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Prolonged occlusion of the hepatoduodenal ligament to reduce risk of bleeding and tumor spread during recipient hepatectomy for living donor liver transplantation
Ann Hepatobiliary Pancreat Surg 2019 Feb;23(1):61-4
Published online February 28, 2019;
Copyright © 2019 Korean Association of Hepato-Biliary-Pancreatic Surgery.

Jin-Uk Choi, Shin Hwang, Chul-Soo Ahn, Deok-Bog Moon, Tae-Yong Ha, Ki-Hun Kim, Gi-Won Song, Dong-Hwan Jung, Gil-Chun Park, and Sung-Gyu Lee

Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
Received December 26, 2018; Revised December 30, 2018; Accepted January 10, 2019.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Backgrounds/Aims: Prevention of excessive bleeding during liver transplantation (LT) operations presents a major challenge. Compared to deceased donor LT, living donor LT (LDLT) is more vulnerable to bleeding because of additional dissection procedures. We herein introduce our technique for prolonged occlusion of the hepatoduodenal ligament applied to recipient hepatectomy for LDLT.
Methods: Simulated assessment of splanchnic hemodynamics on prolonged occlusion of the hepatoduodenal ligament showed that patients with cirrhotic liver appeared to tolerate the procedure as like in the patients with normal liver. We accumulated experience on the prolonged Pringle maneuver with curved intestinal clamps.
Results: This technique was applied to more than 60 cases of adult LDLT operations from early 2014 until the end of 2018. Initially, application of this technique was limited to patients showing heavy bleeding during perihilar mobilization. Thereafter, this technique was applied at the start of liver mobilization and stopped after complete mobilization of the retro-hepatic vena cava. Recently, this technique was also applied during dissection of the hepatoduodenal ligament. The mean total occlusion duration was 67±13 minutes. No patient suffered from major serosal peritoneal tearing-associated bleeding or hepatic artery problems. Intentional prolonged occlusion over two hours was applied to five patients who had advanced hepatocellular carcinoma.
Conclusions: We believe that prolonged occlusion of the hepatoduodenal ligament is a simple effective method to reduce intraoperative bleeding, and that it has potential benefit to reduce the risk of intraoperative tumor spread during LDLT operations.
Keywords : Living donor liver transplantation; Bleeding; Pringle maneuver; Portal hypertension


February 2019, 23 (1)