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Background: Driven by organ shortage, the liver transplant community has introduced liver bipartition to augment the number of
grafts for transplantation. However, split liver transplantation has not yet reached its full potential application and results not even in
the centers that do high volume splitting. This probably-in part-due to the high rates of complications associated with it. Based on the
knowledge gleaned from an intricate anatomical study I present two theoretical techniques for tri-partition of the deceased�??s liver that
might overcome the complications associated with ischemic or congested grafts and expand the deceased donor pool.
Materials & Methods: The techniques proposed here have been based on data obtained from the dissection of 18 normal fresh
livers of adult cadavers at the Centers for Surgical Anatomy and Technique, Emory University School of Medicine, Atlanta, Georgia,
USA. The livers were obtained from Emory�??s Body Donor Program after ensuring the adherence of the research project to ethical
guidelines. The livers were injected differentially with colored latex; dissection casts were prepared; and the intricate architecture at
the sheath ramifications�?? level was studied.
Proposed techniques: The liver might be split into three grafts by one of two ways. First, the liver parenchyma is transected
immediately right to the falciform ligament and the middle hepatic vein. The procured grafts will be composed of a left lateral
section; a left medial section-Caudate lobe�??s left part, and a right lobe. The left lateral section graft will be drained by the left hepatic
vein. Through inferior vena cava split and maintaining the middle hepatic vein with the left medial section-caudate lobe�??s left part
and the necessary reconstruction of its tributaries from segments 5 and 8 the other two grafts would be effectively drained. The left
lateral section is procured with the artery and the bile duct of the section and with a venous portal patch formed by the left half of
the umbilical part of the left portal branch that would be reconstructed. The celiac trunk, left portal vein branch and left hepatic
duct would be maintained with the medial segment- Caudate lobe�??s left part graft. The bile duct, right branch of the hepatic artery,
and main portal vein trunk would be maintained with the right lobe graft. Second, the liver parenchyma is split on the right sides
of the falciform ligament and middle hepatic vein to procure a graft composed of the inferior part of the left medial section (S4b)
and the major superficial fraction of its superior part (S4a). The left parenchymal incision starts superiorly inferior to the junction
of the left and middle hepatic veins. The right parenchymal incision starts superiorly distal to the middle hepatic vein�??s tributary
from segment 8. The superior parenchymal incision runs between the superior ends of the right and left parenchymal incisions and
is deepened, aiming at the hilar plate. This graft is drained by the middle hepatic vein transected below the confluence of its major
tributary from segment 8 and by the umbilical fissure�??s vein in case the latter is/more than 5 mm in diameter. The graft�??s artery is the
artery of segment 4 and its duct constantly begins at the corner formed by the umbilical and transverse portions of the left portal vein.
This segment 4 graft is procured with venous patch formed by the right half of the umbilical part of the left portal vein. The second
graft is composed of the left lateral section; caudate lobe�??s left part, and the deep part of S4a. The celiac axis and left hepatic duct are
maintained with the graft. The third graft is composed of the right lobe, the part of caudate lobe located deep to the inferior vena cava
and caudate process. The bile duct, right branch of the hepatic artery, and main portal vein trunk are maintained with the graft. The
inferior vena cava is split: The left aspect of the cava is maintained with the second graft; the anterior and right aspects of the cava are
maintained with the third.
Conclusion: Our anatomical results suggest that tri-partition into viable grafts might be feasible. The techniques are complex;
however, as the learning curve is mastered they would be gain able.
Biography
Ramadan El Gharbawy is Professor of Anatomy and Embryology, Faculty of Medicine, Beirut Arab University, Lebanon. Professor of Anatomy and Embryology
(en secondment), Faculty of Medicine, AlexandriaUniversity, Egypt. Consultant of General Surgery, Egypt. Ex-scholar at the Centers for Surgical Anatomy and
Technique, Emory University, USA
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