“Rooftop and skeletonization technique” of hepatic transection to include or exclude the middle hepatic vein during donor hepatectomy in living donor liver transplantation: Solving the middle hepatic vein controversy-experience in 397 sequential live donors

Background: Right lobe living donor liver transplantation (LDLT) has become an important source of liver allografts in Asia due to insufficient deceased donation. However, right hepatectomy in healthy donors is often technically challenging due to the presence of hepatic venous variations and need for back-table reconstruction, as well as the controversy about inclusion of the middle hepatic vein (MHV) in right liver allografts. Several technical innovations to make the donor surgery safe have been described recently. We herein describe the novel ‘rooftop and skeletonization’ technique of hepatic transection during donor hepatectomy by exposing the roof of the MHV. Material/Methods: From January 2011 to December 2014, 397 donors underwent right hepatectomy during LDLT using this technique. The donor survey protocol and details of the technique are described in the article. All the donors in the study cohort were classified into 2 groups. Group A was right hepatectomy with the MHV inclusion in the graft. Group B was right hepatectomy without the MHV inclusion in the graft. Results: We harvested 225 right liver allografts with inclusion of the MHV. For the Group A donors, the mean right liver volume was 801.57±156.45 ml and it was 803.71±188.35 ml (63.76%) for the Group B donors. The average graft weight for Group A was 767.33±148.69 gm while for Group B it was 725.56±161.41 gm (p=0.301). Average intraoperative blood loss in donor hepatectomy was 456.25±219 ml (range, 150 to 900 ml) and 343.75±156 {range, 150to 650 ml. (p=0.42)} for Group A and B, respectively. Conclusions: Rooftop and skeletonization is a highly refined technique for donor hepatectomy, limiting the extent of donor hepatectomy even if the MHV is included in the graft.