After visual and manual exploration of the liver and the entire abdominal cavity, the vascular structures (median hepatic vein and its branches from segments V and VIII) are evaluated by ultrasound with a special emphasis on anatomical variations that may complicate the procedure (i.e., absence of right portal trunk). Next, a wedge biopsy is performed for the evaluation of fibrosis, as the presence of fibrosis or cirrhosis is a contraindication for auxiliary liver transplantation. Parenchymal necrosis is common and its intensity does not necessarily predict the likelihood of recovery.
The lateroposterior peritoneal sheath of the right part of the hepatoduodenal ligament is opened and the right hepatic artery is gently dissected from behind the common hepatic duct up to its bifurcation and marked with a vessel loop. The right branch of the portal vein is cautiously freed from the hilar plate. This maneuver cannot be performed safely without having controlled and cut one or two small branches to the caudate process. The vein is also marked with a vessel loop.
The right hepatic artery and the right portal vein are temporarily occluded with vascular clamps in order to reveal the demarcation line between left and right hemiliver. Then both vessels are divided between ligatures, as distally as possible.
The right hepatic duct should not be isolated extrahepatically. It can easily be trans-sected during the parenchymal dissection.
The liver parenchyma is transected 1 cm to the right of the main portal fissure, preserving the median hepatic vein. Transection is conducted posteriorly to the retro-hepatic vena cava and the right hepatic duct is divided through the liver parenchyma at the confluence of its anterior and posterior branches. The bile duct from segment one is carefully preserved. Then, the right hepatic vein is transected by means of a vascular stapler (or another technique; see chapter "Right Hemihepatectomy"). At the end the retrohepatic segment of the inferior vena cava is widely exposed, ready to receive the right hepatic graft.
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