Living donor liver transplantation using a right liver graft with additional vein reconstructions for patient with situs inversus

Applications of hepatic round ligament/falciform ligament flap and graft in abdominal surgery-a review of their utility and efficacy

BACKGROUND AND PURPOSE

Despite their ubiquitous presence, easy availability and diverse possibilities, falciform ligament and hepatic round ligament have been used less frequently than their potential dictates. This article aims to comprehensively review the applications of hepatic round ligament/falciform ligament flap and graft in abdominal surgery and assess their utility and efficacy.

METHODS

Medical literature/indexing databases were searched, using internet search engines, for pertinent articles and analysed.

RESULTS

The studied flap and graft have found utility predominantly in the management of diaphragmatic hernias, gastro-oesophageal reflux disease, peptic perforations, biliary reconstruction, venous reconstruction, post-operative pancreatic fistula, post-pancreatectomy haemorrhage, hepatic cyst cavity obliteration, liver bleed, sternal dehiscence, splenectomy, reinforcement of aortic stump, feeding access, diagnostic/therapeutic access into portal system, composite tissue allo-transplant and ventriculo-peritoneal shunting where they have exhibited the desired efficacy.

CONCLUSIONS

Hepatic round ligament/falciform ligament flap and graft are versatile and have multifarious applications in abdominal surgery with some novel and unique uses in hepatopancreaticobiliary surgery including liver transplantation. Their evident efficacy needs wider adoption to realise their true potential.

Deceased donor liver transplantation in an adult recipient with situs inversus totalis: A case report of 10-year clinical sequences following primary and repeat transplantation

The feasibility of liver transplantation (LT) in adult patients with situs inversus (SI) was demonstrated with advances in surgical techniques. However, SI is very rare, and the experience of LT in adult patients with SI is very limited. We present a case of an adult patient with SI who underwent deceased-donor LT and late retransplantation because of chronic rejection. A 42-year-old man with SI totalis who suffered from acute-on-chronic hepatic failure because of hepatitis B virus-associated liver cirrhosis and alcoholic liver disease was referred to our center and underwent successful orthotopic deceased-donor whole-liver transplantation. We used a modified piggy-back technique with cavo-cavostomy and inserted a tissue expander for mechanical support of the unstably located liver graft. The patient recovered uneventfully. At 3 years after the first LT, this patient underwent retransplantation because of chronic rejection. In the second LT, we used similar surgical techniques, but performed splenectomy to make space to accommodate the second liver graft. The patient was discharged after long hospitalization. At 5 years after the second LT, he underwent living-donor kidney transplantation because of chronic renal failure developed after the second LT. Currently, he has done well for 10 years after the first LT. In conclusion, SI is a rare anomalous condition hindering LT. Careful perioperative planning with thorough assessment of the donor and recipient livers and use of patient-tailored surgical techniques can lead to successful LT.

Living donor liver transplantation in situs inversus totalis with a patient-specific three-dimensional printed liver model

We utilized patient-specific 3D liver models based on preoperative computed tomography images as intraoperative navigation and describe our experience. A 1-year and 10-month-old girl with situs inversus totalis underwent living donor liver transplantation for biliary atresia. Information on the hepatic artery, portal vein, inferior vena cava, and liver parenchyma was extracted and segmented from computed tomography images using liver analysis software. Laser lithography produced each 3D part of the liver from these data. The 3D models of each part of the liver were molded from polyurethane resin using different colors for each part and combined together, resulting in a patient-specific liver model. The industrial computed tomography scan of the patient-specific 3D liver model revealed that the gaps between the liver model and the original data were <0.4 mm in the 90% area, <0.8 mm in the 98% area, and 1.53 mm at the maximum. The 3D liver model was brought into the operative field and used as intraoperative navigation for total liver resection. The procedure was finished successfully without any major intraoperative complications. In conclusion, the 3D model facilitates the identification of vessels during operations; it is possible to promptly share patients' anatomy with the operative team.

Liver Transplantation in an Adult Recipient With Situs Inversus Totalis: Case Report and Review of the Literature

BACKGROUND

Over the past few decades, reports have demonstrated the feasibility of liver transplantation in adult patients with situs inversus. However, this disease entity remains rare and experience remains limited in adult recipients with situs inversus undergoing transplantation.

METHODS

A 23-year-old woman with situs inversus totalis and end-stage liver disease secondary to congenital biliary atresia was referred to our center and underwent a successful orthotopic liver transplantation.

RESULTS

We report our experience and review the literature. We performed a modified piggy-back technique with cavo-cavostomy. Using a triangulated wide orifice, the suprahepatic cava was anastomosed in an end-to-side fashion. The patient underwent an uneventful hospitalization and recovery.

CONCLUSION

Situs inversus remains a rare condition. Careful perioperative planning, thorough anatomic knowledge of both donor and recipient liver, and use of a variety of different novel techniques can lead to successful outcomes.

Immunohistochemical evaluation for outflow reconstruction using opened round ligament in living donor right posterior sector graft liver transplantation: A case report

Utilizing the opened round ligament as venous grafts during liver transplantation is useful but controversial, and there are no pathological analyses of this procedure. Herein, we describe the first reported case of a pathological analysis of an opened round ligament used as a venous patch graft in a living donor liver transplantation (LDLT). A 13-year-old female patient with biliary atresia underwent LDLT using a posterior segment graft from her mother. The graft had two hepatic veins (HVs), which included the right HV (RHV; 15 mm) and the inferior RHV (IRHV; 20 mm). The graft RHV and IRHV were formed into a single orifice using the donor’s opened round ligament (60 mm × 20 mm) as a patch graft during bench surgery; it was then anastomosed end-to-side with the recipient inferior vena cava. The recipient had no post-transplant complications involving the HVs, but she died of septic shock with persistent cholangitis and jaundice 86 d after LDLT. The HV anastomotic site had no stenosis or thrombus on autopsy. On pathology, there was adequate patency and continuity between the recipient’s HV and the donor’s opened round ligament. In addition, the stains for CD31 and CD34 on the inner membrane of the opened round ligament were positive. Hepatic venous reconstruction using the opened round ligament as a venous patch graft is effective in LDLT, as observed on pathology.

Living donor liver transplantation in an adult patient with situs inversus totalis

Situs inversus totalis (SIT) is a rare congenital anomaly, and liver transplantation (LT) in an adult SIT patient is extremely rare. Liver transplantation in a SIT patient is also technically challenging due to reversed anatomical structures. Here we present the case of an 18-year-old female with SIT in whom left lobe living donor LT was performed. The patient suffered from cirrhosis due to autoimmune hepatitis. The recipient and donor are doing well without complications 20 months after LT. Situs inversus totalis should not be considered a contraindication for LT. If possible, use of a living donor left lobe graft for LT is more feasible than a living donor right lobe graft. It is also technically easier than using deceased donor full-size liver graft in SIT patients who require liver transplantation.