Caudal Arantius Hanging Maneuver for Donor Left Liver Resection and Splitting: A Novel Anatomical Beacon in Pediatric Liver Transplantation

This is the authors' abstract. We don't add key points for this paper.

BACKGROUND: Left liver resection and split liver surgery demand precise anatomical orientation during parenchymal transection, particularly in the context of organ procurement and pediatric liver transplantation. METHODS: We describe the "Arantius hanging maneuver", which involves preserving and transposing the caudal stump of the Arantius ligament into the parenchymal cut surface. A double hanging maneuver using the caudal Arantius' stump and the round ligament consistently guides dissection toward the left biliary plate, enhancing procedural safety. To illustrate its application, we retrospectively reviewed 134 living donor hepatectomies performed between 2015 and 2019 (119 left lateral sectionectomies, 15 left hepatectomies) with donor outcomes assessed at 3 months using the Clavien-Dindo classification. The maneuver was subsequently implemented in 32 split liver procedures (in-/ex-situ). RESULTS: Donor outcomes were favorable, with no complications in 128 donors (95.5%). Postoperative morbidity included three grade II complications (2.2%), one grade IIIa complication (0.7%) treated by percutaneous drainage, and two grade IIIb complications (1.5%) requiring surgical or endoscopic management. No grade IV or V complications occurred. Recipient 1-year biliary complication rate was 15.6%. In split liver procedures, the maneuver also facilitated identification and division of the left biliary plate. CONCLUSIONS: The « Arantius hanging maneuver » is a simple and reproducible technique for left liver resection and splitting procedures, associated with encouraging results in both donors and recipients. The caudal portion of the Arantius ligament, often overlooked, may represent an anatomical beacon precisely guiding the surgeon during the procedure.