High hilar dissection: New technique to reduce biliary complication in living donor liver transplantation

Abstract

Biliary complications after living donor liver transplantation (LDLT) continue to be problematic. For reducing the biliary complications, the authors applied an intrahepatic Glissonian approach to the recipient hepatectomy. We called this Glissonian dissection technique at the high hilar level high hilar dissection (HHD). In this study, we introduced this HHD technique and evaluated its outcome in 31 recipients of a living donor liver transplant (LDLT). With total occlusion of hepatoduodenal ligament Glissonia pedicles were divided at the intrahepatic level at the third level of pedicles or beyond. After portal vein and hepatic artery were isolated from the hepatoduodenal ligament, unused bile ducts and bleeding were controlled with continuous suture of the hilar plate. Single duct anastomosis was performed in about 21 and dual duct anastomosis in 10 recipients. Bile leakage of the biliary anastomosis did not occur. There were 6 biliary complications in five patients; 2 bile leaks from the cut liver surface and 4 biliary strictures of which one of unknown etiology. In none of the patients with biliary complications, conversion to a hepaticojejunostomy was necessary. This new HHD technique during recipient hepatectomy may contribute to reduce the biliary complications in duct-to-duct anastomosis by allowing a tension free anastomosis and preserving adequate blood supply to the bile duct. Moreover, it facilitates multiple ductal anastomoses without difficult surgical manipulation. (Liver

Biliary Complications After Liver Transplantation: Old Problems and New Challenges

“…Moreover, the blood supply of the donor as well as the recipient bile duct is critical. Many technical refinements of the donor (93)(94)(95) as well as the recipient operation (96)(97)(98) are aiming at an optimal blood supply of the anastomotic region. In general, during the donor operation the arterial branches to the right respectively left hepatic duct are preserved by sparse dissection of the hepatic artery and especially by avoidance of dissection between the hilar plate and the artery to minimize injury to the communicating artery and the peribiliary plexus (5).…”

Is Duct to Duct biliary Anastomosis the Rule in Orthotopic Liver Transplantation?

“…Hence, it is important to freshen the donor stump as short as possible to maintain adequate blood supply [6]. The high hilar dissection technique in the recipient hepatectomy ensures preservation of the blood supply [2,7,8].…”

“…The single right duct is identified in only 50 % of donors [8]. Some studies have indicated that multiple bile ducts in the graft are strongly correlated with a high risk of biliary complications [9].…”

Duct-to-Duct Biliary Reconstructions and Complications in 100 Living Donor Liver Transplantations

“…If there is inadequate bleeding, the bile duct must be shortened. Lee et al 14 introduced a useful technique to prepare the recipient bile duct: a high hilar dissection to provide sufficient length and blood supply of the recipient bile duct. We think this technique is useful especially when preparing a length of recipient bile duct or when multiple duct-to-duct anastomoses are necessary.…”