Modified technique of total hepatectomy in polycystic liver disease with caval flow preservation: the exposure left lateral sectionectomy

Background Liver transplantation (LT) for polycystic liver disease (PLD) is rare, extremely challenging and hemorrhagic, without standard approach. Moreover, LT for PLD presents the highest mortality rate (12 to 18%) among all causes of LT. In this setting, the combination of difficult mobilization of a heavy polycystic native liver with narrow access to inferior vena cava (IVC) and fragile venous wall may lead to venous tearing and cataclysmic bleeding during dissection. The aim of this study was to evaluate a modified technique of total hepatectomy in order to limit hazardous liver manipulation and improve exposure of IVC in patients with massive hepatomegaly related to PLD: the exposure left lateral sectionectomy (ELLS). Methods From 2011 to 2018, ELLS was performed during LT for PLD. Key technical points for safe and fast ELLS include avoidance of left triangular ligament section and placement of a tape behind the left lateral section allowing its ascension and prior dissection of the hepatic pedicle to limit bleeding. The transection plane is mainly composed of cysts, with limited parenchyma, this allows for rapid and bloodless transection using electric scalpel. Results Fifteen patients had ELLS with no postoperative death or intraoperative complication. Median ELLS duration was 16 min and no massive bleeding occurred during this step. During total hepatectomy, median blood loss was 500 ml and no patient required total caval clamping. All patients were alive at the end of the follow-up. Conclusions ELLS during LT for PLD facilitates total hepatectomy with vena cava and caval flow preservation. Corresponding author: Prof. Olivier Soubrane, MD, PhD, Département de Chirurgie Hépato-pancréato-biliaire, AP-HP Hôpital Beaujon, Clichy, 100 Boulevard du Général Leclerc, 92210 Clichy, France. Tel: 01 40 87 52 52. Fax: 01 40 87 50 67. Mail: olivier.soubrane@aphp.fr ORCID : 0000 0002 4668 9275 Autorship page: Participated in research design: FC, OS, FD Participated in the writing of the paper : BL, OS, FD, Participated in the performance of the research: OS, FC; TY Contributed new reagents or analytic tools: SD, EW, MC, CF Participated in data analysis: AS, FD, SD, EW, MC, CF Disclosure of conflict of interest: The authors of this manuscript have no conflicts of interest to disclose. Disclosure of funding: None Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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