Functional venous anatomy for right‐lobe grafting and techniques to optimize outflow
Functional venous anatomy for right‐lobe grafting and techniques to optimize outflow
复制标题
右叶移植的功能性静脉解剖学和优化流出技术
作者：
A. Marcos;M. Orloff;L. Mieles;A. Olzinski;J. Renz;J. Sitzmann
右叶活体肝移植已成为尸体移植的替代方案。对右叶独特的解剖结构和行为的认识已经出现，并促成了技术上的修改。活体供体接受右叶切除术，包括保留重要的肝下静脉。沿接近肝中静脉（MHV）后三分之二右侧边界的平面分割肝实质，但向前偏离以包括带有移植物的MHV远端三分之一。第VIII段的大型静脉支流得以保留。接受者的吻合是通过完全腔静脉成形术完成的。在技术上可行的情况下，重建了重要的下静脉、MHV的支流和MHV的远端部分。以所述方式进行了48例右叶切除和移植。没有供体并发症归因于该技术。48名受者中有46名存活，46名存活患者中有44名具有原始移植物。仅3例患者重建了第VIII段和/或MHV远端部分的静脉支流。2例患者在术中发现流出道梗阻; 1例患者切除了腔静脉网，另1例患者需要对主要吻合口进行翻修。两个器官都没有丢失。无其他严重静脉并发症。腹水的发生率与全器官受者相同。这些实质横断和静脉重建的方法导致并发症发生率低。MHV与肝右静脉之间的广泛吻合和侧支通路似乎比重建来自第VIII段或远端MHV的支流更重要。
Right‐lobe living donor liver transplantation has emerged as an alternative to cadaveric transplantation. An appreciation of the unique anatomy and behavior of the right lobe has emerged and has precipitated technical modifications. Living donors underwent right lobectomy, including preservation of significant inferior hepatic veins. The parenchyma was divided following a plane approximating the right border of the posterior two thirds of the midhepatic vein (MHV), but deviating anteriorly to include the distal one third of the MHV with the graft. Large venous tributaries from segment VIII were preserved. Anastomosis in the recipient was accomplished by means of complete cavoplasty. Significant inferior veins, tributaries to the MHV, and the distal portion of the MHV were reconstructed when technically possible. Forty‐eight right‐lobe resections and transplantations were performed in the manner described. There were no donor complications attributable to the technique. Forty‐six of the 48 recipients are alive, and 44 of the 46 surviving patients have their original graft. Venous tributaries from segment VIII and/or the distal portion of the MHV were reconstructed in only 3 patients. Outflow obstruction was recognized intraoperatively in 2 patients; 1 patient had a caval web excised and the other patient required revision of the main anastomosis. Neither organ was lost. There were no other significant venous complications. The incidence of ascites was the same as that in recipients of whole organs. These methods of parenchymal transection and venous reconstruction resulted in a low rate of complications. The wide anastomosis and collateral pathways between the MHV and right hepatic vein seem to be more critical than reconstruction of tributaries from segment VIII or the distal MHV.