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Pure laparoscopic left lateral graft procurement with removing segment 3 employing Glissonean approach, indocyanine green fluorescence imaging and in situ splitting for a small infant
Akira Umemura, Hiroyuki Nitta, Takeshi Takahara, Yasushi Hasegawa, Hirokatsu Katagiri, Shoji Kanno, Daiki Takeda, Akira Sasaki
Department of Surgery, Iwate Medical University, Yahaba, Japan
| Date of Submission | 06-Sep-2021 |
| Date of Acceptance | 09-Jan-2022 |
| Date of Web Publication | 02-Jun-2022 |
Correspondence Address:
Akira Umemura,
Department of Surgery, Iwate Medical University, 2-1-1 Idaidori, Yahaba, 028-3695
Japan
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/jmas.jmas_290_21
We report on a pure laparoscopic left lateral graft procurement with removing segment 3 that employs the Glissonean approach, indocyanine green (ICG) fluorescence imaging and in situ splitting. We first mobilised the liver and confirmed the root of the left hepatic vein (LHV). We then encircled the left Glissonean pedicle, and the segment 3 Glissonean pedicle (G3) was also individually encircled. We performed parenchymal transection of the left lateral segmentectomy using Pringle's manoeuvre. We clipped G3 and confirmed the demarcation line using ICG fluorescence imaging. The inflow in the S2 area was confirmed via intraoperative sonography, and we split segment 3 (S3) from the left lateral sector graft in situ. The left hepatic artery, left portal vein and left hepatic duct were also encircled and divided. The LHV was transected using a linear stapler, and the S2 monosegment liver graft and removed S3 were procured. Our technique reasonably prevents graft-related complications.
Keywords: Indocyanine green fluorescence imaging, laparoscopic donor hepatectomy, laparoscopic liver resection, living donor liver transplantation, monosegment liver graft
How to cite this URL:
Umemura A, Nitta H, Takahara T, Hasegawa Y, Katagiri H, Kanno S, Takeda D, Sasaki A. Pure laparoscopic left lateral graft procurement with removing segment 3 employing Glissonean approach, indocyanine green fluorescence imaging and in situ splitting for a small infant. J Min Access Surg [Epub ahead of print] [cited 2022 Jul 3]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=346495 |
| ¤ Introduction | |  |
Left lateral sector graft (LLSG) is usually used in paediatric living donor liver transplantation (LDLT) because LLSG has few anatomical anomalies, and the graft volume (GV) is suitable for pre-school children.[1] However, there are several major concomitant problems with LDLT for neonates and very small infants as LLSG may induce large-for-size graft syndrome due to a too high GV, with the consequent insufficient flow and compression by the abdominal cavity leading to graft failure.[2] The segment 2 (S2) monosegment graft is established as a feasible and strong alternative that surmounts these problems.[2]
Currently, laparoscopic liver resection (LLR) has progressed rapidly, and graft procurement via LLR has been performed at high-volume surgical centres. We have previously reported on the standardisation of pure laparoscopic LLSG procurement.[3] Subsequently, we encountered a small infant with congenital biliary atresia (CBA) who required LDLT for rescue. Thus, we elaborately simulated and performed LDLT and pure laparoscopic left lateral graft procurement with removing segment 3 on the donor. We herein report on a pure laparoscopic left lateral graft procurement with removing segment 3 that employs the Glissonean approach, indocyanine green (ICG) fluorescence imaging and in situ splitting.
| ¤ Modification | | |
Kasai procedure due to CBA. However, jaundice did not improve after surgery, and she was referred to Iwate Medical University Hospital for LDLT. The pediatric end-stage liver disease score was 20, and consequently, immediate setting of LDLT was considered as better. A 24-year-old-the recipient's mother - stood as a donor candidate. Dynamic-enhanced computed tomography (CT) and a drip infusion CT cholangiogram revealed no anatomical anomaly in the donor. We then evaluated the GV of the entire LLSG and the S2 monosegment graft [Figure 1]a and [Figure 1]b, and finally, the S2 monosegment graft was selected to be procured for the donor's daughter. | Figure 1: (a) Computed tomography volumetry reveals that S2, and S3 are 141 mL, and 83 mL, respectively, (b) Pre-operative simulation reveals positional relationships of the vessels in S2 monosegment liver graft
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The donor is placed in a supine position under general anaesthesia, and we begin operation using the five-trocar technique. We usually employ intra-operative monitoring of central venous pressure, airway pressure, and direct arterial pressure to control intra-operative bleeding during laparoscopic donor hepatectomy. Intra-operative pneumoperitoneum pressure is also set to 10–12 mmHg to control bleeding from the hepatic veins. We routinely perform a liver biopsy before commencing procurement and confirm that there are no obvious findings that make the donor liver unsuitable for liver graft. We transect the falciform ligament and the left triangular ligament and confirm the root of the left hepatic vein (LHV) [Figure 2]a. Then, we open the omental bursa and transect the Arantius' duct near the root of the LHV [Figure 2]b. After mobilisation of the LLSG, we encircle the left Glissonean pedicle from the hepatic hilus to the ventral side of the Arantius plate [Figure 2]c, and the segment 3 Glissonean pedicle (G3) is also individually encircled [Figure 2]d. We temporally clamp G3 and confirm the demarcation line between S2 and segment 3 (S3) using both normal view and ICG fluorescence imaging [Figure 2]e and [Figure 2]f. Then, we perform parenchymal transection of the LLS using Pringle's manoeuvre, with the root of the LHV fully visualised [Figure 2]g. | Figure 2: (a) The root of the left hepatic vein (LHV) is visualised after mobilisation of the left lateral sector (LLS), (b) The Arantius' duct is transected near the root of LHV, (c) The left Glissonean pedicle is encircled by our original forceps, (d) The G3 is also encircled beyond the Laennec's capsule, (e) We confirm the demarcation line between S2 and S3 in normal view, (f) Indocyanine green imaging reveals a clear demarcation line between S2 and S3, (g) The root of LHV is totally visualised after parenchymal transection of LLS, (h) We perform in situ S3 removal, and V3 is clipped and divided, (i) The left hepatic artery (red tape), portal vein (blue tape) and hepatic duct (green tape) were individually encircled, (j) The LHV is transected by a linear stapler after in-flow interception of the liver graft
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We clip G3 and repeatedly confirm the demarcation line and the inflow in the S2 area via intra-operative sonography, and then, we split S3 from the LLS in situ - as per typical LLR [Figure 2]h. At the hepatic hilus, the left hepatic artery and portal vein are individually encircled. The left hepatic duct is also encircled [Figure 2]i, and we confirm the cutting line of the left hepatic duct using ICG fluorescence imaging. We clip and transect the corresponding hepatic artery, portal vein and hepatic duct. The LHV is transected with a linear stapler [Figure 2]j. Finally, the S2 monosegment liver graft and removed S3 are placed in a plastic bag and procured from the extended intra-umbilical incision. Our surgical procedure is summarised in a supplemental video clip [Supplemental Video 1].
The operative time and blood loss of the donor were 332 min and 34 mL, respectively. The donor recovered without any post-operative complications and was discharged on the post-operative day 13. The operation on the recipient was also uneventful, the recipient was discharged on the post-operative day 31 [Figure 3]a and [Figure 3]b. | Figure 3: (a) The picture shows the functioning S2 monosegment liver graft after reconstruction, (b) A computed tomography scan shows the patent flow of all intrahepatic vessels on post-operative day 7. Intrahepatic artery is indicated by a red arrow, and the left hepatic vein is also indicated by a blue arrow
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| ¤ Benefits | | |
A major challenge in paediatric LDLT for neonates and extremely small infants with liver failure is the lack of size-matched donor organs. Transplant surgeons try to surmount this problem by using a monosegment liver graft. There have been some reports of the feasibility and good graft survival of monosegment liver grafts.[2] However, the surgical procedure for monosegment liver graft procurement is technically demanding, and only three cases employing the laparoscopic technique have been reported - including our case [Supplementary Table 1].[4],[5] All three cases were performed using ICG fluorescence imaging and the in situ splitting technique, but the Glissonean approach was not utilised in the prior two cases. The Glissonean approach in major LLR has been discussed repeatedly. Laennec's capsule is the border between the hepatic parenchyma and the hilar plate; consequently, the typical Glissonean approach is performed at the layer of Laennec's capsule. However, during LDLT, we purposely dissect beyond Laennec's capsule to hang the Glissonean pedicles to avoid biliary tract injury.[3]
We believe that our technique has several advantages in reducing graft-associated post-operative complications. The first is that we can easily confirm the demarcation line and the anatomical variation of intrahepatic bile ducts via ICG fluorescence imaging, and thus, we can avoid misidentification of the perfusion area and anatomical anomaly of the intrahepatic bile duct. The second is that our technique reduces the cold ischaemic time between procurement and put in, as employing in situ splitting makes ex-situ graft trimming unnecessary. In addition, blood flow in the liver graft is maintained just before procurement. Finally, this technique is a replication of the open technique; therefore, both transplant surgeons and minimally invasive surgeons can easily imagine and introduce this technique.
In conclusion, pure laparoscopic left lateral graft procurement with removing segment 3 employing the Glissonean approach, ICG fluorescence imaging and in situ splitting is demonstrated to be feasible in our presentation.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| ¤ References | | |
| 1. | Kasahara M, Umeshita K, Eguchi S, Eguchi H, Sakamoto S, Fukuda A, et al. Outcomes of pediatric liver transplantation in Japan: A report from the registry of the Japanese Liver Transplantation Society (JLTS). Transplantation 2021;105:2587-95.  |
| 2. | Sakuma Y, Sasanuma H, Miki A, Shimizu A, Sata N, Yasuda Y, et al. Living-donor liver transplantation using segment 2 monosegment graft: A single-center experience. Transplant Proc 2016;48:1110-4. |
| 3. | Umemura A, Nitta H, Takahara T, Hasegawa Y, Katagiri H, Kanno S, et al. Pure laparoscopic living donor left lateral sectionectomy using glissonean approach and original bridging technique. Surg Laparosc Endosc Percutan Tech 2021;31:389-92. |
| 4. | Hong SK, Suh KS, Kim HS, Yoon KC, Ahn SW, Kim H, et al. Pediatric living donor liver transplantation using a monosegment procured by pure 3D laparoscopic left lateral sectionectomy and in situ reduction. J Gastrointest Surg 2018;22:1135-6. |
| 5. | Li H, Zhu Z, Wei L, Tan Y, Zeng Z, Qu W, et al. Laparoscopic left lateral monosegmentectomy in pediatric living donor liver transplantation using real-time ICG fluorescence in situ reduction. J Gastrointest Surg 2020;24:2185-6. |
[Figure 1], [Figure 2], [Figure 3]
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