Split liver transplantation in adult patients: hepatic and portal vein division and reconstruction.

Split liver transplant technique was developed to improve the pediatric organ supply without affecting the adult donor pool. Moreover the introduction of the in situ split liver (ISSL) grafting allowed to improve the quality of the liver grafts. The shortage of liver grafts for adult patients has urged to extend this technique to a full adult usage. The transition from whole liver grafting to segmental liver grafting urged technical improvement in venous reconstruction. Hepatic vein obstruction is a critical but rare vascular complication in end-to-end anastomoses between the inferior vena cava (IVC) of the recipient and the suprahepatic IVC of the whole graft liver. Between July 1997 and July 2000, 131 OLT were performed at our institution, 50 of them (38.2% of the global activity) using split grafts. Fifty ISSL procedures were performed either at our institution and the respective graft was then shipped to the sharing center, or the procedure was performed by us or with our assistance at the sharing center itself.Splitting procedures were performed in 50 heart-beating donors hemodinamically stable and eligible for ISSL. The ISSL took a mean time of 1 hours 50 minutes with a mean blood loss of 280 mL. The introduction of the ultrasound dissector significantly reduced blood loss and the operative time. We did not experience any thrombosis or stenosis of the vena cava; instead we experienced two cases of acute outflow block rescued with a side to side cavocavostomy. One recipient of a right hemiliver died 8 days after OLT for graft failure due to poor venous outflow. We did not experience stenosis or thrombosis of the portal vein. Split liver transplantation is an important option to improve the pool of cadaveric liver grafts but its feasibility is based on resolving challenging problems both at splitting and at implantation, being able to provide for unusual venous reconstruction in the majority of cases.