the two - stage total hepatectomy with temporary portocaval shunt and subsequent liver transplantation ( lt ) were first described by ringe et al .   in 1988 . the rationale for the procedure is based upon the concept that patients with fulminant hepatic failure or graft failure that can lead to a toxic hepatic syndrome , or massive haemorrhages resulting in uncontrollable bleeding , can benefit from urgent removal of the native liver followed by lt when an organ becomes available [ 2 , 3 ] . the first stage of the procedure consists of a total hepatectomy with preservation of the recipient 's inferior vena cava ( ivc ) and suture of the three hepatic veins . then a temporary end - to - side portocaval shunt ( tpcs ) is created to re - establish the splanchnic outflow during the anhepatic phase . the second stage consists of removing the tpcs and implanting the liver graft when one becomes available . we report a case of a two - stage total hepatectomy and lt in which a temporary end - to - end anastomosis between the portal vein and the middle hepatic vein ( tpmhv ) was performed as an alternative to the classic end - to - end tpcs . a 43-year - old woman underwent urgent laparotomy for spontaneous massive rupture of a subcapsular liver hematoma associated with hellp syndrome . the right lobe of the liver was entirely replaced by a large hematoma and areas of necrosis , and there were deep ruptures in both lobes . after establishing that neither conservative surgical   treatments nor partial resections would have been effective ; a total hepatectomy was performed to control the hemorrhage . after isolating the hilar structures , the bile duct and hepatic artery were ligated and divided . after division of all ligamentous attachments , the liver was progressively mobilized to the left until the retrohepatic vena cava was completely exposed . all the accessory hepatic veins encountered were ligated and divided , and the right   hepatic vein was clamped , divided , and oversewn . rotating the liver towards the right , the left and middle hepatic veins were isolated for 3 - 4  cm within the hepatic parenchyma and divided permitting the removal of the liver . after suturing the stump of the left hepatic vein , it was noted that the orifice of the stump of the middle hepatic vein matched the orifice of the portal vein in length and diameter . a temporary end - to - end porto - middle hepatic vein anastomosis was created using a running suture ( prolene 5/0 ; ethicon , somerville , nj ) , instead of the standard tpcs ( figure 1 ) . the patient was taken back to the icu for hemodynamic and metabolic monitoring and management . twelve hours after placing the patient on the liver transplant waiting list with a status 1 designation , a liver became available . the patient returned to the operating room for a lt which was performed in a piggyback fashion . the recipient ivc was cross - clamped tangentially , occluding approximately half of its lumen , but leaving the tpmhv open and untouched due to its position above the caval clamp . after a longitudinal incision of the recipient ivc anterior wall , the graft was placed orthotopically and rotated to the right , and an end - to - side anastomosis between donor and recipient ivc was performed ( figure 2 ) . next , the tpmhv was taken down , and an end - to - end pv anastomosis was completed . after removing the ivc and portal vein clamps , the liver perfused well , and the patient remained hemodynamically stable . the patient was discharged 47 days after the liver transplant with normal hepatic , renal   kidney , and respiratory functions . the creation of a tpmhv as described above proved technically feasible and showed some advantages over the standard tpcs . firstly , this technique avoids the partial ivc clamping that is required for the creation of the traditional tpcs which may have a negative impact on a patient who is hemodynamically compromised . in contrast , the creation of the tpmhv requires only the clamping   of the origin of the middle hepatic vein alone , leaving the caval flow untouched . secondly , during implantation of the graft , the positioning manoeuvre of the caval clamp longitudinally on the ivc and the subsequent creation of a side - to - side caval anastomosis can be made more difficult in the presence of placement of a tpcs which usually lies on the lower portion   of the retrohepatic ivc . the use of a tpmhv permitted the unimpeded placement of the ivc clamp as well as the creation of the caval anastomosis . moreover , throughout the icv clamping phase , because the standard tpcs is placed upstream of the caval clamp , the portal flow becomes unavoidably at least partially obstructed , with consequent increased risk of splanchnic congestion and hemodynamic alterations . this situation is avoided by the tpmhv which remains downstream of the caval clamp , allowing full portal flow throughout the procedure . in conclusion , in cases of two - stage lt procedures with side - to - side caval reconstruction , tpmhv can be considered as a safe and effective alternative to standard tpcs . in addition to this setting , this shunt technique may also be applied in living donor liver transplantation ( ldlt ) .   a recent report from kyoto   described a series of ldlts in which the authors performed a hemi - portocaval shunt when the pv pressure was   20  mmhg at the time of laparotomy , as prevention of small size syndrome . to avoid splanchnic congestion during the anhepatic phase , a tpcs between the ivc and pv branch constructed in all cases . in the case of hemi - portocaval shunt , the distal end of the pv vein branch for the shunt was extended with a vein graft in advance and anastomosed to the ivc , since a short shunt may seriously hamper adequate mobilization and anastomosis between the graft pv and the other branch of the recipient pv . in these cases , using a right lobe graft , we think that a tpmhv between the left branch of the portal vein and the mhv may be a useful alternative to the tpcs in that it would not impede the venous or portal anastomoses , and when necessary , it could be left in place replacing the hemi - portocaval shunt .
two - stage liver transplantation ( lt ) has been reported for cases of fulminant liver failure that can lead to toxic hepatic syndrome , or massive hemorrhages resulting in uncontrollable bleeding . technically , the first stage of the procedure consists of a total hepatectomy with preservation of the recipient 's inferior vena cava ( ivc ) , followed by the creation of a temporary end - to - side porto - caval shunt ( tpcs ) . 
 the second stage consists of removing the tpcs and implanting a liver graft when one becomes available . 
 we report a case of a two - stage total hepatectomy and lt in which a temporary end - to - end anastomosis between the portal vein and the middle hepatic vein ( tpmhv ) was performed as an alternative to the classic end - to - end tpcs . 
 the creation of a tpmhv proved technically feasible and showed some advantages compared to the standard tpcs . in cases 
 in which a two - stage lt with side - to - side caval reconstruction is utilized , tpmhv can   be considered as a safe and effective alternative to standard tpcs .