Surgical Anatomy of the Left Lateral Segment as Applied to Living-Donor and Split-Liver Transplantation

Abstract

Although highly variable, the biliary and hepatic venous anatomy of the LLS can be broadly categorized into distinct patterns. The identification of the LLS duct origin lateral to the umbilical fissure in segment 4 in 50% of cast specimens is significant in the performance of split-liver and living-donor transplantation, because dissection of the graft pedicle at the level of the round ligament will result in separate ducts from segments 2 and 3 in most patients, with the further possibility of an anterior segment 4 duct. A connective tissue bile duct plate, which can be clinically identified, is described to guide dissection of the segment 2 and 3 biliary radicles.

Split-Liver Transplantation: A Review

“…The left hepatic vein is isolated and encircled with a vessel loop. Occasionally, the division of the middle and left hepatic veins will not be distinguishable or segments II and III will have independent orifices to the cava (41). A common middle and left hepatic vein requires separation after parenchyma division.…”

“…A common middle and left hepatic vein requires separation after parenchyma division. Recognition of independent segment II and III veins is critical to avoid inadvertent injury and requires that both orifices are incorporated on a common caval patch (41).…”

“…The left hepatic artery is encircled and dissection is continued along its entire length. Particular attention is devoted to the preservation of segment IV penetrating arteries (41,42) (Figure 4). If the segment IV branch arises high off the left hepatic artery and provides significant inflow, our practice is to anastomose the segment IV artery to the right trisegment graft's gastroduodenal remnant.…”

“…With vascular control of the left lateral segment achieved, parenchyma transection is initiated with electrocautery by scoring the liver surface approximately 1 cm to the right of the falciform ligament (41). The parenchyma is divided atic vein orifice to the vena cava is suture ligated, as are the smaller accessory hepatic veins along the inferior vena cava.…”

“…The common portal vein and common hepatic duct are maintained with the right graft while preserving the celiac axis with the left graft. The authors' preserve the celiac axis with the left graft to maximize arterial supply to segment IV, which is routinely derived from branches of the left and right hepatic arteries (37,41,44) (Figure 6). The left and middle hepatic veins are taken from the suprahepatic vena cava as a common cuff and the left bile duct is flushed with UW solution prior to cold storage ( Figure 7).…”