Procurement of the left lateral section (Couinaud segment 2 and 3) is usually appropriate for infants and small children who need a liver transplantation. Living donation minimizes cold ischemia time and preservation injury and eliminates the uncertainty and complications of being on a waitlist. Optimal timing of the operation is possible, and patients who otherwise might not receive a deceased donation are given a chance to benefit and reduce the time on the waitlist. Also, a left lateral section can be achieved from a split liver of a good deceased donor. Actually, the left lateral sectionectomy performed for pediatric living-donor liver transplantation (LDLT) is a gold-standard procedure with a significantly low morbidity and mortality rate for the donor.1
In LDLT a meticulous donor evaluation by a multidisciplinary team, with preoperative labs and imaging, must be performed. Special attention is paid to the liver anatomy, including the vascular and biliary system. A multidetector computed tomography scan and magnetic resonance imaging evaluation are done to elucidate the left lateral volume, fat load, and vascular and biliary anatomy (Fig. 63-1). To accurately assess arterial and portal anatomy, an angiography of the celiac axis and superior mesenteric artery with mesenteric-portal return is routinely performed (Figs. 63-2 and 63-3).
Left lateral section volumetric reconstruction by multidetector computer tomography scan.
Evaluation of arterial anatomy by digital angiography. In this figure, the catheter is placed in the common hepatic artery.
Portal and superior mesenteric vein anatomy by digital angiography.
To have a good and secure exposure, a laparotomy is done by a bilateral subcostal or midline incision (Fig. 63-4). In case of LDLT, the left lateral section can be procured by the laparoscopic approach.2
Abdominal approach by a supraumbilical midline incision.
Once the abdominal cavity is open, the left lateral section is mobilized by dissection of the falciform and left coronary and triangular ligaments. It is of utmost importance to check the existence of a left hepatic artery branch from the gastric artery that runs through lesser omentum before opening it.
Hilar dissection begins with identifying the common hepatic artery. The left hepatic artery is dissected close to its origin (Fig. 63-5). The arterial branch to segment 4, if it originates from the left hepatic artery, is ligated to ensure sufficient artery length.
Left hepatic artery dissection.