Recipient liver splitting for hepatectomy during living donor liver transplantation in massive polycystic liver disease: Technical experience from two cases

Recipient hepatectomy in patients with massive polycystic liver disease (PLD) can be difficult because massive hepatomegaly limits operative space and distorts the hepatic hilum and hepatic venous anatomy.Several anterior or lobe-first approaches have been described, but operative sequencing varies among reports.We retrospectively reviewed two patients with massive PLD who underwent living donor liver transplantation with recipient liver splitting during hepatectomy.In the first patient, the approach was used as a bailout after conventional mobilization resulted in substantial bleeding.Based on that experience, parenchymal transection before extensive mobilization was planned from the outset in the second patient.In Case 1, recipient liver splitting was used as a bailout after bleeding occurred during conventional mobilization.In Case 2, parenchymal transection was planned before extensive mobilization.The explanted liver weights were 10,134 and 6,400 g, and estimated blood losses were 14,000 and 10,200 mL, respectively.Case 1 was discharged on postoperative day 48.In Case 2, no graft-related vascular or biliary complication was identified; however, the patient developed persistent acute cellular rejection, graft dysfunction, infection, and sepsis and died approximately 2 months after transplantation.Recipient liver splitting for hepatectomy provided access to the hilar and hepatic venous structures when conventional mobilization was restricted by massive hepatomegaly.However, the substantial blood loss in both operations and the early postoperative death in Case 2 preclude conclusions regarding the safety or reproducibility of this approach.