jkstn The Journal of the Korean Society for Transplantation J Korean Soc Transplant 1598-1711 The Korean Society for Transplantation 10.4285/jkstn.2011.25.3.155 jkstn-25-155 Review Article Transplantation Techniques Unique in Pediatric Liver Transplantation YiNam-JoonM.D. LeeKwang-WoongM.D. SuhKyung-SukM.D. LeeKuhn UkM.D. KimSoo TaeM.D. Division of HBP Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea 09 2011 10 09 2011 25 3 155 164 Copyright © 2011 The Korean Society for Transplantation 2011 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract

In previous decades, pediatric liver transplantation has become a state-of-the-art operation with excellent success and limited mortality. Graft and patient survival have continued to improve as a result of proper selection criteria for both donors and recipients, improvement in medical, surgical and anesthetic management, organ availability, balanced immunosuppression, and early identification and treatment of postoperative complications. Most of all, refinements of the technique has directly related to good outcome. Therefore rapid establishment of surgical knowhow is mandatory. In pediatric liver transplantation, the utilization of split-liver grafts and grafts for living donors has provided more organs for pediatric patients and has had a significant impact on graft and patient survival. This has been one of the brilliant outcomes of surgical evolution. In addition, new surgical technique of minimal invasive live donor surgery has been recently widening the living donor liver transplantation for children. Although the recent outcome has been rapidly improved and the volume of living donor liver transplantation has been larger and larger in Korea, pediatric liver transplantation has been performed in a very limited large volume centers. Therefore, this review focuses on surgical technique in order to share the experiences and to improve the outcome of pediatric liver transplantation.

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Portal vein reconstruction. (A) Portal vein reconstruction without vein graft, (B) Portal vein reconstruction with vein conduit from donor. Reprinted from reference (7).

Living donor liver transplantation. (A) Left lateral sectionectomy in a live donor. There is usually no ischemia and congestion in the graft, but the left medial section and a part of caudate lobe become ischemic in the remnant liver of the donor. (B) Hepatic vein anastomosis and the position of the graft in transplantation of a left lateral section. Reprinted from reference (12,13). Abbreviations: LHV, left hepatic vein; LBD, left bile duct; LPV, left portal vein; MPV, main portal vein; PHA, proper hepatic artery.

Split liver transplantation of left lateral section and right trisection. (A) Classic split technique. The left graft composed of segment 2 and 3 includes the left hepatic vein, the left portal vein, the left hepatic artery from the common hepatic artery and the celiac triad, and the left hepatic duct. The right graft composed of segment 1 and 4∼8 includes the vena cava, the main portal vein, the right hepatic artery, and common bile duct. Reprinted from reference (3). Adapted split technique mimicking a graft from a live donor. The difference of the classical split liver graft is the arterial division level. Usually the left lateral graft includes only the left hepatic artery. Reprinted from reference (19). Abbreviations: BD, bile duct; CBD, common bile duct; PV, portal vein; LHV, left hepatic vein; LPV, left portal vein; S, segment.

Reduced left lateral section. (A) Monosegment (Segment 3). Reprinted from reference (22). (B) Hyperreduced left lateral section (LLS). Cutting lines to reduce a LLS; (1) the lateral part of the LLS is resected first while preserving the medial branches of the LHV.(2) Further resection of the caudal part is performed without ligation of any portal branches of the S3. (3) The additional resection of the dorsal part is carried out, while preserving portal branches of the S2. Reprinted from reference (20). Abbreviations: HV, hepatic vein; LHV, left hepatic vein; LPV, left portal vein; S, segment.

Laparoscopic left lateral sectionectomy in a live donor. (A) Port placement (n=port size, mm) for laparoscopic left lateral sectionectomy in a live donor. (B) Division of the left portal vein, hepatic artery, bile duct, and hepatic vein for harvest of a left lateral section. Reprinted from reference (26,27).

Use of a left lateral section graft to a recipient affected hepatic malignancy with replacement of the recipient's IVC using a cryopreserved iliac vein. Reprinted from reference (3).

Anastomosis between the left hepatic vein of the graft and the inferior vena cava of the recipient, performed with the triangulation technique. (A) Total clamp of the IVC for reconstruction of hepatic vein. The bridge between the ostia of the right, middle, and left hepatic veins is cut to obtain a single opening. (B) Enlargement of IVC opening. The opening is further enlarged by cutting the anterior face of the vena cava to obtain a wide triangular orifice. (C) Anastomosis of the left hepatic vein to the IVC. Reprinted from reference (3).

Microscopic technique of hepatic artery anastomosis. (A) Adventisectomoy of the end of the hepatic artery reducing thrombosis. ① Adventisectomoy of the end of the hepatic artery. ② Proper needling for hepatic artery anastomosis. (B) End-to-end anastomosis of hepatic artery. ① Carrel technique. ② Seidenberg technique. (C) Overcome size discrepancy of hepatic artery anastomosis. ① Fish mouth technique. ② Oblique technique. ③ Branch patch technique using the small right gastroepiploic artery of the recipient. Abbreviation: RGEA, right gastroepiploic artery. Reprinted from reference (31).

Auxiliary parital orthotopic liver transplantation. (A) Schematic figure of reconstruction. (B) Auxiliary liver transplantation of the left lateral section. Abbreviations: IVC, inferior vena cava; HV, hepatic vein; PV, portal vein.