INTRODUCTION
Liver transplantation (LT) techniques have changed continually over the last 4 decades. Caval preservation, first reported by Calne and Williams in 19681 and popularized by Tzakis et al. in 19892 as the piggyback (PB) technique, has been adopted by many transplant teams.3–6 In 1992, we described a procedure preserving the caval flow during the whole procedure.7 Hemodynamic stability was sought by the adjunction of a temporary portocaval shunt.3, 7 Preservation of the vena cava has gained many indications because it allows the implantation of a partial graft (split and living donor). Although preservation of both caval and portal flow avoids the need of venous bypass,3 its hemodynamic superiority is contrabalanced by the risk of outflow obstruction.8, 9 It was shown in 2001 that a very large side caval anastomosis, if necessary with temporary caval clamping during the anastomosis procedure, is necessary for good graft liver function.3 All these technical modifications focus on graft implantation and vascular reconstruction. Technical procedures used during total hepatectomy with caval preservation and its effects on hemodynamic variations have not been exhaustively described. One particular point linked to this technique is that hemodynamic changes related to torsion of the vena cava can occur during explantation of the native liver.
The aim of this article is to describe a “left-to-right approach total hepatectomy,” which allows removal of the recipient liver with minimal mobilization of the vena cava, limiting hemodynamic disturbances related to variation of the caval flow.
LEFT-TO-RIGHT TOTAL HEPATECTOMY: TECHNIQUE
The liver is exposed through a bilateral subcostal incision with or without a superior midline extension to the xiphoid. The round ligament is divided, and the falciform ligament is sectioned until the suprahepatic vena cava. A mechanical retractor is placed under both costal arches to provide excellent exposure.
Extensive mobilization of the right liver is avoided. Total hepatectomy starts with skeletonization of the individual structure of the hepatic pedicle: in particular, one of the most important points is to leave the vessels and bile duct as long as possible, especially in the case of transplantation with a partial graft. The cystic duct and artery are ligated and divided first. The branches of the hepatic artery are dissected and transected close to the liver to provide adequate length, and the common hepatic artery is isolated. The bile duct is ligated and divided, and the portal vein is dissected, clamped, and transected. The gastrohepatic ligament is sectioned mainly by suture ligation because of the presence of collateral veins and an accessory hepatic artery. In most cases, a temporary termino-lateral portocaval shunt is performed for portal decompression.
The anterior surface of the suprahepatic inferior vena cava (IVC) is dissected with the punch-burn-cut method, and the confluence of major hepatic veins and suprahepatic vena cava is exposed. The space between the right hepatic vein and middle hepatic vein is dissected 3 to 4 cm downward with a right-angled dissector and a vascular clamp; this is like the technique described for a hanging maneuver.10, 11 The left lobe is mobilized by the opening of the left triangular ligament; the ligamentum venosum (Arantius), a good anatomical landmark for the dissection of the middle hepatic vein and left hepatic vein, is ligated and divided near the suprahepatic IVC. A vascular dissector is inserted cranially along the left antero-lateral surface of the IVC between the 1 and 2 o’clock positions with the Arantius vein stumps as landmarks by gentle dissection toward the previously dissected space between the right hepatic vein and middle hepatic vein. Normally, this dissection can be performed without any resistance being encountered. The common trunk is clamped by a vascular angular clamp and divided by scissors as far as possible within the liver parenchyma (Fig. 1). At this point, the left lobe is rolled to the right, and this exposes the caudate lobe. The cranial edge of the caudate lobe is lifted from the IVC, and all hepatic veins are divided and ligated from left to right up to the level of the right hepatic vein without twisting of the IVC (Fig. 2). The right hepatic vein is dissected, clamped, and divided (Fig. 3). The right inferior accessory veins, which in patients with cirrhosis are usually bigger and hypertrophic, are easily dissected, ligated, and divided. Finally, the right ligament is cut, and the right liver is progressively separated from the right diaphragm. Recipient hepatectomy is complete without mobilization or twisting of the IVC (Fig. 4).
Step 1: clamp and section of the common trunk.
Step 2: section of the caudate veins.
Step 3: clamp and section of the right hepatic vein.
Step 4: section of the right triangular ligament.
From January 2006 to December 2007, we performed 154 consecutive LTs using this left approach. In comparison with the classic right-approach PB LT, the mean total hepatectomy time and mean whole operative time were significantly lower: 183 ± 51 versus 220 ± 65 minutes (P < 0.0001) and 493 ± 122 versus 584 ± 131 minutes (P < 0.0001), respectively. There was no difference in the number of portocaval anastomoses performed (72% versus 80%), whereas total cava clamping for vascular injuries occurred in only 12.5% of total hepatectomies versus 17%.
This technique seems to have many advantages. First, the left-to-right approach avoids caval twisting, reducing the transient hemodynamic instability generated by the rotation of the right liver around the vena cava.1 Moreover, the relative atrophy of the right liver, with a bigger caudate and left lobe that is often present in cirrhotic livers, makes caval dissection easier in a left-to-right way. An additional advantage is that the right liver is dissected at the end of the hepatectomy. In fact, patients with cirrhosis frequently have collateral vessels in the right ligament, which are a frequent site of bleeding during hepatectomy. In the case of tumors placed in the right liver, the benefit of less mobilization has already been described in the anterior approach and liver hanging maneuver for right hepatectomy.12 Here, similarly, there is also less chance of tumor dissemination by avoidance of right liver mobilization during PB hepatectomy when it is placed on the right side.
In summary, the technique described is a safe, simple, and feasible adjunct to the surgical armamentarium in LT. The potential benefits of left-to-right hepatectomy in the PB technique include maintenance of hemodynamic stability, reduction in operative blood loss during caval dissection, and right liver liberation during hepatectomy. For these reasons, we consider this approach as an attractive option in PB hepatectomy.
