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 Table of Contents  
Year : 2020  |  Volume : 1  |  Issue : 1  |  Page : 54-60

How to do it: Living donor liver transplantation

1 Department of Surgical Gastroenterology, AIIMS, Rishikesh, Uttarakhand, India
2 Department of Solid Organ Transplant Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
3 President, AIIMS, Rishikesh, Uttarakhand, India

Date of Submission24-Jun-2020
Date of Acceptance25-Jun-2020
Date of Web Publication20-Jul-2020

Correspondence Address:
Prof. Puneet Dhar
Department of Surgical Gastroenterology, AIIMS, Rishikesh - 249 203, Uttarakhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JME.JME_109_20

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Use of living donor has expanded the pool of potential transplant recipients. We have outlined here the indications, contraindications, donor workup and surgical technique of modified right liver graft retrieval, recipient hepatectomy, benching and recipient implantation in brief.

Keywords: Living donor, liver transplantation, surgical technique

How to cite this article:
Dhar P, Agrawal A, Surendran S, Gopalakrishnan U, Nundy S. How to do it: Living donor liver transplantation. J Med Evid 2020;1:54-60

How to cite this URL:
Dhar P, Agrawal A, Surendran S, Gopalakrishnan U, Nundy S. How to do it: Living donor liver transplantation. J Med Evid [serial online] 2020 [cited 2022 Nov 30];1:54-60. Available from: http://www.journaljme.org/text.asp?2020/1/1/54/290136

  Introduction Top

Living donor liver transplantation (LDLT for end-stage liver disease) has been more popular in Asia than in Western countries for the last 30 years because of severe shortage of deceased organ donors in this region. Although the initial grafts done mainly in children used left hemi-livers which were smaller and therefore safer to the donor, for adults, a larger volume of functional liver was necessary and this need was met by using the right liver. This is a more difficult and challenging approach and was first described by Fan et al. in Queen Mary Hospital in Hong Kong in 1996.

We describe here a typical adult-to-adult LDLT using a right hepatic graft and discuss its indications and contraindications, donor selection, steps of the operation (the donor, bench and recipient procedures) and its advantages as well as its disadvantages. There were 1984 liver transplants done in India in 2018, 68% from living and 32% from deceased donors (mainly in the South) which was the fifth largest number in the world countries. There are now 135 centres in this country which are registered to perform the procedure, and the operative mortality in the best institutions is about 5%, which is as good, if not better, than most international reports.

  Indications for Liver Transplantation Top

  • Indications include[1]
  • Acute liver failure: If spontaneous recovery appears unlikely according to certain well-defined criteria
  • End-stage chronic liver disease with a high risk of dying without getting early liver replacement as assessed by various scores (MELD, Child Pugh) or severely affecting the quality of life, such as intractable pruritus, refractory ascites and recurrent bleeding
  • Primary hepatic neoplasms: especially against a background of parenchymal liver disease
  • Metabolic disorders: which a new liver can correct such as Wilson's disease, haemochromatosis and tyrosinaemia (in hereditary disorders, it is important to ensure that the potential donor, if related, is not an asymptomatic carrier)
  • Vascular disorders: e.g., hepatic vein outflow tract obstruction, especially if associated with a coagulation disorder which can be corrected by a new liver
  • Cholestatic liver diseases: primary biliary cirrhosis, primary sclerosing cholangitis, secondary biliary cirrhosis, biliary atresia and Byler's disease.

  Contraindications Top

Recipient considerations

  • Age or severe comorbidity with a poor chance of survival even after a transplant
  • Disseminated malignancy which is unlikely to be cured by a transplant
  • Active alcohol/substance abuse or acute alcoholic hepatitis
  • Active sepsis.

Living donor considerations

Absolute contraindications

  • Severe fatty liver disease (if biopsy shows macrosteatosis >20%)
  • Likelihood of the future liver remnant being <25%
  • Unfavourable biliary or vascular anatomy.

  Donor Selection and Evaluation Top

A guiding principle of LDLT is to ensure that 'no harm should come to the donor'. The selection of a donor is hence of the utmost importance, and every effort should be taken to appropriately screen him or her and ensure a minimal risk during the procedure.

Stepwise donor evaluation

  1. Detailed history and clinical examination
  2. Blood workup: Haemogram, renal function tests, coagulation profile, liver function tests, pregnancy test, appropriate viral serology, thyroid function tests (Thyroid stimulating hormone [TSH], Thyroxine [T4] and Triiodothyronine [T3]), iron, ferritin and tumour markers (Carcinoembryonic antigen, Alphafeto protein, Carbohydrate antigen CA19-9)
  3. Imaging studies: Triple-phase contrast computed tomographic scans (to rule out malignancy and unfavourable anatomy) and Magnetic resonance cholangio-pancreatography (for biliary anatomy evaluation)
  4. Psychological evaluation
  5. Electrocardiogram, chest X-ray, pulmonary function tests, echocardiography and cardiac stress test (if indicated)
  6. Selected consultations: Cardiology, pulmonology and gynaecology
  7. Histology: liver biopsy (if indicated)
  8. Pre-anaesthetic consultation for fitness
  9. Ethics committee evaluation (for second-degree relatives and altruistic donors)
  10. Informed consent (ideally on video).

  Steps of Donor Surgery – Right Lobe Grafts (Without Middle Hepatic Vein [Mhv]) Top

  • An epidural catheter is placed initially (for post-operative analgesia) before endotracheal intubation. Nasogastric tube insertion is done
  • The patient's position is supine – with adequate padding to avoid pressure and injury
  • A right subcostal incision is used (a scar subsequently hidden by clothes). Increasingly to reduce the incision wound, a robot has been used [Figure 1] shows both open and robotic sites]
  • A Thompson self-retaining Retractor® is placed to open the wound
  • The peritoneal cavity is inspected; the liver is visualised and palpated. If there is any doubt of the degree of steatosis – a frozen section liver biopsy is obtained
  • The right liver is completely mobilised by dividing the various ligamentous attachments: right triangular ligament
  • The caudate lobe vein tributaries draining directly into the inferior vena cava (IVC) are clipped, ligated and divided
  • The right hepatic vein (RHV) is isolated and encircled [Figure 2]
  • The gallbladder is mobilised off the hepatic bed. The hepatic plate is lowered, and a cholangiogram is performed through the cystic duct to see if the biliary anatomy is suitable
  • The right hepatic artery and right portal vein are dissected and encircled with a vessel loop avoiding baring the bile duct
  • It must be ensured that the left-sided vascular structures (portal vein and artery) are clearly identified and protected
  • Temporary occlusion of the right hepatic artery and portal vein will help to demarcate the transection plane by the colour change over the liver, and the proposed transection line is marked with a monopolar cautery: it usually runs from the right side of the MHV to the gallbladder fossa deviating to the base of segment IVb [Figure 3]
  • For parenchymal transection, we use the diathermy including bipolar cautery, Cavitron ultrasonic surgical aspirator and hydro-jet dissector. Larger vessels and ducts are tied or clipped, and the smaller vessels are controlled using a bipolar cautery
  • Segment IV and V veins are used to guide towards the location of the distal MHV
  • Most commonly, a modified right liver graft is used and is described here – right lobe graft without taking the MHV and by reconstructing the venous tributaries of MHV in the graft using the recipient portal vein/ Polytertrafluoroethylene (PTFE) graft or a cryopreserved cadaveric vessel
  • Once the MHV has been defined, segment V tributaries are ligated and further transection continues along the course of the MHV on its right to skeletonise it. The segment VIII veins are ligated, and all veins over 5 mm are marked for reconstruction later at the bench procedure [Figure 4]
  • The right bile duct is divided sharply, initially, partially, and the lumen is probed extensively to verify the exact anatomy and location of the left and common ducts. If the anatomy is abnormal, especially the right posterior duct opening into the left, the left duct must be clearly probed before division of the posterior duct and kept safe. Alternately, in robotic graft, indocyanine green can be injected at induction of anaesthesia, and ducts can be visualised using near infrared light before division [Figure 5]
  • Next, the hepatic artery is ligated with clips and ties [Figure 6], the portal vein is secured and divided, the RHV is secured with vascular clamps and divided to remove the graft [Figure 7]
  • The stump of the right hepatic duct is closed with 6-0 Polydioxanone (PDS) suture, and a check cholangiogram is performed to verify the duct integrity
  • Haemostasis is confirmed and a single tube abdominal drain is placed near the hepatic hilum. The remnant lobe is fixed to the anterior abdominal wall to prevent rotation.
  • Abdominal closure is done using loop PDS no. 1, subcuticular monocryl 3-0 and the skin with Dermabond
  • The patient is usually extubated on the table, and the nasogastric tube is removed once he is fully conscious and transferred to the intensive care unit.
Figure 1: Marking of donor incision: Conventional as subcostal and robotic ports and suprapubic for graft extraction

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Figure 2: Looping of the right hepatic vein

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Figure 3: Marking transection line inferiorly after cholecystectomy

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Figure 4: Vessel loop is used anterior to inferior vena cava to lift liver (called hanging liver manoeuvre) and segment 5 and 8 veins are marked

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Figure 5: Indocyanine green delineates bile ducts to facilitate division under near infrared light

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Figure 6: Right hepatic artery cut

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Figure 7: Retrieval of specimen in bag during robotic retrieval

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  Bench Work Top

  • The liver is placed on ice, and immediate flushing of the portal vein and retrograde flushing via the hepatic vein with 1–1.5 L of ice-cold Histidine Tryptophan Ketogultarate (HTK) solution are done till the effluent is clear. Recently, we have begun to flush the artery as well, after we showed the benefits of reducing a subsequent biliary stricture in a randomised trial,[2] but most groups are wary of this for fear of intimal damage
  • The MHV is reconstructed using a conduit of recipient portal vein or PTFE graft by joining the segment V and VIII veins. Any other veins >5 mm (or those with good flow during back table perfusion) should be reconstructed [Figure 8]a and [Figure 8]b. If any of the MHV tributaries are closed, they can be joined together and anastomosed to a conduit [Figure 9]
  • The bile duct should be clearly identified and marked, and any accessory/ caudate ducts should be identified and the smaller ducts should be ligated/clipped to prevent post-operative bile leaks.
Figure 8: (a) MHV anastomosed to 8 mm Dacron graft, (b) segment VIII joined to side opening on graft

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Figure 9: Alternate method if segment V or VIII or other large veins are close to each other they can be joined and sutured to a conduit for implantation

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  Steps of the Recipient Surgery Top

Recipient hepatectomy

  • The patient position is supine with adequate attention paid to padding as it is a long procedure. C drapes are used [Figure 10] to prevent spillage and to suck away blood for the cell salvage in non-malignant cases
  • We use a 'reverse L' right upper quadrant incision with liberal extension to the right and up to the xiphoid process in the midline for easy exposure of the suprahepatic vena cava during surgery. In case of difficulty, this can be extended to a Mercedes Benz incision if needed by extending the transverse arm to the left
  • The skin flap is sutured to the drapes on the right and the Thompson Retractor® is placed
  • The peritoneal cavity is inspected; the liver is visualised and palpated
  • The falciform ligament and ligamentum teres are divided and excised
  • Next, the hepatico-duodenal ligament is dissected. The gastrohepatic ligament is divided after controlling any accessory left hepatic artery
  • The left and right hepatic arteries are identified [Figure 11] and divided (early division of the arteries may reduce blood loss during subsequent mobilisation of the liver)
  • The common bile duct and portal vein are identified and encircled and the components are identified [Figure 12]. The bile duct is divided high making sure it is not separated from the hepatic artery to preserve its blood supply. The portal vein is dissected but not divided [Figure 13]
  • Mobilisation of the liver is now done by dividing the left triangular ligament short of the left hepatic vein junction with the IVC. Next, the right lobe is mobilised and a large sponge is kept behind the liver to move it anteriorly
  • The IVC behind the caudate lobe is also dissected and kept ready for a portcaval shunt
  • The use of a temporary portocaval shunt prevents splanchnic congestion, improves renal function and makes the dissection easier by reducing the bleeding; hence, at this stage, we divide the portal vein and perform an end-to-side portocaval shunt with running 5/0 polypropylene. In a difficult explant with a large caudate lobe encircling the IVC or bleeding due to coagulopathy, an early shunt is helpful before any mobilisation. Although this increases the anhepatic phase, in our experience, less bleeding is preferred to a slightly longer anhepatic time! [Figure 14] and [Figure 15]
  • Complete mobilisation of the right lobe is done to expose the entire retrohepatic vena cava. Small veins from its anterior surface to the caudate lobe are clipped, ligated and divided if this was not done earlier
  • To expose the RHV, the hepatocaval or Makuuchi's ligament is divided by carefully clamping it using vascular clamps or Q vascular stapler. The RHV is clamped and suture ligated followed by the middle and left hepatic veins
  • In some cases, the orifices from the middle and left hepatic veins are difficult to join, and here, an orifice may be created by extending it caudally to the lower IVC. A long venous cuff should be preserved for subsequent anastomosis
  • The native liver is thus removed, and the portal veins are harvested on the back table if required for hepatic vein reconstruction.
Figure 10: Recipient with C drape to prevent spillage and allow blood salvage

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Figure 11: Recipient left and right anterior and posterior arteries looped without baring common bile duct to ensure the crucial arterial supply

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Figure 12: Bile duct looped (yellow), right anterior artery divided other 2 arteries in red loop

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Figure 13: All hilar structures divided except portal vein

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Figure 14: Temporary portacaval shunt – diagrammatic representation

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Figure 15: Photograph showing divided hepatic vein ostia, cava and portacaval shunt

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  • Before the graft is implanted, the surgical field must be clean with complete haemostasis
  • The implantation commences with the anastomosis of the graft vein to the cuff of the hepatic venous orifice created with the middle and left hepatic veins by a running 3/0 polypropylene suture. Venous reconstruction may not be needed at all for a right graft, and if the entire middle hepatic is taken, it is an extended right graft – these differences are highlighted in [Figure 16]
  • Figure 16: Types of liver grafts according to level of harvest of middle hepatic venous system – right graft; right, extended right and modified right

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    • The portocaval anastomosis is taken down by clamping the portal side and closing the caval defect with a running suture. The portal anastomosis is done with a running suture using polypropylene or PDS [Figure 17], [Figure 18], [Figure 19].
    Figure 17: Portal vein start sutures at 4 and 8 o' clock allows anterior wall to flop out of the way

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    Figure 18: Portal vein just before reverse blood flush. Graft artery and two bile duct openings

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    Figure 19: Portal vein anastomosis diagrammatic

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  • The arterial anastomosis is done with a running 7/0 or 8/0 polypropylene suture at the level of the common hepatic artery bifurcation. A handheld Doppler confirms the flow in the arterial reconstruction
  • Following this, the biliary tract is reconstructed. Our standard technique is end-to-end choledocho-choledochostomy with the posterior layer continuous and the anterior interrupted 5/0 PDS or Maxon to minimise luminal compromise in these small ducts. We do not use any biliary stent. Rarely, we use a Roux-en-Y hepaticojejunostomy for multiple ducts or biliary disease (sclerosing cholangitis/biliary atresia)
  • Intra-operative Doppler is done next by a dedicated radiologist to confirm the patent flow across all the vascular anastomoses and as a baseline for post-operative comparison
  • After finishing the vascular and biliary anastomoses, we ensure haemostasis before closure (Completed implant is shown diagrammatically in [Figure 20])
  • We place two tube drains, one near the hilum and the other in Morrison's pouch
  • Wound closure is done in two layers with a running suture using no. 1 loop PDS and the skin is closed with clips.
Figure 20: All anastomosis – implantation completed

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  Advantages Top

  • Organ shortage is a universal problem in the transplantation, and LDLT attempts to overcome it, especially in regions where deceased donor organs are scarce
  • Better utilisation of resources and elective planning and optimisation of donor and recipient
  • Shorter waiting time for recipients and a survival advantage from early transplantation[3]
  • Shorter cold ischemia time.

  Disadvantages Top

  • Risk of donor morbidity and, even though statistically rare, chance of donor mortality
  • Smaller grafts compared to Deceased donor Liver transplant (DDLT); hence, early allograft dysfunction/small for size is common, especially when the graft to recipient ratio is small (<0.8)
  • Living donor recipients have longer operative times and higher rates of biliary and vascular complications and re-transplantation as compared to DDLT
  • The cost of LDLT exceeds that of deceased donor transplantations.[4]

  Summary Top

LDLT is a technically more demanding surgery but can increase donor pool. It has been continuing to evolve since its inception to maximise graft size, minimise complications and avoid any morbidity for the donor. We have outlined the technique using a modified right liver graft. Potential use of robotic surgery for the donor has also been highlighted.


We would like to acknowledge Dr Pragya Singh, Senior Resident, Department of Radiation Oncology, for drawing the sketches

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Varma V, Mehta N, Kumaran V, Nundy S. Indications and contraindications for liver transplantation. Int J Hepatol 2011;2011:121862.  Back to cited text no. 1
Shaji Mathew J, Kumar KY, Nair K, Thankamony Amma BS, Krishnakumar L, Balakrishnan D, et al. Antegrade hepatic artery and portal vein perfusion versus portal vein perfusion alone in living donor liver transplantation: A randomized trial. Liver Transpl 2019;25:1353-62.  Back to cited text no. 2
Shah SA, Levy GA, Greig PD, Smith R, McGilvray ID, Lilly LB, et al. Reduced mortality with right-lobe living donor compared to deceased-donor liver transplantation when analyzed from the time of listing. Am J Transplant 2007;7:998-1002.  Back to cited text no. 3
Trotter JF, Mackenzie S, Wachs M, Bak T, Steinberg T, Polsky P,et al. Comprehensive cost comparison of adult-adult right hepatic lobe living-donor liver transplantation with cadaveric transplantation. Transplantation 2003;75:473-6.  Back to cited text no. 4


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20]


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