Background : We will discuss the technical issue for right extended graft procurement with multiple drainage veins and suitable outflow reconstruction.

Methods : A 47-year-old man suffered from decompensated liver cirrhosis due to hepatitis B. He had esophageal varix bleeding event. His sister, 42-year-old woman volunteered for living liver donor. There were no abnormal findings on the preoperative examination. In CT imaging, portal vein and hepatic artery anatomy were normal, hepatic vein was complex vasculature. Right hepatic vein (RHV) drained segment 7 only, and there were 2 right inferior hepatic veins (RIHV) for S6 drainage. Middle hepatic vein (MHV) branch of segment 5 (V5) and segment 8 (V8) were present, segment 8 branch drained S5 territory. Segment 4a drainage vein (V4a) was separated. In volumetry, right lobe graft was 559g, graft-to-recipient weight ratio (GRWR) 0.83% and remnant left liver was 355g, 38.8% of whole liver volume. the patient MELD score was 8 point and there was no living donor except his sister. We decided living donor liver transplantation.

Results : We planned laparoscopic V4a-preserving right extended donor hepatectomy, and recipient’s splenectomy due to remnant left liver volume and GRWR. On bench work, V5, V8 and MHV were reconstructed using Dacron graft. Venoplasty was performed on RHV and MHV to create one orifice, reconstructed RHV-MHV was anastomosed to recipient RHV. 2 RIHV was also reconstructed for one orifice and anastomosed to inferior vena cava. The graft was no congested area after reperfusion. Donor had cut surface bile leak, it resolved without intervention. Recipient discharged uneventfully at postoperative day 20.

Conclusions : Right extended graft is sufficient for recipient’s metabolic demand; however, post-hepatectomy hepatic failure risk is high for donor. Thorough review of preoperative examination of donor and recipient and experienced transplant surgeons for liver resection and vascular reconstruction was essential for decision-making.