All-In-One Ex Vivo Self-Reconstruction Technique Using An Autologous Inferior Vena Cava For A Right Lobe Liver Graft with Multiple and Complex Venous Orifices

In right lobe (RL) living donor liver transplantation (LDLT), reconstruction of the middle hepatic vein (MHV) tributaries draining segments 5 (V5) and 8 (V8) of the liver or sometimes the right inferior hepatic veins (RIHVs) is essential to prevent congestion of the designated drainage area.1 Various reconstruction techniques have been proposed, and there has been clinically significant success in cases with simple venous anatomy.2-6 Meanwhile, a few reports7, 8 have described techniques for reconstructing multiple tributaries with cryopreserved vein grafts obtained from cadavers. However, the availability of such vascular grafts is extremely limited, particularly in countries in which cadaveric donors are scarce. Here we describe 2 cases for whom we applied a novel all-in-one venous reconstruction technique for an RL graft with multiple and complex hepatic vein (HV) orifices. To achieve this, we used the recipient's whole exenterated inferior vena cava (EIVC) and a complete portal vein (PV) procured from the explanted liver [explanted portal vein (EPV)]. EIVC, exenterated inferior vena cava; EPV, explanted portal vein; HV, hepatic vein; IVC, inferior vena cava; LDLT, living donor liver transplantation; LHV, left hepatic vein; MHV, middle hepatic vein; PV, portal vein; RHV, right hepatic vein; RIHV, right inferior hepatic vein; RL, right lobe; V5, hepatic vein draining segment 5 of the liver; V8, hepatic vein draining segment 8 of the liver. The recipient was a 59-year-old Japanese man who had liver cirrhosis due to alcoholism and small hepatocellular carcinomas that met the Milan criteria. There were at least 5 major HVs draining the RL, including the right hepatic vein (RHV), 2 large RIHVs, a large V5, and V8 (Fig. 1A). The total drainage area of the 4 HVs (not including the RHV) was calculated with 3-dimensional calculating software (Region Growing, Hitachi Medical, Tokyo, Japan) to be 601 mL, which amounted to 87.1% of the total graft volume.9 Therefore, we decided to reconstruct all the HVs. (A) Preoperative 3-dimensional computed tomography image of the multiple HVs of case 1. There were 5 major HVs draining the RL of the liver. (B) RL graft at the back-table. Five HV orifices were confirmed. The donor procedure was performed with the usual method. The diameters of the RHV, V5, V8, and 2 RIHVs were 14, 11, 15, 13, and 12 mm, respectively (Fig. 1B). The recipient procedure was as follows. Total hepatectomy was performed, as usual, and all the short HVs draining into the inferior vena cava (IVC) were divided. The PV was divided at the level of the main PV trunk, and this meant that the entire length of the EPV could be used later as a vascular graft. The diaphragm was dissected off the suprahepatic IVC to the proximal side as much as possible so that the suprahepatic IVC could be relaxed and clamped as proximally as possible. After completion of the total hepatectomy, the venovenous bypass was established with standard procedures. The whole IVC graft, which incorporated the RHV, MHV, and left hepatic vein (LHV) orifices, was procured and stored in heparinized saline (Fig. 2). The entire length of the recipient's PV, from the umbilical portion to the distal end of the right anterior PV and posterior PV, was procured from the explanted liver by ligation of all the branches in a bloodless field (Fig. 3A), as we have described previously.2 Schematic view of the procurement procedure for the autologous IVC graft. The IVC was divided proximally to the HV orifices, and this left the RHV, MHV, and LHV orifices intact within the EIVC graft. Schematic views of the back-table procedure. (A) The EPV graft was procured from the explanted liver; all branches were ligated in a bloodless field. (B) An all-in-one reconstruction using the EPV and the EIVC was performed in a bloodless field. At the back-table, the umbilical portion side of the EPV was anastomosed to the V5, and the common trunk of the EPV was anastomosed to the V8 in an end-to-end fashion; for both, 7-0 Prolene continuous sutures (Ethicon, Somerville, NJ) were used. The RHV orifice of the EIVC graft was anastomosed to the RHV orifice of the RL graft. Both RIHVs in the RL graft were anastomosed to the independent hole made in the posterior wall of the EIVC graft with 6-0 Prolene continuous sutures. The common orifice of the anterior and posterior PVs of the EPV was anastomosed to the common orifice of the MHV and LHV of the EIVC graft with 6-0 Prolene continuous sutures (Fig. 3B), and the RL graft was ready to be transplanted. The implantation procedure for the RL graft was performed in exactly the same manner as that for a whole liver graft; that is, the suprahepatic IVCs were anastomosed to each other, and the infrahepatic IVCs were then anastomosed to each other. Both were done with 4-0 Prolene continuous sutures (Fig. 4A). The PV anastomosis was performed with 6-0 polydioxanone continuous sutures with a growth factor (Fig. 4B). The anhepatic, cold ischemic, and warm ischemic times were 246, 174, and 43 minutes, respectively. The total operative time was 16 hours and 15 minutes. The estimated blood loss was 8500 mL; for this, 30 U of packed red blood cells, 40 U of fresh frozen plasma, and 60 U of platelets were transfused. The immediate graft function was excellent, and hemostasis was quickly obtained. We performed serial Doppler ultrasound examinations for each HV before closing the abdomen on postoperative days 1 to 14, and all of the examinations revealed excellent results. The computed tomography scans on days 7 and 14 confirmed that all of the reconstructed HVs were patent. The patient was discharged from the hospital 20 days after LDLT without complications. (A) Schematic view of the implantation procedure. The implantation of the RL graft was performed as it would be for cadaveric whole liver transplantation. (B) The graft after reperfusion. The EPV graft sat well and naturally without tension, and the wide drainage orifice was secured. The recipient was a 56-year-old Japanese woman with end-stage liver cirrhosis due to hepatitis C and a small hepatocellular carcinoma with a Model for End-Stage Liver Disease score of 14. The donor was her 33-year-old daughter. The preoperative imaging studies revealed 4 significant HVs (RHV, V5, and 2 RIHVs) to be reconstructed. The reconstruction technique described for case 1 was indicated. The recipient and donor procedures were performed in exactly the same way as that described for case 1. As expected from the preoperative imaging studies, there were 4 significant HV orifices (RHV, 15 mm; V5, 7 mm; RIHV-1, 17 mm; and RIHV-2, 10 mm) on the RL graft, all of which were reconstructed. The anhepatic, cold ischemic, and warm ischemic times were 253, 223, and 50 minutes, respectively. The operative time was 15 hours and 44 minutes with an estimated blood loss of 5018 mL. The postoperative course of the patient was uneventful with excellent graft function, and the patient was discharged from the hospital 18 days after LDLT without complications. In cases of grafts with multiple venous orifices (including the RHV, V5, V8, and multiple RIHVs) that require a more complex reconstruction technique, additional and larger vascular grafts may be necessary. However, the reconstruction of such multiple drainage veins, as in the current cases, poses a particular challenge in the setting of LDLT because the availability of appropriate vascular grafts is very limited. In such situations in which additional larger vascular grafts are not available, RIHVs are usually anastomosed directly to the side wall of the IVC after completion of the RHV anastomosis. However, when the RIHVs are not large or long enough, the direct anastomosis of these veins can be cumbersome because these veins are usually short, small, deep, and sometimes multiple. Furthermore, multiple venous reconstructions in situ should be associated with a longer warm ischemic time, which might lead to poor graft performance. To overcome these problems, Makuuchi et al.10, 11 proposed the systematic use of cryopreserved vein grafts, such as the vena cava, iliac veins, and femoral veins, for the complete reconstruction of these multiple orifices at the back-table. Hwang et al.12, 13 reported a quilt venoplasty technique using autologous saphenous veins and cryopreserved iliac arteries. Recently, we reported a 1-step venous reconstruction technique for multiple venous orifices that uses only autologous venous grafts, such as the entire length of the EPV and the recipient's internal jugular vein.14 As an alternative, we have also used the anterior wall of the recipient's autologous IVC as a patch graft for reconstructing multiple venous orifices.15 Nevertheless, these authors have collectively demonstrated the feasibility of reconstructing these tributaries at the back-table to create a larger and single anastomotic orifice. As for the advantages and disadvantages of using homologous cryopreserved veins and arteries, they are not uniformly or readily available at every institution. Furthermore, the walls of the veins can be too thin and fragile for them to be used as interposition grafts, and thus cryopreserved arteries are often preferred.5 Kuang et al.16 reported poor outcomes with the use of cryopreserved veins for pediatric LDLT. On the other hand, Makuuchi et al.11 have routinely used cryopreserved veins and reported various complex venous reconstruction methods with satisfactory results. We believe that the present technique is universally applicable and reproducible and could overcome the need for homologous vein grafts. The most important limitations of this technique are the potential for a long anhepatic time and the necessity for venovenous bypass. In fact, the anhepatic times of these 2 cases (246 and 253 minutes) were significantly longer than the anhepatic times of normal LDLT cases with or without bypass. This longer anhepatic time could lead to coagulopathy, which requires longer operative time and larger amounts of blood products to achieve hemostasis after reperfusion. To obtain the maximum length of the EIVC graft incorporating the RHV, MHV, and LHV orifices and to secure a suprahepatic anastomotic margin, the suprahepatic IVC should be dissected as caudally as possible, and this should include dividing the right and left phrenic veins. In some patients with advanced liver cirrhosis, the native retrohepatic IVC can be much smaller than the usual size even after complete isolation of the IVC. The technique cannot be used in such a situation.