The recipient hepatectomy usually represents the most difficult stage of the entire liver transplant procedure. It may not be possible to dissect the anatomy of the liver individually due to previous surgery, massive formation of varices, invasions of hepatocellular carcinoma.
We introduce several types of difficult recipient hepatectomy case.
1) Recipient hepatectomy for re-transplantation
2) No touch isolation technique for advanced malignant tumor
3) Recipient hepatectomy for prior treatment of trans-arterial radio embolization (TARE)
4) Bidirectional approach for extensive portal vein thrombectomy
Re-liver transplantation is considered to be a high-risk procedure because of the technical demands of the operation and the severity of illness in the recipient. The approach to the technical aspects of re-LT is different from that of primary LT because the anatomy is distorted. Vascularized adhesions are usually present. Because the recipients are immunosuppressed, tissue integrity is usually poor, especially in late, living-donor, and/or pediatric re-LT. Meticulous surgical technique should be used to avoid hollow organ injury, especially during initial exposure, dissection of the graft, and dissection of the allograft hilum.
No touch isolation technique is concept of preventing tumor spread during tumor operation. It is dangerous to mobilization and manipulation of tumors during recipient hepatectomy especially in cases of far advance hepatocellular carcinoma. Both inflow and outflow system should be isolated prior to recipient hepatectomy because tumor could be spread during that procedure.
Trans-arterial radio embolization (TARE) prior to liver transplantation was performed in the patients who had advance stage hepatocellular carcinoma. Sometimes totally necrosis of tumor was reported after operation. TARE is good modality for pre-transplant treatment for far advanced stage case of hepatocellular carcinoma as bridging and down-staging procedure.
Portal vein reconstruction is a major challenging in case with extensive portal venous thrombosis (PVT), because of the limited length of the graft portal vein from live donor and lack of readily available tissue for reconstruction. To overcome this critical surgical challenge, various techniques have been introduced to remove the thrombus, depending on the extent of PVT. Bidirectional approach could be feasible technique for in that case.