Mobilization of the right lobe of the liver for right adrenalectomy

Exposure of the right adrenal gland can be a problem with a transabdominal approach because of the overlying liver. The usual method of handling the liver to gain access to the right adrenal gland is to retract the liver superiorly and laterally, but when the right adrenal gland or tumor within it is high lying, exposure may be inadequate. In this situation, mobilization of the right lobe of the liver will provide direct access to the right adrenal gland and vein.     

Intrahepatic rupture of a caudate lobe adenoma in liver adenomatosis

Hepatic adenomatosis is a rare benign disease that is more common in young and middle-aged women who are non-steroid dependent; it is usually symptomatic, progressive, and susceptible to hemorrhagic complications. Malignant transformation within adenomas is rare. The management of hepatic adenomatosis remains difficult due to the absence of predictive signs of complications, other than the size of the adenomas. Resective surgery is usually indicated, but liver transplantation could be an indication in highly symptomatic or progressive forms of the disease and represents the treatment of choice in cases of malignant transformation. We report a case of intrahepatic rupture of a caudate lobe adenoma which occurred in an adolescent with hepatic adenomatosis; we also present a brief review of the literature.     

Adult living donor liver transplantation using the right lobe

BACKGROUND: This article reviewed our experience with right lobe donor hepatectomy in living donor liver transplantations (LDLT), particularly in the context of preserving donor safety. MATERIALS AND METHODS: From January 2000 to August 2005, we performed 206 adult LDLT operations using the right lobe. The donor characteristics, operative findings, postoperative results including the peak values of liver enzymes (aspartate transferase [AST], alanine transferase [ALT], and bilirubin) and regeneration volumes, as evaluated by computed tomography volumetry, were reviewed at 1 week, as well as 3 and 6 months after surgery. The effects of three risk factors on donor safety were analyzed: age (<55 years, > or =55 years): fatty change in the donor liver (<10%, > or =10%); and remnant volume (<35%, > or =35%). RESULTS: The liver enzymes and regeneration volumes showed no significant difference according to age, only ALT was significant increased associated with the severity of fatty change (P < .05). There were significant differences in postoperative AST, ALT, and regeneration volume between the group with <35% and the group with > or =35% remnant liver volume (P < .05). Upon further analysis with combinations of two out of three risk factors, the group according to remnant volume and fatty change was meaningful. Follow-up data on donor ALT showed a return normal levels and after postoperative 3 months there was regeneration of the remnant liver to more than 70% of the whole liver preoperatively. There was no donor mortality, but postoperative complications were observed in 39 patients (39/206, 18.9%). Biliary complications were encountered in 24 patients: one bile duct injury, 22 bile leakages, and one bile duct stricture. Other complications consisted of pleural effusion (n = 8), delayed gastric emptying (n = 6), atelectasis (n = 1), and hepatic encephalopathy (n = 1). CONCLUSION: In cases of careful donor selection, a right lobectomy can be performed safely with minimal risks when the remnant liver volume exceeds 35% of the total liver volume and shows less than 10% fatty changes.     

Venous hemodynamics in living donor right lobe liver transplantation

We evaluated the influence of portal and hepatic venous hemodynamics on the immediate and 3-month postoperative function of living donor right lobe grafts. Portal velocity was measured prospectively by ultrasound in 14 consecutive donor/recipient pairs. Velocity was converted to flow with the Moriyasu formula. Measurements were taken in donors in the operating room and in recipients at 1 hour after reperfusion and 3 months after transplant. Recipient liver function tests were measured postoperatively. Prereperfusion and postreperfusion liver biopsies were evaluated and correlated with the hemodynamic and biochemical results. There were 11 male (78.6%) and 3 female donors (mean age, 38.9 ± 9.8 years) for 10 male (71.4%) and 4 female recipients (mean age, 49.3 ± 14 years). The mean graft/recipient weight ratio was 1.22 ± 0.3. The mean right portal vein pressure was 8 ± 1.8 mm Hg in donors versus 13 ± 4.7 mm Hg in recipients (P < .05). The mean peak flow velocity (Vmax) in the portal vein in donors was 47.6 ± 12.8 cm/sec (normal, 44 cm/sec). One hour after graft reperfusion in the recipient, the mean portal Vmax was significantly higher at 94.7 ± 28.4 cm/sec (P = .004), but by 3 months follow-up, mean portal Vmax had fallen to 58.8 ± 37.8 (P = .01). Recipient portal vein Vmax highly correlated with portal flow (r = 0.7, P = .01). Increased recipient total bilirubin on postoperative day 2 correlated highly with higher recipient portal flow one hour after transplant (r = 0.6; P = .03). Portal vein velocity/flow dramatically increases after reperfusion, returning to baseline about 3 months after transplant. Evaluation of hepatic and portal venous flow is a relatively easy skill to acquire. Intraoperative ultrasound may enable the surgeon to predict graft dysfunction and possibly, may be used to implement pre-emptive therapies. (Liver Transpl 2002;8:809-813.)     

Transplantation of the liver right lobe from a related donor

From 1997 to 2003 transplantation of liver's right lobe from alive related donor was performed in 64 patients (28 men, 36 women) aged from 6 to 61 years (mean age was 22.6 +/- 3.2 years). Body weight of recipients ranged from 18 to 92 Kg (52.7 +/- 2.8 Kg on average). Indications for surgery were following: cirrhosis of liver due to Wilson's disease (34), primary sclerotic cholangitis (6), viral cirrhosis of liver (6), primary biliary cirrhosis (4), Bayler's disease (3), Caroly's disease (3), Budd-Chiary syndrome (3), secondary biliary cirrhosis (2), cirrhosis of liver due to deficient of alpha(1)-antitrypsin (1), hepatocellular carcinoma (1), total nodular transformation of liver (1). Intensive care before transplantation was needed for 68.75% potential recipients. Donors of liver's right lobe were relatives of patients similar to blood group. Age of donors ranged from 18 to 49 years, mean age was 37.9 +/- 1.4 years. Donors underwent right-sided hemihepatectomy, there were no complications. Lethal outcome in recipients was seen in 2 (3.1%) cases and was not associated with function of transplant. Lethal outcome in long-term period after transplantation was seen in 4 (6.5%) cases. All the others patients survived and followed from 1 to 73 months (23.8 +/- 2.4 months on average). Quality of life was good. Transplantation of liver's right lobe from related donor is the independent line in orthotopic transplantation of liver and ensure reliable results.     

Factors influencing liver regeneration following living-donor liver transplantation of the right hepatic lobe

BACKGROUND: As a result of the shortage of cadaveric livers for adults, many institutes perform living-donor liver transplantation (LDLT) using right-lobe grafts. It is important to learn whether regeneration of the graft is compromised by division of middle hepatic vein (MHV) tributaries. Accordingly, we studied the effect on graft regeneration of transection of the MHV tributaries and other factors, including graft versus body weight ratio (GRBW). METHODS: Of 100 adult recipients having undergone right-lobe LDLT, 30 6-month survivors were studied. Liver regeneration was assessed by volumetry based on the computed tomography (CT). A regeneration index was defined as the ratio of the graft volume 6 months after LDLT to the preoperative value. The dominance of the MHV tributaries over the right hepatic vein in venous drainage of the anterior segment was evaluated by preoperative CT using a 5-point scale. RESULTS: The regeneration index of the posterior segment was significantly greater than that of the anterior segment (Wilcoxon signed rank test, P=0.01). The relatively poor regeneration of the anterior segment compared with the whole graft was associated with preoperatively dominant MHV tributaries (Spearman rank correlation: R=-0.44, P=0.01). The only significant determinant of the whole-graft regeneration, however, was GRBW (stepwise regression: Y=-0.80X+0.2, R(2)=0.70, P<0.0001). CONCLUSIONS: Despite deprivation of MHV tributaries, a graft will regenerate to meet the metabolic demand, and a smaller graft for the recipient is capable of regenerating to a greater extent.