Deep left hilar pedicle isolation technique with in situ umbilical portion dissection for recipient hepatectomy in adult living donor liver transplantation.

Abstract

To overcome technical challenges in vascular reconstruction during adult living donor liver transplantation, we routinely dissect the umbilical portion of the portal vein in situ, enabling extensive dissection of the left and middle hepatic arteries. The umbilical portion with the round ligament can also be used as an autologous graft for venous reconstruction. Herein, we present our surgical technique and assess its clinical impact, which has not been systematically evaluated. Adult recipients who underwent living donor liver transplantation at our institution from 2018 to 2024 were retrospectively reviewed. Vascular and biliary complications, autologous graft patency compared with cryopreserved homograft, and their association with this surgical technique were analyzed. Of 322 living donor liver transplantation recipients, this isolation technique was applied to 232 patients (72.0%). The incidence of hepatic arterial thrombosis was 1.9% in the overall cohort and 0.4% in patients who underwent this isolation technique. In multivariable analysis, this surgical technique was independently associated with a reduced risk of hepatic arterial thrombosis (odds ratio, 0.13; 95% confidence interval, 0.006-0.96; P = .045). The patency of reconstructed veins using the autologous graft was comparable to that of cryopreserved homografts. Our surgical technique facilitates meticulous reconstruction of multiple hepatic arteries, is associated with a low incidence of hepatic arterial thrombosis, and provides the umbilical portion as a useful autologous graft for venoplasty. This practical and reproducible strategy may contribute to improved outcomes in adult living donor liver transplantation.