Middle Hepatic Vein Reconstruction in Living-Donor Liver Transplantation Using the Right Lobe
The major limitation of adult-adult living donor liver transplantation (A-A LDLT) is graft size insufficiency. Frequently, a left lobe graft from a small donor cannot meet the metabolic demands of a larger recipient. To overcome this limitation many institutes have performed LDLT using a right lobe graft with varying results. However, right lobe graft with no middle hepatic vein (MHV) trunk might be complicated by severe congestion of the anterior segment. The need for MHV reconstruction when using a right lobe graft has not yet been clearly described in the literature. We have had experience with anterior segment congestion of a right liver lobe graft. Our first five right lobe grafts without an MHV trunk were transplanted to two patients with hepatitis B virus (HBV) cirrhosis, two with fulminant hepatic failure, and one with secondary biliary cirrhosis. The right liver grafts weighed 650–1000 g, which corresponded to 48%–83% of the recipient’s standard liver volume. All accessory right hepatic veins (middle and inferior right hepatic veins) were anastomosed to the side of the recipient’s vena cava. Immediately after portal reperfusion, extremely severe congestion and dusky discoloration of the anterior segment developed in two patients followed by prolonged massive ascites and severe liver dysfunction. One of the patients died of sepsis with progressive hepatic dysfunction 20 days after transplantation.