A Preliminary Report on Heterotopic Segmental Living-Related and/or Split-Liver Cadaveric Transplantation M. Haberal, G. Moray, N. Bı˙lgı˙n, H. Karakayali, G. Arslan, S. Boyacioglu, C. Baysal, and Z. Kayhan P OSTNECROTIC cirrhosis is the major etiologic factor in end-stage liver disease in Turkey, and most liver recipients are adults. Scarcity of cadaveric donor organs remains a serious problem in our country, as in other parts of the world. Turkey’s first orthotopic liver transplantation was performed by our team in 1988. Since then we have taken a number of important steps with the aim of offering liver transplantation to more patients in need. We per- formed the first pediatric living-related segmental liver transplantation (LRSLT) in March 1990 and the first adult LRSLT in April 1990. Still, these efforts have not positively impacted the donor situation. Acquiring a size-matched graft for every recipient in orthotopic LRSLT is a difficult task. As a consequence of these issues and based on experimental studies using a canine model (eight experi- mental heterotopic segmental liver transplantations), we set up our clinical heterotopic segmental liver transplantation (HSLT) program to carry out living segmental or split-liver cadaveric transplantations. In this study, we present a new HSLT technique in detail and evaluate our eight cases to date. MATERIALS AND METHODS We performed eight HSLT in five male and three female patients (mean age 29.5  12.3 years; range 16 to 50 years). The etiologic factors involved were postnecrotic cirrhosis in four recipients, Budd-Chiari syndrome in one, cryptogenic cirrhosis in one, Wil- son’s disease in one, and fulminant hepatic failure in one recipient. Although the preoperative clinical diagnosis was Wilson’s disease in the latter individual, an intraoperative liver biopsy confirmed diffuse hepatic lymphoma. Technique for Living-Donor Segmental Liver Transplantation Three recipients (one male and two females) received grafts from living-related donors. Donor candidates first underwent blood group identification, HLA tissue typing, and crossmatch. Liver function assessment, hepatic arteriography, magnetic resonance imaging, and volumetric assessment of the hepatic lobes by com- puted tomography were then routinely done. The left hepatic artery was considered suitable for anastomosis if it was greater than 2 mm in diameter, as described previously. 1,2 Briefly, in the donor operation, the left hepatic artery, portal vein, and left bile duct were sequentially isolated following expo- sure of the left hepatic vein. Parenchymal splitting was then carried out, primarily using an ultrasonic dissector. The portal vein was initially perfused with lactated Ringer’s solution; then we flushed with University of Wisconsin (UW) solution via the portal vein, hepatic artery, and biliary tract. In the most recent patient oper- ated, a saphenous vein graft was also prepared at the beginning of the operation. At the back table, a 10-mm diameter PTFE graft was connected to the left portal vein and a 4-mm PTFE graft, or the saphenous vein of the recipient, was connected to the left hepatic artery to give sufficient vessel length. The recipients underwent preparation of the subhepatic space that involved the superior mesenteric vein, inferior vena cava, and the common iliac artery or aorta by kocherization of the duodenum and mobilization of the hepatic flexure, ascending colon, and cecum. During this preparation, no dissection was carried out on the native liver. The left graft liver lobe was placed in the subhepatic space in a “left-side right” position whereby the left corner of the graft liver was turned to the right, with the left side of the liver lobe oriented medially in its natural position and the graft liver lobe oriented laterally. Then end-to-side hepatic vein to inferior vena cava approximately 2 cm below the right renal vein, portal vein to superior mesenteric vein (via 10-mm PTFE graft), and left hepatic artery to aorta or common iliac artery (via saphenous vein graft or 4-mm PTFE graft) anastomoses were performed using the “four-quadrant running suture technique”. 3 A retrocolic Roux-en-Y hepatico-jejunostomy was carried out using a temporary stent that was drawn before the anastomosis was ended. Technique for Split-Liver Cadaveric Transplantation Five recipients (three males and two females) received split-liver cadaveric grafts from a 16-year-old female and 11- and 53-year-old male cadavers. The common and external iliac artery and vein grafts were harvested from the cadaver along with the other solid organs. Once the graft liver was harvested and perfused with UW solution, the splitting procedure was performed at the back table. The graft liver was split from a line approximately 2 cm medial to the left-right lobe division. The middle hepatic vein was divided far from the point of connection with the left hepatic vein to obtain adequate size for anastomosis. The celiac trunk, portal and supe- rior mesenteric veins, choledoch, and the supra- and the infrahe- patic inferior vena cava were left on the right lobe graft. The left graft liver lobe included with it only the left hepatic artery, left From the Baskent University, Faculty of Medicine, Ankara, Turkey. Address reprint requests to Mehmet Haberal, MD, FACS, Baskent University Faculty of Medicine, 1. Cadde No: 77 Kat: 4, Bahcelievler 06490, Ankara, Turkey. © 1999 by Elsevier Science Inc. 0041-1345/99/$–see front matter 655 Avenue of the Americas, New York, NY 10010 PII S0041-1345(99)00767-8 Transplantation Proceedings, 31, 2899–2901 (1999) 2899