Journal of Medical Evidence

: 2020  |  Volume : 1  |  Issue : 1  |  Page : 54--60

How to do it: Living donor liver transplantation

Puneet Dhar1, Abhishek Agrawal1, Sudhindran Surendran2, Unnikrishnan Gopalakrishnan2, Samiran Nundy3,  
1 Department of Surgical Gastroenterology, AIIMS, Rishikesh, Uttarakhand, India
2 Department of Solid Organ Transplant Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
3 President, AIIMS, Rishikesh, Uttarakhand, India

Correspondence Address:
Prof. Puneet Dhar
Department of Surgical Gastroenterology, AIIMS, Rishikesh - 249 203, Uttarakhand


Use of living donor has expanded the pool of potential transplant recipients. We have outlined here the indications, contraindications, donor workup and surgical technique of modified right liver graft retrieval, recipient hepatectomy, benching and recipient implantation in brief.

How to cite this article:
Dhar P, Agrawal A, Surendran S, Gopalakrishnan U, Nundy S. How to do it: Living donor liver transplantation.J Med Evid 2020;1:54-60

How to cite this URL:
Dhar P, Agrawal A, Surendran S, Gopalakrishnan U, Nundy S. How to do it: Living donor liver transplantation. J Med Evid [serial online] 2020 [cited 2020 Sep 26 ];1:54-60
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Living donor liver transplantation (LDLT for end-stage liver disease) has been more popular in Asia than in Western countries for the last 30 years because of severe shortage of deceased organ donors in this region. Although the initial grafts done mainly in children used left hemi-livers which were smaller and therefore safer to the donor, for adults, a larger volume of functional liver was necessary and this need was met by using the right liver. This is a more difficult and challenging approach and was first described by Fan et al. in Queen Mary Hospital in Hong Kong in 1996.

We describe here a typical adult-to-adult LDLT using a right hepatic graft and discuss its indications and contraindications, donor selection, steps of the operation (the donor, bench and recipient procedures) and its advantages as well as its disadvantages. There were 1984 liver transplants done in India in 2018, 68% from living and 32% from deceased donors (mainly in the South) which was the fifth largest number in the world countries. There are now 135 centres in this country which are registered to perform the procedure, and the operative mortality in the best institutions is about 5%, which is as good, if not better, than most international reports.

 Indications for Liver Transplantation

Indications include[1]Acute liver failure: If spontaneous recovery appears unlikely according to certain well-defined criteriaEnd-stage chronic liver disease with a high risk of dying without getting early liver replacement as assessed by various scores (MELD, Child Pugh) or severely affecting the quality of life, such as intractable pruritus, refractory ascites and recurrent bleedingPrimary hepatic neoplasms: especially against a background of parenchymal liver diseaseMetabolic disorders: which a new liver can correct such as Wilson's disease, haemochromatosis and tyrosinaemia (in hereditary disorders, it is important to ensure that the potential donor, if related, is not an asymptomatic carrier)Vascular disorders: e.g., hepatic vein outflow tract obstruction, especially if associated with a coagulation disorder which can be corrected by a new liverCholestatic liver diseases: primary biliary cirrhosis, primary sclerosing cholangitis, secondary biliary cirrhosis, biliary atresia and Byler's disease.


Recipient considerations

Age or severe comorbidity with a poor chance of survival even after a transplantDisseminated malignancy which is unlikely to be cured by a transplantActive alcohol/substance abuse or acute alcoholic hepatitisActive sepsis.

Living donor considerations

Absolute contraindications

Severe fatty liver disease (if biopsy shows macrosteatosis >20%)Likelihood of the future liver remnant being <25%Unfavourable biliary or vascular anatomy.

 Donor Selection and Evaluation

A guiding principle of LDLT is to ensure that 'no harm should come to the donor'. The selection of a donor is hence of the utmost importance, and every effort should be taken to appropriately screen him or her and ensure a minimal risk during the procedure.

Stepwise donor evaluation

Detailed history and clinical examinationBlood workup: Haemogram, renal function tests, coagulation profile, liver function tests, pregnancy test, appropriate viral serology, thyroid function tests (Thyroid stimulating hormone [TSH], Thyroxine [T4] and Triiodothyronine [T3]), iron, ferritin and tumour markers (Carcinoembryonic antigen, Alphafeto protein, Carbohydrate antigen CA19-9)Imaging studies: Triple-phase contrast computed tomographic scans (to rule out malignancy and unfavourable anatomy) and Magnetic resonance cholangio-pancreatography (for biliary anatomy evaluation)Psychological evaluationElectrocardiogram, chest X-ray, pulmonary function tests, echocardiography and cardiac stress test (if indicated)Selected consultations: Cardiology, pulmonology and gynaecologyHistology: liver biopsy (if indicated)Pre-anaesthetic consultation for fitnessEthics committee evaluation (for second-degree relatives and altruistic donors)Informed consent (ideally on video).

 Steps of Donor Surgery – Right Lobe Grafts (Without Middle Hepatic Vein [Mhv])

An epidural catheter is placed initially (for post-operative analgesia) before endotracheal intubation. Nasogastric tube insertion is doneThe patient's position is supine – with adequate padding to avoid pressure and injuryA right subcostal incision is used (a scar subsequently hidden by clothes). Increasingly to reduce the incision wound, a robot has been used [Figure 1] shows both open and robotic sites]A Thompson self-retaining Retractor® is placed to open the woundThe peritoneal cavity is inspected; the liver is visualised and palpated. If there is any doubt of the degree of steatosis – a frozen section liver biopsy is obtainedThe right liver is completely mobilised by dividing the various ligamentous attachments: right triangular ligamentThe caudate lobe vein tributaries draining directly into the inferior vena cava (IVC) are clipped, ligated and dividedThe right hepatic vein (RHV) is isolated and encircled [Figure 2]The gallbladder is mobilised off the hepatic bed. The hepatic plate is lowered, and a cholangiogram is performed through the cystic duct to see if the biliary anatomy is suitableThe right hepatic artery and right portal vein are dissected and encircled with a vessel loop avoiding baring the bile ductIt must be ensured that the left-sided vascular structures (portal vein and artery) are clearly identified and protectedTemporary occlusion of the right hepatic artery and portal vein will help to demarcate the transection plane by the colour change over the liver, and the proposed transection line is marked with a monopolar cautery: it usually runs from the right side of the MHV to the gallbladder fossa deviating to the base of segment IVb [Figure 3]For parenchymal transection, we use the diathermy including bipolar cautery, Cavitron ultrasonic surgical aspirator and hydro-jet dissector. Larger vessels and ducts are tied or clipped, and the smaller vessels are controlled using a bipolar cauterySegment IV and V veins are used to guide towards the location of the distal MHVMost commonly, a modified right liver graft is used and is described here – right lobe graft without taking the MHV and by reconstructing the venous tributaries of MHV in the graft using the recipient portal vein/ Polytertrafluoroethylene (PTFE) graft or a cryopreserved cadaveric vesselOnce the MHV has been defined, segment V tributaries are ligated and further transection continues along the course of the MHV on its right to skeletonise it. The segment VIII veins are ligated, and all veins over 5 mm are marked for reconstruction later at the bench procedure [Figure 4]The right bile duct is divided sharply, initially, partially, and the lumen is probed extensively to verify the exact anatomy and location of the left and common ducts. If the anatomy is abnormal, especially the right posterior duct opening into the left, the left duct must be clearly probed before division of the posterior duct and kept safe. Alternately, in robotic graft, indocyanine green can be injected at induction of anaesthesia, and ducts can be visualised using near infrared light before division [Figure 5]Next, the hepatic artery is ligated with clips and ties [Figure 6], the portal vein is secured and divided, the RHV is secured with vascular clamps and divided to remove the graft [Figure 7]The stump of the right hepatic duct is closed with 6-0 Polydioxanone (PDS) suture, and a check cholangiogram is performed to verify the duct integrityHaemostasis is confirmed and a single tube abdominal drain is placed near the hepatic hilum. The remnant lobe is fixed to the anterior abdominal wall to prevent rotation.Abdominal closure is done using loop PDS no. 1, subcuticular monocryl 3-0 and the skin with DermabondThe patient is usually extubated on the table, and the nasogastric tube is removed once he is fully conscious and transferred to the intensive care unit.{Figure 1}{Figure 2}{Figure 3}{Figure 4}{Figure 5}{Figure 6}{Figure 7}

 Bench Work

The liver is placed on ice, and immediate flushing of the portal vein and retrograde flushing via the hepatic vein with 1–1.5 L of ice-cold Histidine Tryptophan Ketogultarate (HTK) solution are done till the effluent is clear. Recently, we have begun to flush the artery as well, after we showed the benefits of reducing a subsequent biliary stricture in a randomised trial,[2] but most groups are wary of this for fear of intimal damageThe MHV is reconstructed using a conduit of recipient portal vein or PTFE graft by joining the segment V and VIII veins. Any other veins >5 mm (or those with good flow during back table perfusion) should be reconstructed [Figure 8]a and [Figure 8]b. If any of the MHV tributaries are closed, they can be joined together and anastomosed to a conduit [Figure 9]The bile duct should be clearly identified and marked, and any accessory/ caudate ducts should be identified and the smaller ducts should be ligated/clipped to prevent post-operative bile leaks.{Figure 8}{Figure 9}

 Steps of the Recipient Surgery

Recipient hepatectomy

The patient position is supine with adequate attention paid to padding as it is a long procedure. C drapes are used [Figure 10] to prevent spillage and to suck away blood for the cell salvage in non-malignant casesWe use a 'reverse L' right upper quadrant incision with liberal extension to the right and up to the xiphoid process in the midline for easy exposure of the suprahepatic vena cava during surgery. In case of difficulty, this can be extended to a Mercedes Benz incision if needed by extending the transverse arm to the leftThe skin flap is sutured to the drapes on the right and the Thompson Retractor® is placedThe peritoneal cavity is inspected; the liver is visualised and palpatedThe falciform ligament and ligamentum teres are divided and excisedNext, the hepatico-duodenal ligament is dissected. The gastrohepatic ligament is divided after controlling any accessory left hepatic arteryThe left and right hepatic arteries are identified [Figure 11] and divided (early division of the arteries may reduce blood loss during subsequent mobilisation of the liver)The common bile duct and portal vein are identified and encircled and the components are identified [Figure 12]. The bile duct is divided high making sure it is not separated from the hepatic artery to preserve its blood supply. The portal vein is dissected but not divided [Figure 13]Mobilisation of the liver is now done by dividing the left triangular ligament short of the left hepatic vein junction with the IVC. Next, the right lobe is mobilised and a large sponge is kept behind the liver to move it anteriorlyThe IVC behind the caudate lobe is also dissected and kept ready for a portcaval shuntThe use of a temporary portocaval shunt prevents splanchnic congestion, improves renal function and makes the dissection easier by reducing the bleeding; hence, at this stage, we divide the portal vein and perform an end-to-side portocaval shunt with running 5/0 polypropylene. In a difficult explant with a large caudate lobe encircling the IVC or bleeding due to coagulopathy, an early shunt is helpful before any mobilisation. Although this increases the anhepatic phase, in our experience, less bleeding is preferred to a slightly longer anhepatic time! [Figure 14] and [Figure 15]Complete mobilisation of the right lobe is done to expose the entire retrohepatic vena cava. Small veins from its anterior surface to the caudate lobe are clipped, ligated and divided if this was not done earlierTo expose the RHV, the hepatocaval or Makuuchi's ligament is divided by carefully clamping it using vascular clamps or Q vascular stapler. The RHV is clamped and suture ligated followed by the middle and left hepatic veinsIn some cases, the orifices from the middle and left hepatic veins are difficult to join, and here, an orifice may be created by extending it caudally to the lower IVC. A long venous cuff should be preserved for subsequent anastomosisThe native liver is thus removed, and the portal veins are harvested on the back table if required for hepatic vein reconstruction.{Figure 10}{Figure 11}{Figure 12}{Figure 13}{Figure 14}{Figure 15}


Before the graft is implanted, the surgical field must be clean with complete haemostasisThe implantation commences with the anastomosis of the graft vein to the cuff of the hepatic venous orifice created with the middle and left hepatic veins by a running 3/0 polypropylene suture. Venous reconstruction may not be needed at all for a right graft, and if the entire middle hepatic is taken, it is an extended right graft – these differences are highlighted in [Figure 16]{Figure 16}

The portocaval anastomosis is taken down by clamping the portal side and closing the caval defect with a running suture. The portal anastomosis is done with a running suture using polypropylene or PDS [Figure 17], [Figure 18], [Figure 19].{Figure 17}{Figure 18}{Figure 19}

The arterial anastomosis is done with a running 7/0 or 8/0 polypropylene suture at the level of the common hepatic artery bifurcation. A handheld Doppler confirms the flow in the arterial reconstructionFollowing this, the biliary tract is reconstructed. Our standard technique is end-to-end choledocho-choledochostomy with the posterior layer continuous and the anterior interrupted 5/0 PDS or Maxon to minimise luminal compromise in these small ducts. We do not use any biliary stent. Rarely, we use a Roux-en-Y hepaticojejunostomy for multiple ducts or biliary disease (sclerosing cholangitis/biliary atresia)Intra-operative Doppler is done next by a dedicated radiologist to confirm the patent flow across all the vascular anastomoses and as a baseline for post-operative comparisonAfter finishing the vascular and biliary anastomoses, we ensure haemostasis before closure (Completed implant is shown diagrammatically in [Figure 20])We place two tube drains, one near the hilum and the other in Morrison's pouchWound closure is done in two layers with a running suture using no. 1 loop PDS and the skin is closed with clips.{Figure 20}


Organ shortage is a universal problem in the transplantation, and LDLT attempts to overcome it, especially in regions where deceased donor organs are scarceBetter utilisation of resources and elective planning and optimisation of donor and recipientShorter waiting time for recipients and a survival advantage from early transplantation[3]Shorter cold ischemia time.


Risk of donor morbidity and, even though statistically rare, chance of donor mortalitySmaller grafts compared to Deceased donor Liver transplant (DDLT); hence, early allograft dysfunction/small for size is common, especially when the graft to recipient ratio is small (<0.8)Living donor recipients have longer operative times and higher rates of biliary and vascular complications and re-transplantation as compared to DDLTThe cost of LDLT exceeds that of deceased donor transplantations.[4]


LDLT is a technically more demanding surgery but can increase donor pool. It has been continuing to evolve since its inception to maximise graft size, minimise complications and avoid any morbidity for the donor. We have outlined the technique using a modified right liver graft. Potential use of robotic surgery for the donor has also been highlighted.


We would like to acknowledge Dr Pragya Singh, Senior Resident, Department of Radiation Oncology, for drawing the sketches

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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