One‐step venous reconstruction for a right lobe graft with multiple venous orifices in living donor liver transplantation

In living donor liver transplantation (LDLT) using the right lobe (RL) without the middle hepatic vein (MHV), reconstruction of the MHV tributaries, such as hepatic vein draining segment 5 (V5) and hepatic vein draining segment 8 (V8) of the liver, is often essential to avoid congestion of the associated area. However, ideal vascular grafts to reconstruct such tributaries are scarce, especially in the setting of LDLT. Various reconstruction techniques have been reported using autologous vein grafts such as the greater saphenous vein, the left portal vein (PV), or the paraumbilical vein. Moreover, some techniques have been reported using cryopreserved veins or arteries; however, the availability of such vascular grafts is extremely limited. Here, we present a 1-step venous reconstruction technique for an RL graft with multiple and complex hepatic vein (HV) orifices, using the recipient’s internal jugular vein (IJV) and an entire length of the PV procured from the explanted liver. The recipient was a 58-year-old Japanese male who had liver cirrhosis due to hepatitis C and multiple hepatocellular carcinomas within the Milan criteria. His liver function was Child-Pugh Class B, his total bilirubin levels were 1.1 mg/dL, his albumin levels were 3.0 g/dL, and his prothrombin time was 68% (international normalized ratio of 1.26). The Model for End-Stage Liver Disease score was 9. Imaging studies revealed severe liver cirrhosis with 3 hypervascular nodules (maximum size, 2.3 cm) in segments 8, 6, and 7 of the liver, which were compatible with hepatocellular carcinomas. An LDLT was indicated because of the expected poor prognosis with conventional therapeutic modality. The donor was the recipient’s healthy 48-year-old wife, whose blood type was identical to that of the recipient. The estimated graft volume (GV) of the RL, calculated by a 3-dimensional computed tomography scan, was 567 mL, corresponding to 47% of the recipient’s standard liver volume. The donor remnant liver volume was 306 mL or 35% of the whole liver volume, which was acceptable for the RL donation according to our criteria (the remnant liver volume was 35% of the whole liver volume). The vascular anatomy of the RL revealed the separated right anterior portal vein (APV) and posterior portal vein (PPV) with a single right hepatic artery (HA). The anatomy of the HV was complex. There were 5 major HVs draining the RL, including the right hepatic vein (RHV), 2 large short hepatic veins (SHVs), a large V5, and a V8 (Fig. 1A). The calculated total drainage area of the 4 HVs, except for the RHV, was 445 mL, which amounted to 66.5% of the total GV. Therefore, we decided to reconstruct all of these HVs. The donor procedure was performed with the usual method preserving all of the significant HVs. The MHV was not procured with the graft. The actuarial graft weight was 565 g, which accounted for 46.9% of the recipient standard liver volume. As expected, there were 5 significant HV orifices seen on the graft. The diameters of the RHV, 2 SHVs, V5, and V8 were 25, 16 and 10, 13, and 7 mm, respectively. In the recipient, the left IJV, which was 8 cm in