Living Donor Left Hepatectomy
Derek Dubay
Anand Ghanekar
DEFINITION
Living donor left hepatectomy can only be performed at accredited transplant centers.
Living donor left hepatectomy is defined as the removal of the full left lobe of the liver including segments 2, 3, and 4 with the middle hepatic vein from a voluntary donor. Living donor left hepatectomy is an ideal-sized graft for an adolescent or small adult. Improvements in the medical and surgical management of small-for-size syndrome have now also made it possible to use left lobe grafts that are < 0.8 graft-to-recipient weight ratio in select average-sized adults without severe portal hypertension.1,2
The benefits of a living donor left hepatectomy, compared to a living donor right hepatectomy, are lower morbidity to the donor and almost always one hepatic bile duct to reconstruct.
Although not common in the United States, living donor left hepatectomy is a common liver transplant donor graft in Southeast Asian transplant centers.
Transplant centers that perform live donor partial hepatectomy need clear patient treatment algorithms: postoperative housing, lab order sets, common treatment processes (deep vein thrombosis [DVT] prophylaxis, transfusion thresholds, etc.), dedicated transplant anesthesia, staff surgeon postoperative checks, early postoperative physical therapy to assist in ambulation, and formalized discharge process.2,3
PATIENT HISTORY AND PHYSICAL FINDINGS
Chapter 19 provides a detailed living donor evaluation and criteria.
Prior to any workup, the donor ABO is verified to be compatible with the potential recipient. A brief review of the potential donor’s medical history is performed to identify obvious medical contraindications to donation (exceeding body mass index [BMI] limits, infectious diseases such as hepatitis C virus [HCV] or HIV, etc.).
Many centers will not consider candidates with BMI over 35 kg/m2. Donor candidates with a BMI over 30 kg/m2 are younger and without any comorbidities.
To avoid any sense of coercion, a physician not directly involved in the care of the potential recipient should perform the initial workup of the potential donor.
A thorough personal and family history should be performed. The goals are twofold: first, to assess for absolute and relative medical contraindications for partial hepatectomy, and second, to assess for risk factors for steatohepatitis.
The donor should be independently evaluated by a psychiatrist to evaluate for mental illness and for evidence of coercion.
The donor should be evaluated by a social worker. Donors are typically young, healthy individuals who often have young children or are employed, so there often are work-related and parental issues that need to be investigated to ensure that there is an acceptable plan for the 6- to 12-week recovery following the donor operation.
Perform a thorough physical examination, with attention for evidence of previous abdominal operations, hepatomegaly, and liver dysfunction. Assess the costal margin for determination of the best incision for exposure.
If the potential donor is deemed to be an acceptable candidate following these assessments, the patient is referred to transplant hepatologist and transplant surgeon for further assessment with laboratory evaluation and imaging studies.
IMAGING AND OTHER DIAGNOSTIC STUDIES
Reconfirm donor ABO compatibility.
Extensive laboratory evaluation is performed including complete blood count (CBC), serum chemistries, measurements of renal function, liver profile, coagulation testing, hemoglobin A1c (HbA1c), urine analysis, urine drug screen, and urine or plasma nicotine.
Pregnancy testing is performed for all women of childbearing age.
A thorough infectious screening is performed including serologies for cytomegalovirus (CMV), Epstein-Barr virus (EBV), HIV, hepatitis B virus (HBV), and HCV. Nucleic acid testing (NAT) for HIV, HBV, and HCV is performed.
Age-appropriate health maintenance screening needs to be up-to-date. Common examples include a prostate-specific antigen (PSA) and digital rectal examination (DRE) in men or a mammogram and breast examination in women. All donors older than the age of 50 years should have a screening colonoscopy.
A chest x-ray and electrocardiogram (EKG) are performed in all potential donors.
All liver donors receive both a liver protocol computed tomography (CT) scan and magnetic resonance imaging (MRI) (MRI only in the case of a severe iodine allergy) to evaluate for anatomic compatibility and to calculate the volumetrics of the donor left graft and future liver remnant right lobe (Table 1).
CT scan of abdomen
The arterial phase is used to verify conventional left arterial anatomy. The left medial artery (segment 4) and the left lateral artery (segment 2/3) are confirmed to come to a common trunk off the proper hepatic artery. Alternatively, a completely replaced left hepatic artery (off the left gastric artery) is acceptable as long as segment 4 is perfused via the replaced hepatic artery and not via an additional branch off the proper hepatic artery.
The venous phase is used to verify acceptable portal venous inflow anatomy. Hepatic venous outflow anatomy is confirmed. Volumetrics are calculated from this phase, using the middle hepatic vein as the border landmark for which to guide the transection plane.
The delayed (“equilibrium”) phase is used only in the case of focal hepatic lesions to help in diagnosis
MRI of the abdomen
The T1 in/out phase is used to assess for steatosis.
Magnetic resonance cholangiopancreatography (MRCP) reconstructions to assess for acceptable biliary anatomy
Table 1: Donor Imaging
Liver Protocol CT Scan
Noncontrast phase
Can be used to estimate steatohepatitis
Used to characterize any focal hepatic lesions detected
Arterial phase
Verify acceptable arterial anatomy.
•
Common left trunk bifurcating into left medial (segment 4) and left lateral (segment 2/3) branches
•
Completely replaced left hepatic artery with branches that also supply segment 4
Venous phase
Verify acceptable portal and hepatic venous anatomy.
Look for anomalous biliary anatomy when anomalous portal venous anatomy is detected.
Use venous phase for donor graft and recipient future liver remnant volumetrics, using the middle hepatic vein as a landmark.
Equilibrium phase
Used to characterize any focal hepatic lesions detected
Liver Protocol MRI
T1 in/out phase
Best estimate of steatohepatitis
MRCP
Used to delineate biliary anatomy
Other phases
Used to characterize any focal hepatic lesions detected
CT cholangiogram
Best anatomic imaging of biliary tract available
Necessary only when MRCP does not clearly demonstrate biliary anatomy
CT, computed tomography; MRI, magnetic resonance imaging; MRCP, magnetic resonance cholangiopancreatography.
In patients where the MRCP does not clearly delineate the biliary anatomy, a CT cholangiogram is obtained.
A preoperative donor liver biopsy is indicated if there is evidence of steatohepatitis, abnormal liver function tests, or for pathologic diagnosis of an indeterminate liver lesion.
Common anatomic “deal breakers” are listed in Table 2.
Table 2: Common Anatomic Deal Breakers | |||||||||
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SURGICAL MANAGEMENT
Preoperative Planning
Communicate with the preoperative care unit and anesthesiologist to minimize intravenous (IV) fluids preoperative and prior to parenchymal transection. It is commonplace for many preoperative care units to give 1 L of crystalloid prior to the patient even getting to the operative room, a practice that must be avoided for optimal donor partial hepatectomy. The goal is to perform parenchymal transection with a central venous pressure (CVP) less than or equal to 5, and the best way to achieve this goal is to minimize IV fluids to 1 to 2 L prior to graft excision (Table 3).
Make sure a C-arm compatible operative gurney is available and that the patient is positioned to where the C-arm can rotate freely under the patient’s right upper quadrant.
Use a cell saver.
Consent should include inherent risks of the operation including bleeding, need for blood transfusion, hepatic vessel thrombosis, bile leak, abscess formation, injury to surrounding organs, pneumonia, symptomatic pleural effusion, DVT, pulmonary embolus, wound infection, incisional hernia formation, unsightly scar, and chronic wound-related pain. Consent should also include the risk of abandoning surgery based on intraoperative findings, need for additional operative interventions, acute liver failure, and biliary stricture.
Central venous access and arterial line placement are necessary for anesthesia monitoring and rapid infusion should the need arise. A urinary catheter is placed to monitor urine output.
Positioning
The patient is positioned supine. It is useful to tuck the left arm to facilitate C-arm advancement onto the field. The right arm can be tucked or left extended, depending on surgeon preference and type of retractor employed. All pressure points are adequately padded and the patient is firmly affixed in place.
Use sequential compression devices (SCDs) and subcutaneous heparin.
Use standard skin preparation. Cefazolin is appropriate for preoperative antibiotics.Related posts:
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