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Livers removed during transplant hepatectomies could represent a useful anatomic ex vivo resource for surgical training, since they are intact and not altered by post-mortem changes yet. The aim of this study is to investigate the effectiveness of such kind of surgical training applied on some hepatic surgery techniques. In the present paper, we focused on split liver operation and middle hepatic vein (MHV) bipartition/reconstruction, since these procedures have a quite long learning curve. Seven native livers were submitted to split liver procedure by a senior resident assisted by a fully trained hepatic surgeon. Pre-splitting ultrasound mapping was compared to pre-operative CT scan. The whole graft was divided into two hemi-livers and the MHV into two hemi-confluents and reconstructed by venous or arterial patches obtained by deceased donor iliac homograft. Water tightness of the anastomosis was confirmed by hydro-pneumatic test and bench portal perfusion. Reduction in operating time was considered an indirect indicator of surgical skill improvement. In all cases, the US confirmed the anatomical distribution of MHV tributaries observed by pre-transplant CT scan. The "ex situ" splitting procedures and MHV bipartition and reconstruction were performed in all native livers in the usual time required for liver transplantation bench surgery (range 50-75 min). Liver grafts removed during hepatectomy could represent a useful resource of intact organs to perform surgical training and boost surgical confidence. In our initial experience, the study of venous drainage of the MHV and application of liver splitting technique and MHV reconstruction resulted technically feasible.

The main goal of organ allocation systems is to guarantee an equal access to the limited resource of liver grafts for every patients on the waiting list, balancing between the ethical principles of equity, utility, benefit, need, and fairness. The European heath care scenario is very complex, as it is essentially decentralized and each Nation and Regions inside the nation, operate on a significant degree of autonomy. Furthermore the epidemiology of liver diseases and HCC, which is different among European countries, clearly inpacts on indications and priorities. The aims of this review are to analyze liver allocation policies for hepatocellular carcinoma, among different European. The European area considered for this analysis included 5 macro-areas or countries, which have similar policies for liver sharing and allocation: Centro Nazionale Trapianti (CNT) in Italy; Eurotransplant (Germany, the Netherlands, Belgium, Luxembourg, Austria, Hungary, Slovenia, and Croatia); Organizacion Nacional de Transplantes (ONT) in Spain; Etablissement français des Greffes (EfG) in France; NHS Blood & Transplant (NHSBT) in the United Kingdom and Ireland; Scandiatransplant (Sweden, Norway, Finland, Denmark, and Iceland). Each identified area, as network for organ sharing in Europe, adopts an allocation system based either on a policy center oriented or on a policy patient oriented. Priorization of patients affected by HCC in the waiting list for deceased donors liver transplant worldwide is dominated by 2 main principles: urgency and utility. Despite the absence of a common organs allocation policy over the Eurpean countries, long-term survival patients listed for transplant due to HCC are comparable to the long-term survival reported in the UNOS register. However, as the principles of allocation are being re-discussed and new proposals emerge, and the epidemiology of liver disease changes, an effort toward a common system is highly advisable.

Three different standard types of liver bipartition producing six different types of grafts can be created by following a plane directed on the right or the left line of the middle hepatic vein (MHV): a) splitting for adult and pediatric recipients with left lateral graft (LLG) and right extended graft (REG), b) splitting for two adults or for adult and pediatric recipients of large size with creation of left graft (LG) and right graft (RG), c) splitting for two adult recipients with creation of full left graft (FLG) and full right graft (FRG). The absence of an extrahepatic portal vein bifurcation is an absolute contraindication to liver splitting. Division of the portal branches to Segment I optimizes the freeing/lengthening of the left portal vein for the implantation. Identifying the portal tract entering the caudate process at its lower aspect is helpful in preparing for the division of the hilar plate. Early division of the Arantius remnant allows a safe encircling and control of the left hepatic vein. During in situ splitting technique for adult and pediatric recipients, a 1–2-min. selective clamping of the left hepatic vein (LHV) may provide assurance that the hepatic venous drainage of Segment IV is not jeopardized. Recognition of independent segment II and III suprahepatic venous outflow (

In this Chapter we discuss the technical details of the right hemihepatectomy for living donor liver transplantation in adults by open technique. Successful donor outcome and the recipient’s hope for the highest probability of a successful transplant are relevant factors that ethically support the choice for living donor liver tranplantation.

Postoperative pancreatic fistula (POPF) is a common complication of pancreatic resection. Aim of this study is to identify variables related to the development of POPF, analyze their clinical significance and discuss our current approach to the pancreatico-jejunal anastomosis. A series of 129 patients undergoing pancreatico-duodenectomy (PD) have been analyzed. Patients were divided in two groups: group F, 26 patients who have developed POPF; group NF, 103 patients who have not developed POPF. Demographic, clinical and intraoperative data were compared. Seventy-six patients had an end-to-side (ES) pancreatico-jejuno anastomosis, 53 an end-to-end (EE) anastomosis. Fifteen patients developed grade A fistulas, seven grade B, and four grade C; two patients with grade C fistula died from septic shock. Preoperative bile duct lithiasis, diameter of the pancreatic duct and consistency of the pancreatic stump were significantly different between F and NF groups at multivariate analysis. POPF has been related to clinical and biological parameters: preoperative bile duct lithiasis and challenging pancreatico-jejunal anastomosis (with small pancreatic duct and friable pancreatic stump) are the most prominent according to our experience. As the incidence of POPF seems to be related to technically demanding surgery, we presently reserve the EE anastomosis to the cases in which a friable gland or a very small duct will make a direct anastomosis on the pancreatic duct unreliable. In case of grade C fistulas a total spleen-preserving pancreatectomy should be considered an adequate treatment to prevent the onset of a multi-organ failure or a septic shock if no other treatment seems suitable. © 2014 Springer-Verlag Italia