Ann Liver Transplant.  2021 May;1(1):58-70. 10.52604/alt.21.0006.

Tailored techniques of graft outflow vein reconstruction in pediatric liver transplantation at Asan Medical Center

• Hwang S
• Namgoong JM

• KMID: 2560853
• DOI: http://doi.org/10.52604/alt.21.0006

Abstract

Pediatric recipients are vulnerable to vascular complications because recipient vessels are small. Once graft outflow vein stenosis occurs, it is difficult to treat it effectively. To minimize the risk of hepatic vein outflow obstruction, it is necessary to perform individually designed reconstruction customized to each pediatric liver transplantation (LT) operation. We present our tailored surgical techniques for hepatic vein reconstruction in pediatric LT with the following five topics. 1) recipient hepatic vein unification venoplasty for implantation of left liver and left lateral section grafts; 2) graft hepatic vein venoplasty for left lateral section grafts; 3) graft hepatic vein venoplasty for left lateral section grafts with anomalous left hepatic vein anatomy; 4) graft hepatic vein unification venoplasty for left liver grafts; 5) inferior vena cava replacement during pediatric living donor liver transplantation; and 6) modified piggyback anastomosis of the graft inferior vena cava in infant-to-infant whole liver transplantation. There are three features in our techniques for graft hepatic vein reconstruction, including maximal usage of the recipient hepatic vein stumps, maximal widening of the graft outflow vein orifice through unification and patch venoplasty, and frequent use of vein homografts. In conclusion, secure graft outflow vein reconstruction is the most important step for successful pediatric LT. Thus, every effort should be done to minimize the risk of hepatic vein outflow obstruction. We strongly suggest that the diameter of graft hepatic vein anastomosis should be made as large as possible regardless of recipient age and body size.

Keyword

Hepatic vein stenosis; Hepatic vein outflow obstruction; Vascular insufficiency; Endovascular stenting; Left hepatic vein

Figure

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  Figure 1 Illustrations of unification venoplasty of the recipient hepatic veins to make their stumps thick and long. (A) The hepatic vein stumps are transected, leaving a bulk of the hepatic parenchyma. (B) The intervening septum between the left and middle hepatic vein openings is cut. (C) The intervening septum between the right and middle hepatic vein openings is transected. (D) Three hepatic vein openings are unified to make a wide single orifice.

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  Figure 2 Unification venoplasty of the recipient hepatic vein stumps. (A) The native liver of the recipient is completely dissected and the hepatic parenchyma is then incised with a surgical knife. (B) A bulk of the hepatic parenchyma is left around the hepatic vein stumps. (C) A longitudinal incision is applied at the hepatic parenchyma between the right and middle hepatic vein trunks, by which the attached parenchyma is separated. (D) The hepatic parenchyma is forcefully pulled out to detach from the hepatic vein stumps. (E) The septa between the right and middle hepatic veins and between the middle and left hepatic veins are incised. (F) The defect at the anterior wall between the right and middle hepatic vein stumps is repaired with continuous sutures. (G) The size of the unified hepatic vein orifice is twice larger than the diameter of the inferior vena cava. (H) The size of the unified hepatic vein orifice is well matched with that of the graft hepatic vein orifice.

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  Figure 3 Graft hepatic vein reconstruction in a patient with agenesis of the inferior vena cava (IVC). (A, B) There is agenesis of the retrohepatic IVC. (D) The portal vein is continued with the azygos vein (arrow). (C) The orifices of the three hepatic veins at the suprahepatic confluence are unified. (D) The suprahepatic confluence of the recipient hepatic veins is directly anastomosed with the graft hepatic vein.

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  Figure 4 Pathways to choose the hepatic vein venoplasty method for left lateral section grafts. LHV and sLHV indicate the orifices of the left hepatic vein and its superficial branch, respectively. Incision indicates an incision on the medial side of the left hepatic vein wall. Vein patches are applied to the semicircular area or to the full circumference.

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  Figure 5 Hepatic vein reconstruction of a left lateral section graft without patch venoplasty. (A) A small superficial left hepatic vein branch is located at the left end of the left hepatic vein stump. (B) This vein branch is incised to expose the lumen. (C) A septum between the two vein orifices is incised. (D) The two graft vein openings are unified with a continuous suture.

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  Figure 6 Hepatic vein reconstruction of a left lateral section graft with patch venoplasty. (A) A small superficial left hepatic vein branch is not recognized at a glance. (B) A very small branch is identified through a thorough examination and incised to expose the lumen. (C) The two vein openings are unified with a continuous suture. (D) A vein homograft patch is attached over the periphery of the incised superficial branch.

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  Figure 7 Hepatic vein reconstruction of a left lateral section graft with incision and circumferential patch venoplasty in a laparoscopically recovered graft. (A) A small superficial left hepatic vein branch is not recognized at a glance. (B) The medial wall of the left hepatic vein trunk is incised first. (C) A vein patch is attached at the medial half of the left hepatic vein opening. A very small superficial left hepatic vein branch is incidentally identified and incised. (D) A vein patch is attached at the lateral half of the opening, resulting in a completely circumferential patch.

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  Figure 8 Classification of the hepatic vein anatomy in the left lateral section based on the patterns of the left lateral section graft hepatic vein openings. Type 1 makes a single opening. Type 2 makes two widely spaced openings. Type 3 makes two large and small adjacent openings. Type 4 makes two widely spaced openings. Crossed circles indicate the location of the umbilical portion.

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  Figure 9 Interposition-wedged unification venoplasty to join the two anomalous hepatic vein openings. (A) Design of customized venoplasty techniques to unify a widely spaced segment III hepatic vein (V3) orifice to the left hepatic vein (LHV) trunk is illustrated. (B) A separate V3 orifice is located at the liver cut surface (arrow). A cryopreserved ilio-femoral vein allograft is prepared. (C) End-to-side anastomosis is performed to the V3 orifice. (D) The interposed vein is attached to the incised left hepatic vein trunk. Some interposed vein cuffs are preserved for later size matching to the recipient hepatic vein orifice.

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  Figure 10 Customized funneling venoplasty for an anomalous graft left hepatic vein opening. (A) Illustrations show the design of funneling venoplasty. Arrow indicates a slit incision. (B) The small left hepatic vein orifice is partially incised to increase the diameter and a vein patch is attached to make a funnel-shaped conduit. Arrow indicates a slit incision. (C) The hepatic vein openings at the recipient inferior vena cava and the graft are well matched in size.

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  Figure 11 Hemodynamically compliant techniques of wedged unification venoplasty commonly used for left liver grafts. (A) Some liver parenchyma between two hepatic vein orifices is excavated. If necessary, additional crossing septotomy (bidirectional arrow) can be performed to deepen this common channel portion. When two hepatic vein openings are separated by a substantial distance, the intervening parenchyma should be removed to facilitate approximation. An excavated portion such as this is simply repaired by central approximation tying and bidirectional suturing with a monofilament. (B) After graft regeneration/remodeling, the inferior vena cava (IVC) portion is expected to be compressed. Maintenance of the common channel within the hepatic parenchyma (arrows) is beneficial to preserve hepatic outflow into the IVC.

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  Figure 12 Patched unification venoplasty for two separate hepatic vein openings used in a laparoscopically recovered left liver graft. (A) There are two separate openings of the left hepatic vein (LHV) and middle hepatic vein (MHV). (B) The intervening hepatic parenchyma between these openings is excised through septotomy. (C, D) A unification septoplasty is performed. (E) An incision is made at the medial wall of the MHV trunk. (F) A vein homograft patch is attached, making the graft outflow vein orifice large enough.

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  Figure 13 Inferior vena cava (IVC) replacement with IVC homograft in a pediatric patient with hepatoblastoma. (A) The middle and left hepatic vein orifices of the left liver graft are unified. (B, C) An IVC homograft is anastomosed to the left liver graft. (D) The graft IVC is anastomosed to the recipient IVC stump.

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  Figure 14 Inferior vena cava (IVC) replacement with IVC homograft in an infant patient with hepatoblastoma. (A) The left hepatic vein orifice of the left lateral section graft is enlarged with patch venoplasty. (B) A common iliac vein homograft is attached to the graft to replace the retrohepatic IVC. (C, D) The supra- and infra-hepatic ends of the recipient IVC are anastomosed with the graft IVC conduit.

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  Figure 15 Modified piggyback anastomosis of a graft inferior vena cava (IVC). The matched IVC walls at the graft and recipient are incised with unification of the recipient hepatic vein orifices. Three corners of two inverted triangles are sutured for anchoring to adjust the suture lines (dotted bidirectional arrows).

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  Figure 16 Modified piggyback anastomosis of a graft inferior vena cava (IVC) in infant-to-infant whole liver transplantation. (A) The dorsal wall of the graft IVC is incised longitudinally close to the infra-hepatic stump of the graft IVC. (B) The anchoring suture starts at the apex of the inverted triangles. (C) The operation field for IVC anastomosis is very narrow in infant patients, thus the caudal apex of the anastomotic triangle should be sutured first, and then the side walls are gradually sutured toward the hepatic vein orifices. (D) More than three-fourth of the graft IVC are anastomosed in the side-to-side fashion.

Reference

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