Surgical techniques used in adult living donor liver transplantation

Key Points 1. The main goal of hepatectomy for adult living donor liver transplantation (ALDLT) is to provide a graft with sufficient volume and adequate vascular inflow and outflow. 2. Although the risk is increased in the donor, right grafts, which provide maximum liver volume, are used by a majority of transplant teams. 3. Although right grafts are easily positioned in the donor, facilitating the right hepatic vein anastomosis, the venous drainage is not always complete because the anterior sector is drained through the middle hepatic vein. 4. The harvesting of the middle hepatic vein, which allows the optimal venous drainage for the recipient, is debated with the fear of adverse effects for the donor. 5. The back-table procedure is essential for vascular reconstruction of the hepatic veins and for portal and arterial reconstruction in case of dual vessels. 6. There is a tendency to perform duct-to-duct biliary anastomosis. 7. The use of left grafts, which are an anatomical entity with single inflow and outflow orfices, is limited by the small volume of the grafts. 8. In order to overcome the small-for-size syndrome, some promising technical procedures (partial porto-systemic shunt and splenic artery ligation) are under evaluation.