Fig. 7.1
All aspects of the liver are carefully inspected
2.
Beginning with the posterior aspect of the liver, the retrohepatic IVC (broken blue line) is visualized, and excess retroperitoneal tissue is removed. If present, an assistant can help by placing his or her finger into the IVC during this step (Fig. 7.2). The adrenal vein (blue arrow) and any lumbar veins are identified and ligated; the adrenal gland (broken yellow line) is removed.
Fig. 7.2
An assistant can place a finger into the retrohepatic inferior vena cava (IVC) (broken blue line). Excess retroperitoneal tissue is removed. The adrenal vein (blue arrow) and any lumbar veins are identified and ligated; the adrenal gland (broken yellow line) is removed
3.
Diaphragm attached to the right and left lobe is dissected free and discarded. Phrenic vein branches (yellow arrow) should be identified and ligated (Fig. 7.3).
Fig. 7.3
Diaphragm is dissected free, and phrenic vein branches (yellow arrow) should be ligated. The vena cava is outlined by the broken blue line
4.
The cava can be inspected and probed from the inside to ensure that all phrenic branches and the adrenal vein have been ligated (Fig. 7.4). The hepatic vein outflow technique dictates the final step in IVC preparation. If caval replacement is planned, the IVC orifices are left open. If a standard piggyback technique is planned, the infrahepatic cava is closed with a running suture, except for a small corner that remains open to allow for later flushing of the liver once the anastomoses are completed. If a side-to-side cavaplasty is planned, both the suprahepatic and infrahepatic caval openings are closed and a cavotomy is made longitudinally in the IVC at the center of its posterior aspect.
Fig. 7.4
The cava can be inspected and probed from the inside to ensure that all phrenic vein branches and the adrenal vein have been ligated
5.
The hilum is inspected and the common bile duct (CBD), hepatic artery, and portal vein are identified (Figs. 7.5 and 7.6). The portal vein (blue arrow) is dissected free distally in the hilum until the bifurcation is seen. The arterial blood supply (yellow arrow) is inspected for variations. An aortic patch is fashioned.
Fig. 7.5
The common bile duct (CBD), hepatic artery, and portal vein are identified
Fig. 7.6
The portal vein (blue arrow) is dissected free distally in the hilum until the bifurcation is seen. The arterial blood supply (yellow arrow) is inspected for variations. The gastroduodenal artery stump (green arrow) is seen
6.
Strategies for aberrant arterial anatomy: An accessory left hepatic artery (HA) usually arises from the left gastric artery, a branch of the celiac axis (Fig. 7.7). Generally no reconstruction is required. The accessory left HA is traced from its origin to the liver, and branches not going to the liver are ligated.
Fig. 7.7
An accessory left hepatic artery usually arises from the left gastric artery
7.
Strategies for aberrant arterial anatomy: An accessory right HA usually arises from the superior mesenteric artery (SMA) and passes behind the common bile duct. Several reconstructive options are available: We prefer an end-to-end anastomosis to the gastroduodenal artery (GDA) (Fig. 7.8a). Alternatives include an anastomosis to the stump of the splenic artery (SA) (Fig. 7.8b) or anastomosing the common hepatic artery itself onto the stump of the SMA (Fig. 7.8c).
Fig. 7.8
An accessory right hepatic artery usually arises from the superior mesenteric artery (SMA) and passes behind the common bile duct. Several reconstructive options are available: We prefer an end-to-end anastomosis to the gastroduodenal artery (GDA) (a). Alternatives include an anastomosis to the stump of the splenic artery (b) or anastomosing the common hepatic artery itself onto the stump of the SMA (c)
8.
Finally, the IVC is prepared depending on the method of planned outflow reconstruction. If a caval replacement technique is planned, the inferior vena cava is left open at both ends (Fig. 7.9a). If a standard piggyback technique is planned, the infrahepatic cava is closed with a running stitch (Fig. 7.9b). A small corner of this closure is left open to allow for later flushing of the liver once the anastomoses are completed. If a side-to-side cavaplasty is planned for outflow reconstruction, both the suprahepatic and infrahepatic caval openings are closed and a venotomy is made in the middle of the cava, along its posterior aspect (Fig. 7.9c).
Fig. 7.9
The IVC is prepared depending on the method of planned outflow reconstruction: For a caval replacement technique, the IVC is left open at both ends (a). For a standard piggyback technique, the infrahepatic cava is closed with a running stitch, leaving a small corner open (b). For a side-to-side cavaplasty, both the suprahepatic and infrahepatic caval openings are closed and a venotomy is made in the middle of the cava, along its posterior aspect (c)
7.3 Adult Deceased Donor Liver Transplant: Operative Procedure
1.
The patient is positioned in the supine position with both arms abducted. A bilateral subcostal incision usually suffices but a midline extension towards the xiphoid may be required (Fig. 7.10). Both groins should be prepped to allow for a venovenous bypass (VVB) option. VVB requires the following access: (1) 18F right IJ percutaneous line (grey arrow) (2) cannulae placed in the femoral veins, (percutaneous and open techniques) portal veins, or both.
Fig. 7.10
With the patient supine, a bilateral subcostal incision usually suffices, but a midline extension towards the xiphoid may be required. A right internal jugular percutaneous line may be needed for a venovenous bypass
2.
After entrance into the abdomen, the ligament of Teres is divided between ligatures; the liver is retracted inferiorly and the falciform ligament (blue arrows) is divided with electrocautery or an advanced thermal device (Fig. 7.11).
Fig. 7.11
The liver is retracted inferiorly and the falciform ligament (blue arrows) is divided
3.
The left triangular ligament is divided (broken line), stopping medially at the left hepatic vein (arrow) (Fig. 7.12).
Fig. 7.12
The left triangular ligament is divided (broken line), stopping medially at the left hepatic vein
4.
Isolation and control of the hepatoduodenal ligament: The gastrohepatic ligament is divided from the edge of the hepatic hilum superiorly to the edge of the left hepatic vein (Figs. 7.13 and 7.14). If present, the accessory left hepatic artery should be ligated and divided. Any attachment from the gallbladder to the duodenum should be judiciously divided; at the completion of this step, one can digitally encircle and control the hilar structures.
Fig. 7.13
The gastrohepatic ligament is divided from the edge of the hepatic hilum superiorly to the edge of the left hepatic vein
Fig. 7.14
The gastrohepatic ligament is divided (blue line) from the edge of the hepatic hilum superiorly to the edge of the left hepatic vein
5.
Good retraction of the ribcage is an essential part of the procedure. An upper body retractor fixed to both sides of the chest provides good retraction of the rib cage, even in obese patients (Figs. 7.15 and 7.16).
Fig. 7.15
Good retraction of the ribcage is essential
Fig. 7.16
An upper body retractor fixed to both sides of the chest provides good retraction of the rib cage
6.
Hilar/gastroduodenal ligament dissection: Hilar dissection is then started by dividing the hilar peritoneum, starting high in the hilum close to the liver (broken blue line) (Fig. 7.17). Portal hypertension mandates that meticulous hemostasis with electrocautery and occasional ligation be performed.
Fig. 7.17
Hilar dissection is started by dividing the hilar peritoneum, starting high in the hilum close to the liver (broken blue line)
7.
Proper hepatic artery (PHA) dissection: The PHA is identified first and traced distally to the left and right branches (Fig. 7.18). These are individually divided to allow for later creation of a patch (Fig. 7.19).
Fig. 7.18
The proper hepatic artery (PHA) is traced distally to its left and right branches (yellow lines)
Fig. 7.19
The PHA branches are individually divided
8.
If the artery is small at the level of the hepatic artery bifurcation, it should be traced proximally beyond the gastroduodenal artery (GDA) (yellow arrow) (Fig. 7.20). The GDA can then be divided (broken yellow line) and a patch created for anastomosis using this bifurcation. For living donor transplants, the right or left HA should be dissected further into the liver to optimize length.
Fig. 7.20
If the artery is small at the level of the hepatic artery bifurcation, it should be traced proximally beyond the gastroduodenal artery (GDA) (yellow arrow), which can then be divided (broken yellow line)
9.
Common bile duct dissection: Next the CBD (broken yellow line) is found at the right edge of the hepatoduodenal ligament, and then ligated and divided (Figs. 7.21 and 7.22). The distal end of the recipient CBD will ultimately require fine suture ligation of the accompanying biliary veins to control troublesome bleeding.
Fig. 7.21
The CBD, found at the right edge of the hepatoduodenal ligament, is ligated and divided
Fig. 7.22
The CBD (broken yellow line) is found at the right edge of the hepatoduodenal ligament, and then ligated and divided
10.
Portal vein (PV) dissection: The PV is identified between and deep to the course of the hepatic artery and the CBD. It is isolated and encircled (Fig. 7.23a). All other structures in the hilum at that level (lymphatics, nodes, nerves) can be divided between ligatures or with cautery (Fig. 7.23b). The PV is traced distally until the bifurcation is identified (Fig. 7.24)
Fig. 7.23
(a) The portal vein is isolated and encircled. (b) All other structures in the hilum at that level (lymphatics, nodes, nerves) can be divided between ligatures or with cautery
Fig. 7.24
The portal vein (broken blue line) is traced distally until the bifurcation is identified. The artery (broken yellow line) has been divided beyond its bifurcation
11.
Portal bypass preparation (optional): If the plan is to utilize portal venous bypass, the portal vein (broken blue line) is clamped proximally and divided as far distally as possible. The distal stump is oversewn or suture ligated (Fig. 7.25).
Fig. 7.25
To prepare for portal bypass, the portal vein (broken blue line) is clamped proximally and divided as far distally as possible
12.
A 24F cannula is placed into the portal vein; a heavy silk tie secures the cannula to the vein (Fig. 7.26). We have noted an infrequent incidence of bypass-related complications if the flow is maintained at or above 800 mL/min.
Fig. 7.26
A 24F cannula is placed into the PV; a heavy silk tie secures the cannula to the vein
13.
If the flow requires augmentation or full systemic bypass is preferred, a groin incision or percutaneous approach allows for placement of a cannula into the common iliac vein (Fig. 7.27).
Fig. 7.27
For augmented flow or full systemic bypass, a groin incision or percutaneous approach allows for placement of a cannula into the common iliac vein
14.
Piggyback technique and mobilization of the liver off the IVC: The goal of the piggyback technique is to safely mobilize the liver off the IVC, resulting in the isolation of the three main hepatic veins; this is performed without occluding flow through the IVC. The peritoneum attaching the caudate lobe to the anterior surface of the IVC is divided (greatly facilitated if the portal vein has been divided). The left lobe is retracted medially and the caudate lobe is digitally controlled (green arrow) and retracted off the IVC (blue arrow) (Fig. 7.28). Starting inferiorly, direct venous branches are identified, encircled, ligated, and divided (Figs. 7.28 and 7.29). Liberal use of suture ligature for large veins is warranted and may prevent delayed bleeding. This dissection ends at the lower border of the left hepatic vein (yellow arrow).
Fig. 7.28
The left lobe is retracted medially and the caudate lobe is digitally controlled (green arrow) and retracted off the IVC (blue arrow and outlined by the broken blue line). Direct venous branches are identified, encircled, ligated, and divided. This dissection ends at the lower border of the left hepatic vein (yellow arrow)
Fig. 7.29
The left lobe is retracted medially and the caudate lobe is digitally controlled and retracted off the IVC
15.
Piggyback technique—Right hepatic lobe mobilization: The liver (broken yellow line) is then retracted superiorly and to the left (yellow arrow), and the process is repeated from the right side (Figs. 7.30 and 7.31). In this manner, the liver is completely separated from the retrohepatic cava, leaving it attached only by the three main hepatic veins.
Fig. 7.30
The liver (broken yellow line) is retracted superiorly and to the left (yellow arrows), and the process is repeated from the right side to completely separate the liver from the retrohepatic cava
Fig. 7.31
The liver is then retracted superiorly and to the left; the process is repeated from the right side. In this manner, the liver is completely separated from the retrohepatic cava, leaving it attached only by the three main hepatic veins
16.
We perform either the side-to-side cavaplasty or the standard piggyback technique. For side-to-side cavaplasty preparation, the three recipient hepatic veins are stapled or clamped/transected/oversewn. The articulating endovascular GIA 45-mm stapler functions very nicely in this tight space (Fig. 7.32). The liver is removed (Fig. 7.33).
Fig. 7.32
To prepare for side-to-side cavaplasty, the three recipient hepatic veins are stapled using an endovascular GIA 45-mm stapler or are clamped/transected/oversewn. The line of division is marked by the broken yellow line
Fig. 7.33
The liver is removed
17.
Side–to–side cavaplasty preparation: A large Satinsky clamp (non–IVC-occluding) is placed, and a 5-cm anterior cavotomy is made (Fig. 7.34) During the bench preparation, the suprahepatic and infrahepatic IVC orifices are suture closed except for a 1-cm vent site on the infrahepatic IVC orifice (used for blood flush). A corresponding 5-cm donor cavotomy is fashioned after the donor liver is flushed on the bench. Before implantation, it is important to confirm patency of the orifices of the donor right and left/middle hepatic veins (Fig. 7.35).
Fig. 7.34
To prepare for a side-to-side cavaplasty, make a 5-cm anterior cavotomy (broken blue line)
Fig. 7.35
A corresponding 5-cm donor cavotomy is fashioned after the donor liver is flushed on the bench
18.
Side–to–side cavaplasty anastomosis: 4-0 Prolene is placed on the superior and inferior aspects of the adjoining cavotomy sites (Fig. 7.36), while a third 4-0 Prolene stay suture is placed on the recipient’s left caval wall, optimizing exposure of the back wall during the anastomosis. The surgeon on the right side of the table controls the liver and optimizes exposure while the surgeon on the left side performs the anastomosis.
Fig. 7.36
4-0 Prolene is placed on the superior and inferior aspects of the adjoining cavotomy sites
19.
Preparation for the standard piggyback: A clamp is placed across the cava just distal to the junction with the three hepatic veins (Fig. 7.37a). The cava is only partially occluded, and venous return continues to the heart. The orifices of the three hepatic veins are then opened together to create one common orifice (Fig. 7.37b).
Fig. 7.37
To prepare for the standard piggyback, a clamp is placed across the cava just distal to the junction with the three hepatic veins (a). The orifices of the three hepatic veins are then opened together to create one common orifice (b)
20.
The suprahepatic cava of the donor liver is then sewn to the common orifice of the recipient hepatic veins (arrow) (Fig. 7.38). The donor infrahepatic IVC has already been sutured closed, except for a small opening.
Fig. 7.38
(a, b) The suprahepatic cava of the donor liver is then sewn to the common orifice of the recipient hepatic veins. The donor infrahepatic IVC has been sutured closed, except for a small vent (b)
21.
Caval replacement or “classic” hepatic vein outflow is preferred at some centers. The focus in this technique lies in isolation, dissection, and control of the infrahepatic and suprahepatic IVC while forgoing ligation of direct hepatic veins. After completion of the hilar dissection, the infrahepatic IVC is visualized by division of the peritoneum anterior to it (Fig. 7.39). The adrenal vein, if seen, is ligated and divided, and the infrahepatic IVC is encircled (Fig. 7.40).
Fig. 7.39
In caval replacement or “classic” hepatic vein outflow, the infrahepatic IVC is visualized by division of the peritoneum anterior to it
Fig. 7.40
The infrahepatic IVC (broken blue line) is encircled. The adrenal vein (yellow arrow), if seen is ligated and divided
22.
Left side mobilization: The left lobe is retracted medially and the dissection continues superiorly along the margin of the left side of the IVC. The dissection extends to the point where the left phrenic vein enters the IVC (Fig. 7.41). The liver is placed back in anatomic position and the dissection is carried over the anterior aspect of the three hepatic veins and suprahepatic IVC (Fig. 7.42).
Fig. 7.41
The left lobe is retracted medially and the dissection continues superiorly along the margin of the left side of the IVC
Fig. 7.42
The liver is placed back in anatomic position and the dissection is carried over the anterior aspect of the three hepatic veins and suprahepatic IVC
23.
Completion of the right hepatic lobe mobilization: The liver is rotated to the left, allowing for visualization and division of the right triangular ligament (Fig. 7.43). Continuing to rotate the liver to the left, the entire right lobe along its bare area is mobilized from the retroperitoneum (Fig. 7.44). Care should be taken to stay close to the surface of the liver to avoid bleeding from enlarged retroperitoneal veins. The right lateral aspect of the retrohepatic cava should now be visible.
Fig. 7.43
The liver is rotated to the left, allowing for visualization and division of the right triangular ligament
Fig. 7.44
Continuing to rotate the liver to the left, the entire right lobe along its bare area is mobilized from the retroperitoneum
24.
The suprahepatic cava can now be encircled and plastic tubing or umbilical tape passed around it (Fig. 7.45).
Fig. 7.45
The suprahepatic cava can now be encircled and plastic tubing or umbilical tape passed around it (arrow)
25.
Finally, the posterior aspect of the cava is completely freed from its tissue attachments. The adrenal vein, if not already divided, should be ligated and divided (Fig. 7.46).
Fig. 7.46
The posterior aspect of the cava is completely freed from its tissue attachments, starting from inferiorly and proceeding superiorly (black arrow)
26.
Clamps are then placed on the suprahepatic and infrahepatic IVC; these structures are divided and the liver is removed (Fig. 7.47). With the liver removed, the retroperitoneal area can be inspected for hemostasis. Once this is reasonable, implantation of the graft can begin.
Fig. 7.47
Clamps are then placed on the suprahepatic and infrahepatic IVC; these structures are divided and the liver is removed
27.
Suprahepatic caval anastomosis: The back wall is performed first, using a vertical mattress type of suturing technique (Fig. 7.48a), followed by an “over and over” stitch for the anterior wall (Fig. 7.48b).
Fig. 7.48
The back wall of the suprahepatic caval anastomosis is sutured first, using a vertical mattress technique (a), followed by an “over and over” stitch for the anterior wall (b)
28.
Infrahepatic caval anastomosis: This anastomosis is performed in a similar fashion (Fig. 7.49). A small corner in the anterior wall should be left open to wash blood and storage solution out of the liver at the “flushing” phase.
Fig. 7.49
(a, b) The infrahepatic caval anastomosis is performed in a similar fashion. A small corner in the anterior wall should be left open to wash blood and storage solution out of the liver at the “flushing” phase
29.
Portal vein anastomosis is performed in an end-to-end, continuous fashion. The ends are tied with an “air” knot (arrow) of about 2 cm, to provide a “growth factor” for the vein, preventing narrowing when the vein fills with blood (Fig. 7.50).
Fig. 7.50
Portal vein anastomosis is performed in an end-to-end, continuous fashion. The ends are tied with an “air” knot of about 2 cm, to provide a “growth factor” for the vein, preventing narrowing when the vein fills with blood
30.
Allograft reperfusion: No conclusive data suggest a superior reperfusion technique; we opt for a blood flush of 300–600 mL followed by portal vein reperfusion. The vented blood is scavenged by the cell saver (Fig. 7.51). As previously stated, communication between the surgical and anesthesia teams is mandatory during the potentially challenging post-reperfusion period.
Fig. 7.51
For allograft reperfusion, we opt for a blood flush of 300–600 mL followed by portal vein reperfusion. The vented blood (course outlined by arrows) is scavenged by the cell saver
31.
Hepatic artery anastomosis: The donor proper hepatic artery is sewn in an end-to-end fashion to the recipient’s hepatic artery at the level of the right and left hepatic artery bifurcation, or at the level of the gastroduodenal artery. A bifurcation point is used for the arterial anastomosis so that the vessel can be opened up to create a patch around the main arterial vessel (Fig. 7.52).
Fig. 7.52
The donor proper hepatic artery is sewn in an end-to-end fashion to the recipient’s hepatic artery (HA) at the level of the right and left hepatic artery (LHA) bifurcation. A bifurcation point is used for the arterial anastomosis so that the vessel can be opened up to create a patch around the main arterial vessel
32.
Choledochocholedochostomy: A donor cholecystectomy is performed and the donor CBD is transected to confirm that the CBD is well vascularized. The donor CBD is anastomosed in an end-to-end fashion to the recipient CBD using interrupted absorbable sutures. The back wall is completed first, followed by the arterial wall. Placement of a 5 or 8F internal stent can be helpful, especially if ampullary stenosis is suspected or the CBDs are diminutive (Fig. 7.53).
Fig. 7.53
For choledochocholedochostomy, a donor cholecystectomy is performed and the donor CBD is anastomosed in an end-to-end fashion to the recipient CBD using interrupted absorbable sutures. Placement of an internal stent can be helpful
33.
Alternative biliary reconstructions: If the recipient’s CBD cannot be used (e.g., sclerosing cholangitis), biliary continuity can be restored with a hepaticojejunostomy to a Roux-en-Y bowel loop. The loop itself should be about 40–50 cm in length and should be brought up through the transverse mesocolon (retrocolic) so that it lies next to the donor bile duct without any tension (Fig. 7.54).
Fig. 7.54
If the recipient’s CBD cannot be used, biliary continuity can be restored with a hepaticojejunostomy to a Roux-en-Y bowel loop. The loop should be about 40–50 cm in length and should be brought up through the transverse mesocolon (retrocolic) so that it lies next to the donor bile duct without any tension (course shown by black arrows)
34.
The bile duct is then sewn to a small opening created in the bowel using interrupted absorbable suture. The back wall is done first, followed by the anterior wall. It is helpful to place an external stent through this anastomosis, which is brought out through the Roux loop and then through the anterior abdominal wall (Fig. 7.55).
Fig. 7.55
The bile duct is then sewn to a small opening created in the bowel. It is helpful to place an external stent through this anastomosis
35.
Closure and technical adjuncts: Drains are placed posterior to the right lobe and in the subhepatic space. We often place an internal Doppler probe, which is secured to the hepatic artery with 7-0 PDS; this probe generally eliminates the need for post-LTx sonography. The fascia is closed with heavy, absorbable suture.
7.4 Deceased Donor Split Liver Transplant: Adult/Adult Recipients
The vast majority of split liver transplants (SLTs) have been performed between an adult and a pediatric recipient. The benefits for pediatric recipients have been tremendous, with a significant decrease in waiting times and mortality rates. Splitting an adult liver for pediatric recipients has no negative impact on the adult donor pool, but neither does it increase it. Adults now account for 96 % of patients dying on the waiting list, compared with only 70 % in 1988. If SLTs are to have a significant impact on waiting list time and mortality, they must be performed so that the resulting two grafts can also be used in two adult recipients.
Division of the liver at the falciform ligament will generate a left lateral segment that would have inadequate liver volume for most adult recipients. Transection in the midplane of the liver divides it into the anatomic right lobe (60 % of the liver) and the left lobe (40 % of the liver), usually generating grafts of sufficient size for two adult recipients. The minimum amount of liver mass needed to sustain life immediately posttransplant is unclear. Some experience with living donor liver transplants suggests that a graft weight/recipient weight (GW/RW) ratio of 0.8 % is the minimum. For deceased donors, the minimum amount of liver mass also may be influenced by such factors as donor hemodynamic stability and cold ischemic time.
7.4.1 Selection Criteria
Proper recipient and donor selection are crucial in ensuring a good outcome. A GW/RW ratio of close to 0.8 % should likely be the minimum when selecting appropriate recipients. Graft size is not the only criterion in selecting donors and recipients. Donors should be medically ideal to minimize the risks of primary nonfunction, especially for left lobe recipients. Young, hemodynamically stable donors with normal liver function test results should be selected; with such donors, primary nonfunction for the recipients should be uncommon. Cold ischemic time should be minimized as much as possible in all SLT donors. For this reason, it is preferable to do the actual transection of the parenchyma in situ in the donor. Performing the split on the back table could add up to 2–3 h of cold ischemia. Also, there is likely to be some warming of the liver on the back table, even if the split is being performed in a cold ice bath of University of Wisconsin solution. Performing the split in situ also has other advantages: Significantly less bleeding occurs when the organs are reperfused, and the two liver grafts can be assessed in the donor immediately after parenchymal transection and before vascular interruption, to ensure adequate perfusion and viability.
7.4.2 Technical Aspects
Several technical points need emphasis regarding the donor operation, which is very similar to right lobe liver procurement from a living donor. The transection plane should stay to the right of the middle hepatic vein, so that this structure is retained with the left lobe. Segment IV makes up a crucial part of the left lobe, and hence the middle hepatic vein should be preserved with the left lobe to ensure no congestion. Loss of the middle hepatic vein usually does not significantly affect drainage of segments V and VIII in the right lobe graft, as these segments drain adequately via the right hepatic vein. Regarding the dissection in the hilum, our preference has been to leave the full length of the hilar structures intact with the left lobe. The right-sided hilar structures are usually larger than the left-sided structures, so leaving the main vessels intact with the left lobe makes that transplant easier. One crucial technical point for the recipient operation is ensuring adequate venous outflow of the grafts to prevent congestion. Preserving the cava with the right lobe graft helps to maximize outflow by preserving all inferior hepatic veins, and also allows for back-table reconstruction of any segment V and VIII veins draining from the right lobe to the middle hepatic vein.
7.4.3 Ethics of Splitting
Surgical complications are probably more common in SLT recipients than in whole graft recipients, related to the cut surface of the liver, smaller vessels for anastomosis, and more complicated biliary reconstruction. Therefore, one important aspect of the recipient selection process is adequately informing the potential recipient of the splitting procedure and obtaining informed consent.
7.4.4 Split Potential
More data are needed to better define donor and recipient selection criteria, which are crucial to success. It is difficult to estimate how much impact adult SLTs will have on the donor pool. About 25 % of all deceased donors in the United States are between 15 and 35 years of age. If many of these livers could be used for splits, the number of liver transplants could potentially increase by 20–25 %, or by close to 1,000. However, the fact that MELD (Model for End-Stage Liver Disease) scores at the time of LTx are quite high and increasing in some geographic regions may continue to temper enthusiasm for using these types of split grafts for patients already at high risk for post-LTx complications. With better preservation techniques, more livers may be amenable to splitting, however, and this technique will likely become part of every major liver transplant center’s repertoire in the near future, in order to provide the maximum advantage for their candidates on the waiting list.
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