STEP 1Access and hilar dissection

A bilateral subcostal incision with an upper midline extension to the xiphoid is the preferred access. The most important point to consider during the hilar dissection in living donor liver transplantation is to leave the pedicle of the vessels and bile duct with the greatest possible length, because they are much shorter than those in a cadaveric liver graft. The hepatic arteries are dissected carefully and transected close to the liver to provide adequate length and enough options for arterial reconstruction. In children suffering from biliary atresia the hepatic artery frequently has a larger size than expected. In this particular situation, dissection of the hepatic artery inside the liver of the recipient is required to adjust the size of hepatic artery between the graft and the recipient. Double ties on the proximal side of the hepatic arteries are recommended to prevent injury to the intima. The first ligation is done loosely just to occlude the lumen with 4-0 silk. The second tie is placed tightly just distal to the first.

The portal pedicle is elongated by dissecting the tissue around the portal vein up to the confluence of the superior mesenteric and splenic vein. Removal of the lymph nodes around the portal vein is helpful as it provides the desired smooth curve of the portal vein. The portal flow should be confirmed by unclamping the portal vein. The left gastric vein is divided routinely to increase portal flow.

Hilar Dissection

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