Procurement of the Left Hemiliver

This technique allows the harvesting of two grafts of similar size and is indicated when two adults or two large children are to be transplanted $. The procedure may be considered an anatomic right hemihepatectomy.
Sectioning of the liver $ is made along a plane directed from the right border of the gallbladder fossa, to the division of the portal vein and to the right margin of the median hepatic vein :. The choice of this plane, which is shifted to the left from the conventional midplane of the liver (Cantlie line), may improve venous outflow from the both sides of parenchyma, especially the right one which depends only on the right hepatic vein. This plane divides the left hemiliver, including segments I to IV, from the right hemiliver, composed by the segments V to VIII :. 
The left graft includes the vena cava with the left and median hepatic vein, the left branch of the portal vein along with the vena porta up to the origin of the mesenteric and splenic veins, and the left branch of the hepatic artery along with the common hepatic artery and the celiac tripod. On the other side, the right graft includes the right hepatic vein with a patch of vena cava and the right branch of the hepatic artery. 

The procedure step by step
The donor is placed in a supine position with both arm extended. Monitoring should include a central venous line and an arterial line. Lines for rapid infusion are advisable as far as the section of the parenchyma in this procedure may cause significant bleeding.
The chest and the abdomen of the donor are entered by means of a median incision from the sternal notch to the pubis.
Once the presence of undetected malignancies is excluded, the caecum, the ascending colon with the hepatic flexure and the whole small bowel are mobilized to allow exposure of the retroperitoneum.  The anterior surface of the aorta is exposed and the inferior mesenteric artery is ligated and divided. The aorta is isolated $ at the level of its bifurcation and of the diaphragm and is encircled with bands. This allows the procedure to be converted to a standard rapid operation in case of instability of the donor.
The intestines are replaced in the abdomen and the round ligament is divided between sutures. The falciform ligament is incised by cautery up the sovrahepatic vena cava. The confluence of the hepatic veins is widely exposed.
The hepato-duodeno-gastric ligament is opened at the level of the common bile duct, and the cystic duct and artery are divided between sutures and the gallbladder is removed.
The common hepatic artery is identified and dissected : from the origin of the gastro-duodenal artery up to its division in right and left hepatic arteries. Once that these two branches are clearly identified, the right hepatic artery is encircled with a vessel loop :. 
The lateral and posterior margin of the hepato-duodenal ligament is carefully palpated and dissected to detect an accessory right hepatic artery originating from the mesenteric artery which must be preserved.
The common hepatic duct is traced to the point of penetration into the parenchyma :. A thick layer of fibrous tissue is evident at the junction of the right and left hepatic ducts. The dissection of the confluence of the hepatic duct should be performed from outside this fibrous tissue in which the ducts are embedded, encircling the left duct along with the fibrous tissue passing a right-angle clamp into the parenchyma :. Previous dissection of the hepatic arteries and of the portal vein :, which divide medially and behind the hepatic duct, usually facilitate the dissection of the left hepatic duct, which should be encircled with a vessel loop :. Approaching the left duct medially and from behind usually facilitates the passage of the instrument.
With the hepatic duct and arteries dissected and gently rotated medially and upwards, the portal vein can be dissected up to its bifurcation. The right portal branch is encircled with a vessel loop :. Approaching the bifurcation anteriorly  with a right-angle clamp facilitates this step.
To expose the vena cava below the liver and facilitate the section of parenchyma, the small bridge of hepatic tissue coming from the caudate lobe towards the right hemiliver below the right branch of the portal vein should be divided.
The right hemiliver is now pulled upwards and medially and the right triangular ligament is completely divided by cauterization to expose the vena cava and the right side of the right hepatic vein. Cranially and posteriorly, the vena cava may be encircled by a fibrous layer bridging the left and right hemilivers, the ligamentum venae cavae, which must be pulled up with a right-angle clamp and divided by cauterization. Sometimes instead of the ligamentum vena cava, a bridge of parenchyma encircling the vena cava can be found. In this case the bridge of parenchyma must be encircled with a Satinsky clamp, sectioned by cauterization and oversewn with a 3-0 monofilament running suture. This allows to expose the plane between the anterior wall of the vena cava and the posterior wall of the right hemiliver. All the short hepatic veins  from the right hemiliver draining into the vena cava must be identified and suture-ligated. When a major inferior right hepatic vein is present, this should be temporarily closed with a metal clip on the hepatic side and with a Satinsky clamp on the vena cava :. This allows to detach the vein with a cuff of the vena cava, and to perform and additional anastomosis on the recipient vena cava. In this case the donor vena cava must be repaired with a 5-0 monofilament running suture. 
Once the posterior wall of the right hemiliver is completely free from the vena cava, the posterior and lateral side of the right hepatic vein can be exposed and the fissure between the vein and vena cava gently dissected. A right-angle blunt clamp can be gently inserted from above between the median and right hepatic vein, encircling this vessel with a cotton tape : :.
With the liver placed in its normal position, the left hepatic duct along with the fibrous tissue encircled with the vessel loop is now sharply divided with a scalpel :.
The plane of section of parenchyma is now marked on the liver by cauterization from the right border of the gallbladder fossa, to the division of the portal vein and to the lateral margin of the median hepatic vein on the dome of the liver :.
The cotton tape encircling the right hepatic vein is passed between the median and right hepatic veins on the posterior surface of the liver and between the bifurcation of the vena porta. Pulling up on this tape is helpful in maintaining the dissection of the parenchyma on the correct plane : :. 
The section of the parenchyma can now be performed with the ultrasound dissector. This is a long and demanding dissection in which severe bleeding may occur. Control of hemorrhage from several large vessels must be achieved by  4-0 monofilament stitches.
Once the section of the parenchyma is completed, hemostasis is verified.
At this point the procedure continues as a standard donor operation with i.v. administration of Heparin (300 UI/Kg), incannulation and cross-clamp of the aorta, perfusion with preservation solution, venting of vena cava, and cooling of the abdominal cavity with ice-cold solution.
The right hepatic vein is sectioned with a patch of vena cava. The right portal vein is sectioned just after its origin, preserving all the veins from the caudate lobe. Even the right hepatic artery is sectioned close to its origin and the right graft is removed.
The left graft is removed along with the vena cava, the hepatic artery dissected up to the celiac trunk along with an aortic cuff, and the left branch of the portal vein along with the portal vein dissected up to the origin of the mesenteric and splenic veins.
The grafts are placed in plastic bags at 4°C, and flushed through the portal veins with UW solution.