. Usually, an approximately 8-cm-long, good-quality vein can be obtained. We have procured the left IJV of the recipient in 5 cases as a substitute for a thrombosed PV, and none have developed complications associated with the procedure. Therefore, we believe that this procedure can be done safely. Reconstruction of the SHVs may be performed independently after anastomosis of the other major HVs. However, the outflow of these SHVs can be impaired or troublesome if these were anastomosed directly to the side wall of the inferior vena cava because these veins are usually small or short. Therefore, we believe the present technique is more ideal than the conventional one. In conclusion, the present 1-step HV reconstruction technique offers a wide venous anastomotic orifice, thereby decreasing complications associated with a complex or multiple venous reconstruction.