Hepatoduodenal ligament dissection technique during recipient hepatectomy for liver transplantation: How I do it?

Accurate dissection of the hepatoduodenal ligament in the recipient is vital for the success of liver transplantation surgery. High incidence of anatomic variations at the hepatic artery, portal vein and biliary ducts in the hepatoduodenal ligament is well known. Surgical experience is important to be able to foresee the most common anatomic diversities and the possible variations, in order to make a safe and accurate dissection in the hepatic hilum. Before anastomosis, all these hilar structures must be well identified, safely dissected and must also have a sufficient length for the coming implantation process. At the beginning of our program, we were starting the hepatic hilum dissection close to the liver. In time, however, we modified our surgical technique, preferring to start further away from the liver (closer to the duodenum). This length increased progressively over 1500 liver transplantations (80% living donor liver transplantation). During this process, our main purpose was the early control of the hepatic artery (artery first approach). In this paper, our aim is to share our latest version of the hepatoduodenal ligament dissection technique. We also describe alternative approaches used in extraordinary situations.