Unfortunately, there is an insufficient supply of deceased-donor hepatic allografts to satisfy the need for liver transplantation in patients with end-stage liver disease. Living-donor liver transplantation is necessary to overcome the organ shortage. Living-donor liver transplantation was first performed in children using reduced-size grafts. The first successful adult-to-child liver transplant, using a left lateral segment allograft, was performed in 1989. Since then, living donor liver transplantation has spread using left and right lobes to both children and adults. In general, compared to left lobe living-donor liver transplantation, right lobe grafts provide more liver mass to the recipient; however, they leave the donor with less remnant liver. This chapter will focus on living-donor right lobe hepatectomy.
The donor preoperative evaluation is focused on the safety of the potential donor. It requires a dedicated team comprised of surgeons, hepatologists, social workers, psychiatrists/psychologists, independent physicians, ethicists and dieticians.
Centers will have different thresholds for body mass index, age and medical comorbidity criteria to guide the donor evaluation. The clinical assessment includes a medical history and physical examination followed by blood tests and imaging. Labs including hematology, chemistry, coagulation and viral serology testing should be performed. Indolent liver diseases such as viral hepatitis, autoimmune hepatitis, non-alcoholic steatohepatitis, hemochromatosis, alpha-1-antitrypsin deficiency and Wilson’s disease are excluded. Hepatic steatosis is evaluated with imaging and/or liver biopsy. Patients with macrosteatosis >10% are provided dietary counselling and are re-biopsied to ensure improved macrosteatosis <10% prior to living donor hepatectomy.
The next phase of donor workup involves quadruple-phase CT to evaluate hepatic vascular anatomy and volumetry. In general, a graft to recipient body weight ratio (GRBWR) of >0.8% is accepted, though > 1% is preferable. A donor future liver remnant (FLR) >30% of the entire liver pre-resection is preferable, though in well-selected donors, a FLR > 28% is acceptable. Suitable biliary anatomy is confirmed with magnetic resonance cholangiopancreatography.
Our practice is to perform a right hepatectomy leaving the middle hepatic vein in the donor. On preoperative CT, the landmarks for the transection plane are: the groove between the right and middle hepatic vein, the right border of the middle hepatic vein, the junction of the segment V hepatic vein and the middle hepatic vein, the middle of the gallbladder fossa and the bifurcation of the portal vein (Fig. 65-1).
There are many variations in hepatic arterial inflow. Although the right and left hepatic arteries typically course from the proper hepatic bifurcation in the porta hepatis, there are other common and infrequent arterial variations that must be assessed for. Attention should be paid to the course of the right hepatic artery. Dissection of the artery to the left of the common hepatic duct should be ...