New Technique for Management of Separate Right Posterior and Anterior Portal Veins in Pure 3D Laparoscopic Living Donor Right Hepatectomy

Abstract

Background

Pure laparoscopic donor hepatectomy, including right hepatectomy, is being increasingly performed at experienced centers (Kim et al. Transplantation 101:1106–1110, 2017; Han et al. Medicine (Baltimore) 96:e8076, 2017; Suh et al. Am J Transplant 18:434–443, 2018; Hong et al. Br J Surg 105:751–759, 2018; Lee et al. Transplantation 102:1878–1884, 2018). However, anatomical variations in the portal vein remain major challenges and are regarded as contraindications by some centers. Using a stapler or clip in donors with these anatomical variations may result in kinking of the remnant portal vein due to the thick linear bite, as well as a reduction in the length of the graft portal vein. This report describes a liver donor with separate right posterior and anterior portal veins who underwent pure 3D laparoscopic donor right hepatectomy, focusing on a new technique of managing separate two portal veins.

Methods

A 45-year-old man offered to donate part of his liver to his father, who required a liver transplant for alcoholic liver cirrhosis. The father’s Child-Pugh score was 7 and his Model for End-Stage Liver Disease score was 10.7. Donor height was 175.4 cm, body weight was 79.9 kg, and body mass index was 26.0 kg/m². Preoperative computed tomography and magnetic resonance cholangiopancreatography showed that the donor had separate right posterior and anterior portal veins. Estimated graft-to-recipient weight ratio was 1.4% and remnant liver volume was 35.7%. The entire procedure was performed under 3D laparoscopic view using a flexible scope and real-time indocyanine green fluorescence cholangiography. The right posterior and anterior portal veins were divided using Hem-O-Lok clips. After retrieving the liver, the stumps of the portal veins were replaced with polypropylene sutures, followed by removal of the Hem-O-Lok clips (SNUH technique).

Results

The total operation time was 365 min, with no transfusion and no intraoperative complications. The portal veins were divided safely without any torsion or stricture. The stumps of the portal veins were sutured after retrieval of the liver graft, with suturing requiring about 12 min. The donor was discharged on postoperative day 7 with no complications.

Conclusion

The SNUH technique, consisting of temporary clipping, intracorporeal suturing, and clip removal is safe and useful for pure laparoscopic right hepatectomy in donors with anatomic variations in the portal vein.