Introduction : During living donor liver transplantation (LDLT) using a modified right lobe graft, conjoined reconstruction of the right hepatic vein (RHV) and middle hepatic vein (MHV) interposition conduit has been often used to avoid separate reconstruction of the MHV conduit, especially following laparoscopic donor hepatectomy revealing short RHV and weak MHV stumps. We developed technical tips to facilitate RHV-MHV conjoined reconstruction.

Methods : We analyzed intraoperative photographs and posttransplant follow-up computed tomography (CT) images in adult LDLT recipients who underwent conventional RHV-MHV conjoined reconstruction (n=10). Thereafter we modified the surgical techniques and applied to the clinical practice (n=10).

Results : During conventional RHV-MHV conjoined reconstruction, secure anterior wall suturing was often difficult due to small or weak interposition vein conduit. One-week CT analysis revealed that rash suturing with the inferior vena cava (IVC) wall led to anastomotic stenosis of the conduit, especially when a smaller conduit was used. Our solution to solve these two weak points was attachment of vein patch at the conduit stump. Our usual technique for RHV reconstruction includes application of the vein patch at the incised RHV-IVC angle, thus we made the vein patch cover the whole anterior wall of the conjoined RHV-MHV stump. After its application in 10 cases, suturing became technically easier and stenosis of the MHV was prevented. Follow-up CT imaging analysis confirmed its beneficial effect on luminal patency.

Conclusions : Our simple modification facilitated the outcome of conjoined RHV-MHV stump. Its beneficial effect was evident especially in laparoscopically harvested right lobe graft with very short RHV-MHV stumps.