How to explant a diseased liver for living donor liver transplantation after previous gastrectomy with severe adhesion (with video).

We performed living donor liver transplantation (LDLT) in a patient who had undergone distal gastrectomy for gastric ulcer disease with Billroth I reconstruction 30 years before the LDLT. The adhesion was very severe between remnant stomach and hepatic hilum as well as left liver lobe with shortening of hepatoduodenal structures. After dissection of the infrahepatic inferior vena cava, the Spiegel lobe was identified from the dorsal side. The Spiegel lobe was then penetrated with a right angle dissector so that a plastic tape could be placed around the whole adhesion, including important structures in the hepatoduodenal ligament. Next, the right hepatic vein was transected with a vascular stapler using Pringle's maneuver using the plastic tape to fasten the entire adhesional structure. Subsequently, the trunk of the middle and left hepatic vein was transected after clamping. The remaining short hepatic veins in the left side were divided completely from the cranial to the caudal direction to dissect Spiegel's lobe. Finally, the hepatoduodenal ligament was identified from the attached remnant stomach and the duodenum and a vascular clamp was placed on the entire hepatoduaodenal ligament. Finally, the diseased liver was explanted for graft implantation. Thus, retrograde explantation of the liver was effective in decreasing the risk of damaging vital elements in the hepatoduodenal ligament, the remnant stomach, and the duodenum.