Is left hepatic artery division with middle hepatic artery preservation a viable strategy for right lobe graft procurement in living donor liver transplantation with complex arterial anatomy?

Right lobe grafts typically have a single hepatic artery, although arterial variations are not uncommon. We encountered a rare and complex hepatic arterial anatomy during procurement of a modified right lobe graft (MRLG), in which the right hepatic artery (RHA) arose from the proximal common hepatic artery (CHA) and bifurcated into the right anterior hepatic artery (RAHA) and right posterior hepatic artery (RPHA). The left hepatic artery (LHA) originated from the RAHA, while the middle hepatic artery (MHA) arose from the distal CHA. Preserving the LHA would have resulted in short (7–10 mm) and small-calibre (1 mm) arterial stumps of both the RAHA and RPHA, potentially compromising arterial reconstruction. Following completion of parenchymal transection and right hepatic duct division, the main portal vein and LHA were temporarily clamped. No ischaemic demarcation developed in the remnant liver, indicating adequate intrahepatic collateral arterial communication between the MHA and LHA. The LHA was therefore divided, and satisfactory pulsatile back-bleeding confirmed preserved arterial inflow to the remnant liver. This strategy provided the MRLG with a single RHA stump measuring 3 mm in diameter and 2.5 cm in length, facilitating a technically favourable arterial reconstruction. Both donor and recipient had uneventful postoperative recoveries. In selected LDLT donors with complex arterial anatomy, division of the LHA may be considered only when preoperative imaging demonstrates robust intrahepatic arterial communications with the MHA, intraoperative assessment confirms adequate remnant liver perfusion, and a contingency plan for arterial reconstruction is available.