Advantages of Extrahepatic Glissonean Approach in the Donor Operation in Living Donor Liver Transplantation

Introduction: To eliminate biliary complications in living donor hepatectomy, we introduced the extrahepatic glissonean approach combined with liver hanging maneuver (GA+LHM) since 2017. Method: Surgical procedures are as follows: Prior to liver transection, we encircle the extrahepatic Glissonean pedicle at the graft liver side with a tape. Then, we introduce a hanging tape from the encircled Glissonean pedicle to the groove between middle hepatic vein and right hepatic vein. Liver parenchymal transection is facilitated with the LHM. After the completion of transection, hepatic artery and portal vein of the graft liver are isolated in the hilum. The remaining structure is the hilar plate including the hepatic duct(s). After intraoperative cholangiography, bile duct, hepatic artery, portal vein, and hepatic vein are divided in this order and the graft liver is procured. We analyzed the short-term outcomes of the donor using Clavien–Dindo classification: For bile leakage, the International Study Group of Liver Surgery definition was used. Results: GA+LHM was successfully performed in a total of 44 consecutive living donor hepatectomy (right lobe graft in 28, left lobe graft in 15, and left trisegmental lobe +S1 graft in 1). There were no Grade Ⅲa≦ complications and bile leakage until discharge. Biliary stricture occurred in 1 (2%) patient who was readmitted and required endoscopic biliary stent placement. Conclusions: GA+LHM presumably prevents heat and mechanical injury of the bile ducts of the remnant liver by minimization of hilar dissection, thereby contributes to eliminating bile leakage in living donor hepatectomy.