RECONSTRUCTION OF TYPE 3 VARIANT OF LEFT HEPATIC VEIN IN A LEFT LATERAL SEGMENT LIVER GRAFT FROM A LIVING DONOR Fadl H Veerankutty, Varghese Yeldho, Shabeer Ali T.U, Venugopal B, Manoj K.S.* Departments of HPB & Liver Transplant, and Radiodiagnosis*, Kerala Institute of Medical Sciences, Trivandrum, India. Introduction Variations in the anatomy of the hepatic veins draining the left lateral segment(LLS) are relatively uncommon1. Herein we describe a patch venoplasty technique used for the reconstruction of a rare variant of left hepatic vein(LHV) in a paediatric related living donor LLS liver transplantation Case Report Recipient- 2 year old child with progressive familial intrahepatic cholestasis-1 (Byler's disease) Donor liver imaging showed Type III variant of left hepatic vein(LHV) . Segment II vein was draining directly into inferior vena cava (IVC) and Segment III vein was draining into middle hepatic vein(MHV) after receiving a tributary from segment IV (Image 1) Image 3: Newly created left hepatic vein(LHV) being anastamosed to the inferior vena cava(IVC). Image 4: Follow up doppler ultrasound of graft at 3 months post-transplantation showing normal hepatic venous outflow. Discussion Hepatic venous drainage is the most important factor for the success of living donor transplantation2. The obstruction of hepatic vein outflow usually results from anastomotic narrowing, twisting, or inadequate drainage of accessory veins . It can potentially lead to liver congestion, cut surface bleeding, graft failure and sepsis. Preoperative mapping of the hepatic venous system is indispensable to the success of the living related liver transplantation(LLRT)3. Three types of LHV have been descibed1 Type 1- seg II and III veins join to form a common LHV trunk which joins with MHV (75%) Type II- seg II and III veins seperately drains into MHV(14%-20%) Type III- seg II vein drains into the IVC as LHV and the seg III vein drains separately into the MHV The type 3 variant is usually reconstructed using a vein graft or an iliac artery graft as an interposition conduit necessitating two separate anastamosis at IVC. Advantages of a quadrangular patch -Single and wider anastamosis -Reduced warm ischemia time -Better cut surface haemostasis -Prevent the kinking and rotation Conclusion Identification of rare variations of LHV in living donor LLS liver transplantation and its meticulous reconstruction at the back table is necessary to avoid graft congestion and increased blood loss during the procedure. Image 1: Reconstruction image of donor hepatic veins The ostia of segment II and III at the cut surface was situated about 2.3 cm apart. A 1.5x1.5 cm sized quadrangular venous patch was prepared from a cadaveric iliac vein graft(CIVG). The patch was anchored to the segment II and III veins at the bench to bridge the gap between two veins producing a neo LHV (Image 2). A 3.5cm venotomy was made in the right anterior aspect of the IVC and the reconstructed LHV was anastomosed to the IVC using 5-0 polypropelene sutures (Image 3). Image 2: Seg. II & III veins being anastomosed with a quadrangular venous patch References 1.Faisal S. Dar, Walid Faraj, Nigel D. Heaton, and Mohamed Rela.Variation in the Venous Drainage of Left Lateral Segment Liver Graft Requiring Reconstruction of Segment III Vein with Donor Iliac Artery. Liver Transplantation 14:576-579, 2008. 2.Matsuoka N, Maekawa T, Yamauchi Y, Noritomi T, Hoshino S, Shinohara T, Takahashi Y, Noda N, Yamashita Y. Impact of short hepatic vein reconstruction in living donor adult liver transplantation using a left liver plus caudatelobe graft. Asian J Surg. 2010 Jan. 3. Chen CL, Huang TL, Chen TY, Lee TY, Chen YS, Wang CC, de Villa V, Goto S, Chiang YC, Eng HL, Jawan B, Cheung HK . Magnetic resonance of the hepatic veins with angular reconstruction: application in living-related livertransplantation Transplantation. 1999 Jul. Doppler ultrasound immediately after reperfusion and on postoperative days 1 and 7 showed normal tri-phasic flow. Graft function and Doppler ultrasound at 3 months post- transplantation were normal . (Image 4)