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Split-liver orthotopic liver transplantation: how to divide the portal pedicle.

It is possible to obtain two good-quality hepatic transplants from a single cadaveric liver by separation of right and left lobes of the liver or section between the left medial segment and the left lateral segment medial to the umbilical cleft. We attempt to define the ideal basis of separation of the structures of the portal pedicle, based on anatomic study of 25 livers. Ideally, the following should be sectioned: the left portal vein, longer and more constant than the right; the right branch of the hepatic artery, larger and more constant than the left; and the left hepatic duct, being aware of the vascularization of the common hepatic duct. Use of the left portal vein necessitates the interruption of all left venous portal branches of segment I, which should be systematically resected. A section between the left medial segment and the left lateral segment interrupts all portal venous branches of the left medial segment, which should then be resected. Before hepatic division, a cholangiogram and arteriogram are indispensable to detect variations and avoid an extensive dissection that may endanger bile duct vascularity.