Pyloric Artery to Segment 4 Artery Vascular Reconstruction, a Novel Surgical Technique Developed for Donor Safety after LLS Hepatectomy, and now Proposed for Extended Right Lobe Split Grafts

GABRIEL E. GONDOLESI; DIEGO RAMISCH; ANDRES FRAILE; BARROS SCHELOTTO PABLO; LUIS MERCADO

Congreso; TTS Madrid 2018; 2018

Strategies to increase the pull of organs include the use of segmental liver grafts. Segment 4 (S4), and its arterial supply has been a topic of debate due to the risk of ischemia and necrosis of the mentioned segment after split-liver transplantation and after living donation. Complications related to S4 can occur in up to 22% of the cases and it has been associated to a reduced graft and patient survival. It has been described that the shape of the liver segments, their volumes and the vascular branching have significant variability, increasing the challenges at the time of performing the living donor surgery or the splitting. Aim: To describe the pyloric artery to S4 branch (middle hepatic artery) reconstruction as a novel technique performed for the first time during a pediatric living donor liver transplant and perceived as a possible solution to reduce potential donor risks, and to extend the right lobe graft (ERLG) for adult liver transplant. Case reports: 1) A 45 year old living donor was selected for a pediatric recipient. During the procedure a high dominant S4 artery was dissected. In order to obtain an appropriate left HA length and diameter for the recipient, it was necessary to cut it. Once the graft was removed from the field, the pyloric artery was dissected with a sufficient length to rotate it, and a microsurgical anastomosis to the S4A was performed. No biliary, or cut surface complications. 2) Cadaveric liver transplant done in a patient to 61 years old, HCV with HCC within Milan criteria. The S4 artery was found to be transected during the split procedure. After performing the portal and HAT reconstruction, the S4 remained incompletely perfused, therefore, the pyloric to S4 artery reconstruction  allowed to recover color and Doppler signal. No biliary, or cut surface complications. Conclusions: The described procedure is a simple and novel technique that can be used for left lateral segment donors and ERLG recipients. Its use might contribute to increase the donor selection and to reduce living donor and recipient S4 related complications. Future reports should include a description of the middle hepatic artery.