International Journal of Surgery 82 (2020) 128–133

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International Journal of Surgery

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Perspective

Living-donor liver transplantation: Right versus left T

A R T I C LE I N FO A B S T R A C T

Keywords: A dilemma of graft selection between right or left livers occurs during the planning of living-donor liver
Living donor liver transplantation transplantation (LDLT) as well as splitting a whole liver graft into full right/full left grafts in deceased-donor
Graft selection liver transplantation. The right liver's relation to the whole liver could be considered as the trunk of a tree; it has
Right liver graft a larger volume, the main axis of bile ducts, and the inferior vena cava mainly belongs to the right liver.
Left liver graft
Therefore, it was considered as the standard graft in LDLTs. Whether to procure the middle hepatic vein (MHV)
with a right liver graft or to leave it attached to the left-liver remnant largely depends on the transplant institute.
Recently, most transplant institutes tend to leave the MHV with the left liver for the sake of donor safety. Unlike
hepatectomy for liver tumors, it is vital to preserve inflow and outflow for both the resected as well as the
remaining livers. While procuring any graft type, the most important is to procure a liver graft with re-
constructable portal veins, hepatic arteries, hepatic veins, and bile ducts, which should be well preoperatively
planned using 3D-computed tomography with considerations given to graft volume and potential congestion
areas.

1. Introduction donor and recipient outcomes.

Since the beginning of the third millennium, the indications for
living-donor liver transplantation (LDLT) have been expanding from
pediatric patients to also include adult patients. Since it is unavoidable
to use a partial graft in LDLT, the use of smaller grafts increase the risk
of small-for-size syndrome (SFSS) [1]. Therefore, in order to achieve an
acceptable recipient outcome in adult-to-adult LDLTs, a larger right
liver graft (RLG) or extended right liver grafts (ERLGs) with the middle
hepatic vein (MHV) trunk [2] has been frequently used rather than a
smaller left liver graft (LLG).
In 2002, Boillot O et al. [3] first reported the possibility that active
modulation of graft hemodynamics can increase functional graft size in
partial liver transplantation. This landmark report stimulated trans-
plant science of how to safely transplant living donor partial grafts into
unfavorable environments where a small liver mass receives excessive
portal inflow due to recipient portal hypertension. Since then, espe-
cially over the last 10 years, a lot of reports have stated that relatively
smaller-sized grafts could efficiently function with surgical modulation
of portal venous pressure and flow to decrease excessive shear stress to
the liver graft. Such innovation has subsequently renewed interest in
using smaller left liver grafts to minimize living donor risks. Therefore,
the focus has shifted towards how to manage graft hemodynamics to
safely use a smaller graft without compromising recipient outcomes.
Indeed, previous studies from high volume centers revealed that LLGs
can achieve comparable outcomes to RLGs, in adults [4,5]. However,
according to a European multicenter study, LLGs do not always achieve
comparable outcomes as RLGs, even in experienced hands [6]. There-
fore, this report provides an in-depth review of the current state of
LDLT using hemiliver grafts in terms of important anatomical and
functional differences between LLGs and RLGs, graft selection, and
1.1. Left vs. right liver grafts; definitions, pros and cons
A comparison between graft types (left vs. right) is shown in
Table 1. Regarding venous drainage, LLGs and ERLGs have a better
compliance [7] and quality than RLGs without V5/V8 reconstruction
[8]. Although RLGs and ERLGs have larger graft volumes compared to
LLGs, even with segment (S)1, these grafts have more burden on the
living donor, as previously mentioned [9,10]. However, LLGs pose a
potential risk of hepatic venous outflow obstruction due to twisting of
the liver graft [11]. Various graft types are shown in Fig. 1.
1.2. Graft selection
While deciding whether to use RLGs or LLGs, a few points should be
comprehensively considered;
1.2.1. Will the future liver remnant (FLR) be sufficient for the donor?
First, it is crucial to perform accurate volumetry and follow the
parenchymal transection line during donor operation in LDLT which
was simulated by the volumetry. Most transplant centers have a selec-
tion criterion that the donors’ FLR volume should be more than 30% of
the whole liver, even when using RLGs [12]. Because the anterior
section in RLG is usually drained into MHV via V5 and V8, the con-
gestion area of the anterior section is a problem in RLG without MHV.
When the congestion area is large, the transplant surgeons in many
institutes manage to reconstruct the V5 or V8 according to their criteria
(See, Graft outflow section).

https://doi.org/10.1016/j.ijsu.2020.06.022
Received 31 December 2019; Received in revised form 3 June 2020; Accepted 5 June 2020
Available online 30 June 2020
1743-9191/ © 2020 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
Perspective
Table 1
Definition, pros and cons of graft types.
Graft Type Definition
right liver graft (RLG) right liver without MHV
extended right liver graft (ERLG) right liver with MHV
left liver graft (LLG) left liver with MHV
left liver graft with S1 (LLG with S1) left liver with MHV + left-side caudate lobe
BD; bile duct, MHV; middle hepatic vein, S; segment, V5; drainage vein of segment 5, V8; drainage vein of segment 8.
Fig. 1. Various graft types.
Abbreviations: LHV; left hepatic vein, MHV; middle hepatic vein, PPV; posterior portal vein, RHV; right hepatic vein, RPV; right portal vein, S1; segment 1, S2;
segment 2, V5; drainage vein from segment 5, V8; drainage vein from segment 8.
1.2.2. Will the planned graft be sufficient for the recipient's metabolic
needs?
There are two ways to calculate the required graft volume for the
recipient; (a) graft-to-recipient body weight ratio (GRWR); in which the
estimated graft volume is used instead of the actual graft weight (es-
timated GRWR = graft volume/recipient body weight × 100) [1], and
(b) graft volume (GV) to recipient standard liver volume (SLV) %. SLV
is calculated as follows: 706.2 × body surface area +2.4 [13]. At most
high-volume centers of LDLT, the minimum acceptable GRWR is
0.6–0.8% or 30–40% of GV/SLV [12,14–17]. FLR volume and graft
volume are critical factors for donor safety and recipient survival, re-
spectively. On the other hand, many institutes manage to select the
appropriate graft in consideration of recipient's metabolic needs. Be-
cause the metabolic needs of the recipient may be determined by
multiple factors such as the physique of the recipient, age, gender,
status of infection, portal hypertension, collateral circulation, other
organ status as well as the MELD score, there is no accurate indicator to
measure the metabolic needs so far.
1.2.3. Special anatomical consideration during graft selection
a) Graft inflow
In RLGs, portal vein (PV) branching pattern is a crucial point in the
International Journal of Surgery 82 (2020) 128–133
Advantages Disadvantages
larger than LLG congestion unless reconstruction of V5 and V8
complicated anastomosis of the BD
no congestion more burden for donors
less burden for donors possible twisting of the graft can easily cause outflow block
slightly larger than LLG complicated reconstruction of bile duct, inflow and outflow of
S1
pre-transplant donor assessment. Many transplant institutes consider
Nakamura type D [18], in which the anterior portal vein is originated
intra-parenchymally from left poral vein, the and Nakamura type E, in
which several anterior portal branches are originated from left portal
vein separately, are considering as contraindication for the donor [12].
For Variation of Nakamura B and C, it is common to attach Y-grafts on
the backtable. However, in case of Nakamura D and E type, there is
some choice of change the graft type such as posterior graft or left
trisegment graft if the graft and FLR of the donor are acceptable. Na-
kamura T. et al. [18] reported that with a relatively large graft
(GRWR = 1.14%) case, they sacrificed the P8 and reconstruction the
portal vein successfully.
However, in LLGs, multiple hepatic arteries (HAs) may be en-
countered as a result of anatomical variations of the origin of the S4
artery, which may arise from the right HA [19], as well as the possi-
bility of the presence of accessory left HAs from left gastric arteries
[20], which may add difficulty to HA reconstruction, especially with
potentially small sizes. Actually, the reported rate of multiple HAs was
32.2%–47% in LLG [21–23], and 3.4%–4.7% in RLG [24–27]. After
reconstruction of one artery of the graft, if the back-flow from the other
one is enough, it is not necessary to be reconstructed [18,28]. Lee K.W.
et al. [29] reported that there was no significant difference among the
groups of single HA (n = 149), multiple HAs with total reconstruction
(n = 19), and multiple HAs with selective partial reconstruction
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Perspective International Journal of Surgery 82 (2020) 128–133

(n = 11) in RLG regarding the arterial complication rate (6.0%, 5.9%,
0% respectively; p = 0.70), biliary complication rate, and patient and
graft survival. Marcos A. et al. [26] reported as technical challenges for
these cases with short and multiple arteries, reconstruction using Y
graft from recipient's native liver on the backtable could be performed.
Accordingly, owing to the improvement of the microsurgical technique,
the arterial anatomy has become of a less impact on graft selection.
b) Graft outflow
In RLGs, the anterior section (segment 5 and 8) tributaries (V5 and
V8) to the MHV are a major concern for the transplant team, as they
may lead to early postoperative venous congestion that may cause graft
dysfunction, especially in marginal grafts. Therefore, Kinkhabwala M.
et al. reported that V5 and V8 reconstruction could be reserved for
grafts of marginal size or quality [30]. It was reported that MHVs had
proper branches draining the anterior section in 26.5% of cases [31].
Accordingly, the policy of Kyoto group is to reconstruct V5 or V8 in
RLGs only if each congestion area of a drainage vein exceeds 10% of the
liver graft [32]. The International Liver Transplantation Society re-
commends to preserve and reconstruct major venous branches larger
than 5 mm in diameter that drain a RLG [33]. Interposition grafts
should be prepared to be used in reconstructions of V5 and V8, and
their origin vary according to the transplant institute preference
(10–14). Attention should be paid to procure reconstructable V5 and
V8s in the donor surgery by dissecting along the MHV to ensure the
largest possible V5/V8 stump calibers for complete outflow establish-
ment and least congestion area (Fig. 2). So far, these veins have been
reconstructed using interposition grafts from recipient's autologous
native PV [32,34], cryopreserved veins [35], or lately polytetra-
fluoroethylene (PTFE) vascular grafts [36,37]. Each of these patency
rates is excellent, and there is no evidence that any method is superior.
On the other hand, Kitajima T. et al. reported that LLGs posed a
potential risk of hepatic venous outflow obstruction due to twisting of
the liver graft [11], in which they analyzed LLG was the sole in-
dependent risk factor for hepatic venous outflow obstruction (n = 17)
after LDLT (n = 443). They discussed that it might have been due to the
more rapid regeneration as well as rotation from orthotopic implanta-
tion position compared to RLG after LDLT.
c) Graft biliary anatomy
Biliary anatomy should also be checked preoperatively using mag-
netic resonance cholangiography or three‐dimensional drip infusion
cholangiography‐CT [38]. Anatomical variations of the hepatic duct
pose a major technical difficulty in RLGs. There is a possibility for an
RLG to have two or three bile duct (BD) openings; in particular, when a
posterior section BD drains into the left hepatic duct (LHD). In such
anatomical variations, caution should be also exercised in the LLG
procurement not to injure the BD from the posterior section while
dividing the LHD.
There are still debates regarding the impact of the multiple BDs on
the biliary complication and long-term survival. Anatomically, LLG has
less orifice of the BD in comparison to the RLG [39,40]. Moreover, RLG
has more possibility to have multiple BDs on the different hilar plate,
which should be reconstructed individually.
Kollman D. et al. [41] reported that there was no significant impact
of the presence of two (n = 169) or three BDs (n = 21) compared to a
single BD (n = 320) on postoperative complication or long-term graft
and patient survival rates after LDLT. Furthermore, although Bhangui P.
et al. [42] reported that multiple BDs anastomosis (n = 374; 46.2% of
1536 adult to adult RLGs) showed higher biliary complication rate
(16.9% vs. 13.5%; p = 0.03) compared to overall series, the 5-year
overall survival was similar to overall cohort.
On the other hand, there have been several reports that the donor
complication rate was higher after RLG procurement [43].
1.3. Donor safety
Many institutes use the criteria of donor's FLR ≤30% or 35%.
However, because of delayed functional recovery of remnant liver in
older donors [44], and steatotic donors [45], acceptable FLR should be
set according to the physiological reserve of the donor. Yoshino K. et al.
[44] reported RLG donation was a risk factor for splenic enlargement in
the donor, which led to decreased post‐operative platelet, and aged
donors or those who donated a large graft might be at risk of in-
complete recovery of liver function, even after a long period.
Early studies demonstrated that LLGs yielded inferior outcomes
compared to RLGs, particularly when the GRWR was less than 0.8%. In
order to overcome small-for-size related graft failures, RLGs have be-
come the graft of choice for adult recipients, and the majority of
transplant centers still use RLGs to achieve better recipient outcomes.
However, from a donor safety standpoint, right hepatectomies carry
a higher risk than left hepatectomies, which has been repeatedly ar-
gued. Although this could be simply because the majority of adult cases
have been performed with RLGs worldwide, it is important to keep in
mind that donors with a small remnant volume may not tolerate minor
surgical complications, which left liver donors can easily overcome.
Therefore, functional reserve after living liver donation should be taken
into consideration when determining the graft type in LDLT. However,
it should be noted that center volume and experience are important
factors that influence donor safety. At high volume centers, the com-
plication rates with right liver donors can be as low as those with left
liver donors.
Regarding the impact of MHV procurement within the liver graft,
LLG usually includes the MHV, and there are no reports regarding
problems related to congestion or donor liver remaining volume using
those grafts. On the other hand, transplant surgeons concern about the
congestion of the segment 4 in the remnant liver of the ERLG-donor.
Therefore, ERLG procurement is no longer performed in many institutes

Fig. 2. Tips and pitfalls for V5 and V8 procurement.

Abbreviations: MHV; middle hepatic vein, V5; drainage vein from segment 5, V8; drainage vein from segment 8.
V5 or V8 should be cut at the root of the MHV to be reconstructed. If these tributaries are cut apart from the MHV, longer vein grafts are needed to reconstruct, and
functional volume of these segment will be reduced.

130
Perspective
except highly experienced center. It has also been reported that the
mortality and morbidity of donors after ERLG procurement were high
[10], and their procurement should be warned in less experienced in-
stitutes.
1.4. Recipient outcomes
With accumulating knowledge and experiences of graft inflow
modulation and outflow optimization, posttransplant outcomes with
RLGs are now comparable or even superior to deceased donor liver
transplantations using a whole graft. This has allowed rapid expansion
of LDLT activity in the East, where deceased donor access is limited.
Outcome analyses comparing LLGs and RLGs rely on data from a lim-
ited number of centers. Hongkong group [46], who has the largest
experience of ERLG, reported that there is no significant difference in
patient and graft survival between LLGs (n = 40) and RLGs/ERLGs
(n = 505). According to Kyushu group [4], who has a large experience
of LLGs, graft and patient survival is comparable regardless of the graft
type, except for patients with high MELD scores. It should be noted that
this excellent survival was achieved along with aggressive use of sple-
nectomy as inflow modulation to control excessive portal flow.
1.5. Left liver first graft selection algorithm
With a GRWR of 0.8% being a conservative cut-off for minimal graft
size in adult-to-adult LDLT, the lower limit of graft size has been ex-
panded to as low as 0.6% under optimal circumstances [47]. Such
strategy simultaneously achieves satisfactory recipient outcomes and
maximizes donor safety. On the other hand, there has been a long-time
question about whether a larger graft is needed for poor recipients,
namely high MELD score, severe portal hypertension, re-transplant,
sarcopenia patients etc., but there is no clear evidence so far. Regarding
the graft selection, Kurihara T. et al. reported that the short-term
prognosis of LLG is equivalent to the RLG when both LLG and RLG meet
volumetric criteria [48].
Here we propose a graft selection algorithm in adult LDLT with
smaller LLG as first choice (Fig. 3). When the estimated GRWR
is > 0.8% (GV/SLV > 40%), the LLG is the preferred graft. If the es-
timated GRWR is between 0.6 and 0.8% (GV/SLV 30–40%), non-graft
size factors such as graft quality (donor age, steatosis), recipient portal
hypertension, and recipient disease severity (MELD) should be taken
into account to further evaluate graft-recipient pairing. If a GRWR of
the LLG is < 0.6%, an RLG will be considered. If an RLG does not meet
a GRWR > 0.6% or a FLR is < 30% (or 35% depending on each center),
Fig. 3. Left liver first graft selection algorithm.
Abbreviations: GRWR; graft-to-recipient body weight ratio, MELD; Model for End-Stage Liver Disease, FLR; future liver remnant, DDLT; deceased donor liver
transplantation, LDLT; living donor liver transplantation.
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International Journal of Surgery 82 (2020) 128–133
LDLT may not be indicated and alternative strategies need to be em-
ployed such as deceased donor liver transplantation or a dual graft
LDLT.
1.6. Left vs. right liver grafts; liver regeneration in both donor and recipient
sides
Yokoi H. et al. [45] reported that donors aged 50 years or more had
significantly lower growth rates of their liver remnants than younger
donors at the 3-month time point after donation. However, gender,
intraoperative blood loss, residual liver volume, and liver steatosis had
no influence over the liver regeneration rate. There have been several
reports [44,49] mentioned that the regeneration ratios were almost the
same in both LLGs and RLGs. Akamatsu N. et al. reported that both
RLGs and LLGs regenerated up to the same ratio of GV/SLV (88% vs.
87%) as well as achieved functional recovery 1 year after LDLT, and on
the long-term, no significant difference was observed in function, re-
generation, and outcome between RLGs and LLGs [50].
2. Conclusion
Transplant surgeons should consider donor safety as the first
priority while choosing the liver graft for LDLT and then the graft
suitability for the recipients in terms of volume, inflow, outflow, and
biliary anatomy. Appropriate graft selection in LDLT may achieve suf-
ficient functional regeneration in both living donors and recipients.
Ethical approval
Ethical Approval Number: R1473-1 in Ethical committee of Kyoto
university.
Sources of funding
None.
Author contribution
S.Y. wrote a draft, A.S., D.J. and K.H. revised and S. Y. finalized the
manuscript.
Trail registry number
1 Name of the registry:
Perspective
N.A.
2 Unique Identifying number or registration ID:
3 Hyperlink to the registration (must be publicly accessible):
Guarantor
Shintaro Yagi.
Data statement
Research data for this article.
Because this manuscript is a review paper, we did not use clinical
data except for the image of a case.
Provenance and peer review
Commissioned, externally peer-reviewed.
CRediT authorship contribution statement
Shintaro Yagi: Conceptualization, Writing - original draft, Writing -
review & editing. Ashish Singhal: Writing - review & editing. Dong-
Hwan Jung: Writing - review & editing. Koji Hashimoto: Writing -
review & editing, Supervision.
Declaration of competing interest
None.
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Shintaro Yagi∗
Department of Hepatobiliary Pancreas and Transplant Surgery, Kyoto
University, Kyoto, Japan
E-mail address: shintaro@kuhp.kyoto-u.ac.jp.
Ashish Singhal
Advanced Institute of Liver & Biliary Sciences, Fortis Hospitals, Delhi, NCR,
India
Dong-Hwan Jung
Division of Hepatobiliary Surgery and Liver Transplantation, Department of
Surgery, Asan Medical Center, University of Ulsan College of Medicine,
Seoul, Republic of Korea
Koji Hashimoto
Department of General Surgery, Digestive Disease & Surgery Institute,
Cleveland Clinic, Cleveland, OH, USA
∗
Corresponding author.