Introduction: Liver transplantation is a well-established treatment option for end-stage liver diseases. Pediatric patients present with unique characteristics, including the risk of developing large-for-size (LFSS) syndrome when the graft-to-recipient weight ratio (GRWR) is ≥4%. LFSS syndrome can increase postoperative risks in these patients. Anatomical reduction of the left lateral section (LLS) graft is one of possible ways to avoid LFSS in pediatric liver transplantation.
At our center, laparoscopic graft procurement has become a routine practice in living donor liver transplantation. Taking into consideration the aforementioned factors and our advanced experience in laparoscopic liver surgery, we have combined existing technologies and surgical techniques to perform laparoscopic living donor liver monosegment two procurement using Indocyanine green (ICG) navigation and the Glissonean approach.
Patients and methods: A 20-year-old mother volunteered to be a living donor for her son, who was diagnosed with liver cirrhosis due to biliary atresia. The donor underwent a thorough evaluation of health, which revealed no contraindications for living donation. MRI and CT scans were used to visualize the donor's vascular and biliary anatomy before surgery. The arterial supply of the liver was presented by an aberrant left hepatic artery (LHA) from the left gastric artery, and the right hepatic artery arose from the proper hepatic artery (Michels type II). The portal vein (PV) had a standard anatomy with a bifurcation into the right and left branches. The estimated volume of LLS graft was 426 cm3, with a GRWR of 5.9%. The estimated volume of the S2 segment was 206 cm3, with a GRWR of 2.86%.
Results: The donor's surgery was divided into two steps. The first step involved a standard laparoscopic left lateral sectionectomy, which included the isolation of LHA, dissection of the left PV, and transection of the parenchyma along the falciform ligament. Saline-coupled bipolar coagulation and ultrasound destruction with CUSA were used during the procedure. The second step involved an anatomical reduction of the LLS graft through S3 resection using the Glissonean approach. The S3 Glissonean pedicle was dissected, circled, and clamped with a bulldog clamp. ICG was intravenously injected at a dose of 0.05 mg/kg. Negative ICG staining clearly demarcated the boundary between S3 and the future graft remnant. A resection was performed within the demarcated area, and the Glissonean pedicle and S3 vein were cut between clips. The reduced graft was then procured using standard techniques, including sequential vessel clipping and cutting. The operation took 230 minutes with a blood loss of 50 ml. The donor was discharged without complications, and the recipient's postoperative course was uneventful.
Conclusion: Laparoscopic Living Donor Hepatectomy for S2 procurement with in situ splitting is a feasible and safe procedure in pediatric living donor liver transplantation.