Ultrasonically assisted retrohepatic dissection for a liver hanging maneuver

OBJECTIVE: To establish a safer and technically easier retrohepatic dissection for the liver hanging maneuver with the assistance of intraoperative ultrasound (IOUS). SUMMARY BACKGROUND DATA: The liver hanging maneuver described by Belghiti et al is an innovative suspending technique of the liver and is useful in difficult major right hepatectomies or in donor operations for living donor liver transplantation. The most important complication of this procedure is injury to the short hepatic veins and subsequent massive bleeding with an incidence of 4% to 6%. METHODS: After the cranial dissection of the suprahepatic inferior vena cava (IVC) between the middle and left hepatic veins, a long light curved Kelly clamp is inserted from the caudal edge behind the caudate lobe and passed cranially along the anterior midline of the IVC. On the midway of the dissection, the proper hepatic vein draining the caudate lobe (PrCV) is visualized. A safe dissection path is confirmed by IOUS, identifying the position of the clamp tip, PrCV, and the caudal end of the cranial retrohepatic dissection. When IOUS shows that the clamp tip has reached the caudal end of the cranial dissection, the operator can feel the clamp tip with his/her finger and the retrohepatic dissection is completed. RESULTS: From September 2003 to July 2004, 50 donor operations were performed for adult living donor liver transplantation. Retrohepatic dissection was feasible in 40 cases (80%). Of these, a US-assisted retrohepatic dissection was performed in 34 donors. PrCVs were visualized by IOUS in 48 donors (96%). The location of these PrCVs varied significantly (60 degrees -175 degrees from the right edge of IVC), and there were no distinct landmarks for identifying the location of PrCVs and safe dissecting course (55 degrees -130 degrees ). IOUS found that the dissecting clamp was heading to the PrCV in 3 cases and the direction of dissection was shifted to avoid injury. No substantial bleeding or no other complication related to retrohepatic dissection was encountered in any of the cases. CONCLUSIONS: With the aid of IOUS, the whole course of the blind dissection between the anterior surface of the IVC and the liver could be clearly visualized. IOUS could also identify the PrCV, the most dangerous point in the retrohepatic dissection.