Donor Hepatectomy

The living donor right hepatectomy should be a meticulous and careful operation. Following routine exploration of the abdomen, the hilum of the liver is addressed. The components of the portal triad are identified. Because of synthetic requirements associated with graft volume, the right lobe of the donor liver is routinely removed for LDLT.

The right branch of the hepatic artery, the right branch of the portal vein, and the right hepatic duct, are dissected but not divided. Care should be taken not to extend the plane of dissection to the left of the right portal hepatic structures. This way, injury and devascularization of the extrahepatic biliary tree is avoided. Once the right lobe is mobilized from the retroperitoneal attachments, the right hepatic vein is carefully dissected. Attempts should be made to avoid entering or injuring the IVC. The anterior surface of the IVC is dissected off the liver. The caudate lobe hepatic veins draining directly into the IVC are suture ligated and divided. The liver parenchyma is then divided. Multiple methods of transection are available, ranging from dissection and suture ligation to use of ultrasonic dissectors, harmonic scalpels, or other high energy devices. During the surgery, intraoperative ultrasound imaging can be used to guide the surgeon through the plane of tran-section, usually lateral to the middle hepatic vein. The vessels are clamped, the allograft removed, immediately flushed with preservation fluid, and placed in a preservation fluid bath on ice.

Certain controversies exist in regard to the technical aspects of this operation. In our institution, the donor hepatectomy of choice for an average size adult is the right hepatectomy. The intraoperative cholangiogram, in addition to determining the number and orientation of the bile ducts, allows us to better identify the bile duct bifurcation and therefore minimize dissection and devascularization. The use of the Pringle maneuver in hepatectomies for other indications is common. However, the potential ischemic injury to the graft makes most transplantation surgeons very reluctant to adopt this technique in living liver donation. Recent reports have demonstrated the safety of this technique in the donor with no adverse effects in the recipient. Most likely more transplantation centers will be adopting this technique in the near future.

Different techniques and surgical equipment can be used at the time of parenchymal transection. In our institution, we have modified our approach as we face the significant learning curve of the operation. Currently, we use no Pringle maneuver; the floating ball device (radio frequency with saline) is used for the most anterior and superficial part of the transection and the CUSA dissector for the deepest and perivascular dissection. To minimize bleeding at the time of parenchymal transection, a low central venous pressure (4 to 5 mm Hg) is maintained.

Poor hepatic venous outflow in the recipient can lead to hepatic graft swelling and graft failure. All efforts should be made to maximize hepatic venous outflow. The middle hepatic vein is routinely preserved with the donor. However, some Asian centers feel strongly about incorporating the middle hepatic vein with the graft. Accessory hepatic veins > 5 mm in diameter draining directly to the vena cava should be preserved and reimplanted in the recipient IVC. Controversy exists in the need to preserve and reimplant the anterior sector (segment V, VIII) hepatic veins draining to the middle hepatic vein.

Constipation Prescription

Constipation Prescription

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