Mass clamping of the hilum to facilitate difficult hepatectomy during liver transplantation: A single center 10 year experience

Introduction: Classic dissection of the hilar structures during the hepatectomy portion of the liver transplant procedure is sometimes extremely difficult and even dangerous. In such cases, clamping of the hepatic hilar structures en mass can be an effective alternative. In this study, we describe our center's experience with this technique. Patients and Methods: This is a retrospective analysis of all patients who received a liver allograft using this technique at our center, between September 1996 and September 2007 (n = 150). Postoperative follow-up was through November 30, 2007. Results: One hundred fifty patients underwent 155 liver transplants using hilar mass clamping. These cases represent 7% of the total number of cases performed at our center during that time interval (n = 2219). This included 93 male and 57 female patients, 18 children and 132 adults. There were 103 primary liver transplants, 52 retransplants. Three of the primary transplants were combined liver/kidney transplants. In 7 cases (4.5%), portacaval hemitransposition was performed to establish portal flow.The decision to perform the hepatectomy with mass clamping of the hilar structures was an intraoperative judgment made when severe vascular adhesions and scarring of the hilum (n = 137) or extensive hilar varices (n = 18) were encountered. The hilar pathology was often associated with hepatic artery (n = 15) or portal vein thrombosis (n = 14).Mean surgical time was 11.33 ± 0.28 hours. Average blood replacement was 26.27 ± 2.05 units of packed red blood cells. One patient died intraoperatively (0.64%) while perioperative (30 day) mortality was 6.4%. Venovenous by pass was used in 1 patient (0.64%).One and 5 year patient survival was 75.3% and 61.2%, respectively. One and 5 year graft survival was 73.7% and 48.2%, respectively. There was no patient mortality, graft loss, or technical complications that could be attributed to the mass clamp technique. Conclusion: Mass clamping of the hepatic hilum can be an effective alternative to classic hilar dissection in cases when the latter is difficult or impossible.