The line of hepatic transection should be approximately 1 cm to the right of the middle hepatic vein, identified and demarcated at the start of the procedure by intraoperative ultrasound. The line of demarcation can also be checked by placing a vascular or bulldog clamp on the right hepatic artery and right portal vein.
Alternatively, a partial Pringle maneuver involving the left hemiliver by temporarily occluding the left hepatic artery and portal vein using an umbilical tape is also possible. This allows demarcation of the line of transection, which can be marked using electrocautery. Next, two stay sutures (2-0 silk) are placed on either side of the line of demarcation on the inferior border of the liver as for a conventional right hemihepatectomy.
The anesthesiologist is asked to maintain a low central venous pressure below 3mmHg. In case the hanging maneuver (see chapter "Hanging Maneuver for Right Hepatectomy") is used, it is prepared at this stage. Although different techniques for liver dissection can be used, Hydrojet or CUSA without inflow occlusion is preferred in most centers.
In a standard right donor hepatectomy, the middle hepatic vein is conserved and remains with the donor left liver. When V5 and/or V8 are significant and have to be preserved, they are carefully identified during the dissection and divided between a vascular metal clip on the right side and a ligature of 2-0 silk on the left side close to the middle hepatic vein. This preserves the V5 and V8 veins for venous drainage reconstruction in the recipient.
On completion of the parenchymal transection, time is taken to re-check for hemostasis and any potential bile leakage on both the graft and donor side.
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