Technical progress in living donor liver transplantation for adults.

BACKGROUND: Liver transplantation from a living donor (LDLT) was introduced during the 1990 s to overcome the shortage of donor organs, particularly among children and in those countries in which cadaveric grafts were seldom available. In Japan alone, some 1700 LDLTs were performed in the first 12 years with a 5-year survival rate of 70% in adults and an even higher rate (82%) in children. The major limitation to successful LDLT is inadequate graft size, which usually necessitates the use of the whole right liver unless (I) the caudate lobe is included in a left liver graft, (2) only the right lateral sector is employed (segments VI and VII) or (3) left livers from two donors are implanted into one recipient. DISCUSSION: From a technical standpoint, the main problem with the various types of LDLT has been the venous reconstruction in the recipient. For the left-sided graft, the hepatic vein of the caudate lobe should be re-anastomosed to prevent congestion of this segment. For the right-sided graft, there has been uncertainty about the need to reconstruct the middle hepatic vein (MHV). Implantation is clearly simpler without this additional step, but there is a risk of dysfunction and sepsis in the right paramedian sector. Venous congestion in this sector can be observed during operation, both visually after clamping the MHV and by ultrasonographic assessment of the direction of blood flow in the portal vein. These techniques can be used to determine which patients require bench reconstruction of MHV tributaries or indeed of the inferior right hepatic vein. These manoeuvres should improve graft function and survival.