Hepatic artery reconstruction technique in liver transplantation: experience with 3,000 cases.

Abstract

HepatoBiliary Surg Nutr 2021;10(2):281-283 | http://dx.doi.org/10.21037/hbsn-21-2 Hepatic artery reconstruction (HAR) is the most valuable step in correcting graft and recipient survival after liver transplantation (LT). Hepatic artery thrombosis (HAT) in immediate postoperative period may lead to fatal complications. Hepatic allograft is partial in a living donor liver transplantation (LDLT), and HAR is technically much more difficult than deceased donor liver transplantation (DDLT). The likelihood of HAT in LDLT is higher due to the narrower diameters of arterial vessels. Before the microsurgical HAR period, the incidence of HAT was as high as 14–25% (1). HAR using operative microscope (OM) was first applied by the Kyoto group, in order to reduce the HAT incidence after LDLT (2). HAT incidence after HAR with OM was reduced to 1.7% (2,3). However, it is necessary to be careful when using the literature data here. Because the 25% incidence of HAT before OM belongs to the study on pediatric LDLT in 1991 of Broelsch et al. (1). In this study, hepatic artery flow was provided with aortic conduit using the interposition saphenous vein in 80% of the patients with HAT. Increased experience in LDLT and using microsurgical instruments with surgical loupes at 6 or greater magnification yielded similar or better results in adult and pediatric LDLT than those achieved with OM (4-6). Even the Kyoto group, the inventor of HAR with OM, currently performs HA anastomosis with surgical loupe (7). Nevertheless, there is an ongoing debate that the hepatic artery anastomosis should be performed with the OM or surgical loupes. As a person who is used to both techniques, I would like to mention some of the disadvantages of OM: (I) Setting up OM, which has a fairly large volume, is a time-consuming process and prevents the fluency of the operative stages. (II) Due to the deep working area in HAR, it is not an easy task to focus the OM and use the surgeon s hands effectively. (III) Diaphragmatic movements and heart pulsation make the artery anastomosis difficult. These difficulties are better handled with surgical loupe. (IV) There is an extremely limited field view with OM. There is no chance to interfere with problems such as hemorrhage outside the field of view (7). (V) It is very difficult to expose the graft hepatic arteries on a left lateral used for small infants because of the very small abdominal cavity relative to the hepatic graft. This is true for all left hepatic grafts. In these cases, it is extremely difficult to take proper position with operative microscope and perform HAR. Therefore, we mostly perform HAR before portal vein anastomosis in left grafts as HAR is challenging after portal vein anastomosis. Portal vein anastomosis is performed after HAR and re-perfusion is provided from the portal vein first, and HA is opened within a few minutes when Viewpoint