BACKGROUND:The use of the hinotori™ Surgical System (hinotori) in distal pancreatectomy (DP) is new compared to the da Vinci™ Surgical System (DVSS). The hinotori is equipped with mechanisms distinct from those of DVSS, and comprehensive reports detailing the surgical techniques and outcomes associated with hinotori in DP (hinotori-DP) are lacking. This study aimed to compare the outcomes of DP using the hinotori and DVSS (Xi system), focusing on differences in settings and techniques between the two methods. METHODS:This study retrospectively investigated consecutive patients who underwent robotic DP from April 2010 (the introduction of robotic DP at our institute) to July 2024. The analysis excluded patients who underwent spleen-preserving procedures or procedures performed using robotic platform other than hinotori or daVinci Xi. The hinotori-DP cases were compared with those performed using DVSS (DVSS-DP). The techniques used in hinotori-DP were examined in more detail. RESULTS:A total of 75 robotic DP cases (11 with hinotori and 64 with DVSS) were analyzed in this study. Different port configurations and techniques, including a lesser curvature approach, were used in the hinotori-DP compared to DVSS-DP. The operation time was relatively shorter in the hinotori-DP group (299 vs. 366 min, p = 0.095), and the postoperative complication rates were comparable (pancreatic fistula: 27 % vs. 30 %, p = 0.871; Clavien-Dindo Grade ≥3a complications: 18 % vs. 19 %, p = 0.964) between the two groups. CONCLUSION:The hinotori-DP can be safely performed by focusing on the unique characteristics of the hinotori surgical system.

Robotic pancreaticoduodenectomy (RPD) is technically demanding, and 20–50 cases are required to surpass the learning curve. This study aimed to show our experience of 76 cases from the introduction of RPD and report the changes in surgical results owing to the accumulation of cases and optimization of surgical techniques. A total of 76 patients who underwent RPD between November 2009 and May 2023 at the Fujita Health University Hospital were divided into three groups: competency (n = 23, Nov 2009–Mar 2020), proficiency (n = 31, Apr 2020–Jun 2022), and mastery (n = 22, Jul 2022–May 2023) phases. In the mastery phase, for the education of new surgeons and maintenance of surgical quality, optimization of the procedure, including hanging maneuver with or without stapling transection of the retropancreatic tissue was implemented. The surgical outcomes were compared between the groups. The mean operation time decreased over time despite of the participation of newly started operators in mastery phase [competency: 921.5 min (IQR 775–996 min) vs. proficiency: 802.8 min (IQR 715–887 min) vs. mastery: 609.2 min (IQR 514–699 min), p < 0.001]. Additionally, Clavien–Dindo ≥ grade IIIa complications decreased from 52.2

BackgroundsPancreatojejunostomy is a technically demanding procedure during robotic pancreaticoduodenectomy (RPD). Modified Blumgart anastomosis (mBA) is a common method for the pancreatojejunostomy; however, the technical details for robotic mBA are not well established. During RPD, we performed a mBA for the pancreatojejunostomy using thread manipulation with gauze and an additional assist port.MethodsPatients who underwent robotic pancreatoduodenectomy at Fujita Health University from November 2009 to May 2023 were retrospectively investigated, and technical details for the robotic-modified Blumgart anastomosis were demonstrated.ResultsAmong 78 patients who underwent RPD during the study period, 33 underwent robotic mBA. Postoperative pancreatic fistula (POPF) occurred in six patients (18%). None of the patients suffered POPF Grade C according to the international study group of pancreatic surgery definition. The anastomotic time for mBA was 80 min (54-125 min).ConclusionRobotic mBA resulted in reasonable outcomes. We propose that mBA could be used as one of the standard methods for robotic pancreatojejunosotomy.

Accurate minimally invasive anatomic liver (sub)segmentectomy (MIAS) is technically demanding and not yet standardized, and its surgical outcomes are undefined. To study the impact of the minimally invasive approach on perioperative outcomes of anatomic liver (sub)segmentectomy (AS), we retrospectively studied and compared perioperative outcomes of 99 open AS (OAS) and 112 MIAS (laparoscopic 77, robotic 35) cases using the extrahepatic Glissonean approach, based on the 1:1 propensity score matched analyses. After matching (71:71), MIAS was superior to OAS in terms of blood loss (p < 0.0001), maximum postoperative serum total bilirubin (p < 0.0001), C-reactive protein (p = 0.034) levels, R0 resection rate (p = 0.021), bile leak (p = 0.049), and length of hospital stay (p < 0.0001). The matched robotic and laparoscopic AS groups (30:30) had comparable outcomes in terms of operative time, blood loss, transfusion, open conversion, postoperative morbidity and mortality, R0 resection, and hospital stay, although the rate of Pringle maneuver application (p = 0.0002) and the postoperative aspartate aminotransferase level (p = 0.002) were higher in the robotic group. Comparing the matched posterosuperior (sub)segmentectomy cases or unmatched repeat hepatectomy cases between MIAS and OAS, we observed significantly less blood loss and shorter hospital stays in MIAS. Robotic AS yielded comparable outcomes with laparoscopic AS in the posterosuperior (sub)segmentectomy and repeat hepatectomy settings, despite the worse tumor and procedural backgrounds in robotic AS. In conclusion, various types of MIAS standardized by the extrahepatic Glissonean approach were feasible and safe with more favorable perioperative outcomes than those of OAS. Although robotic AS had almost comparable outcomes with laparoscopic AS, robotics may serve to decrease the surgical difficulty of MIAS in selected patients undergoing posterosuperior (sub)segmentectomy and repeat hepatectomy.

(1) Background: With the increasing demand for repeat hepatectomy, preventing perihepatic adhesion formation following initial hepatectomy is crucial. Adhesion-preventative barriers, like the new spray-type AdSprayTM (Terumo Corporation, Tokyo, Japan), have been proposed to reduce adhesion risk. However, data on their safety in minimally invasive hepatectomy (MIH) remain scarce. This is the first prospective study to evaluate the safety and feasibility of AdSprayTM in MIH. (2) Methods: A total of 124 patients who underwent MIH with AdSprayTM and 20 controls were analyzed. Subgroup analysis according to the AdSpray™ application area was conducted. Major complications were assessed using the Clavien–Dindo classification. Moreover, intraperitoneal pressure during AdSpray™ application was monitored in 20 cases. (3) Results: Major complications occurred in 6.4% of the patients, which was comparable to that in open hepatectomy. Intraperitoneal pressure remained stable below 12 mmHg during AdSpray™ application without any complications. No significant difference in complication rates was observed among subgroups. However, a potential increase in intra-abdominal abscess formation was suspected with AdSpray™ application to the resected liver surfaces. (4) Conclusions: AdSpray™ can be safely used in MIH; however, further research is needed to confirm the appropriacy of using AdSpray™, particularly over resected liver surfaces. Overall, AdSpray™ is a promising tool for enhancing the safety of MIH.

Robotic distal pancreatectomy (RDP) has emerged as a minimally invasive approach to left-sided pancreatic tumors. This study aimed to evaluate the efficacy of the robot-assisted approach (RAA) using a laparoscopic articulating vessel-sealing device (LAVSD) during RDP by comparing it with the pure-robotic approach (PRA). Among 62 patients who underwent RDP between April 2020 and December 2023 at Fujita Health University, 22 underwent RAA (the RAA group). In RAA, console surgeons mainly prepared the surgical fields, and assistant surgeons actively dissected the adipose and connective tissues using LAVSD. The surgical outcomes of these patients were compared with those of 40 consecutive patients who underwent RDP with PRA. In total, 28 males and 34 females with a median age of 71 years were analyzed. The console surgeon’s prior experience of performing RDP was similar between the groups (RAA; median, 6 [range, 0–36], PRA; median, 5.5 [range, 0–34] cases). The operation time was significantly shorter in the TST group (median, 300.5 [range, 202–557] vs. 363.5 [range, 230–556] min, p = 0.015). Major complications (Clavien–Dindo ≥ grade 3a) occurred less frequently in the RAA group (4.6

Background: Posthepatectomy liver failure (PHLF) remains a severe complication after liver resection. This retrospective study investigated the correlation of three hepatic functional tests and whether 99mTc-galactosyl human serum albumin (99mTc-GSA) scintigraphy and modified albumin–bilirubin (ALBI) score are useful for predicting PHLF. Methods: A total of 413 consecutivepatients undergoing hepatectomies between January 2017 and December 2020 at our institution were enrolled in this retrospective cohort study. To evaluate preoperative hepatic functional reserve, modified ALBI grade, indocyanine green clearance (ICG-R15), and 99mTc-GSA scintigraphy (LHL15) were routinely examined before the scheduled hepatectomy. Based on the retrospective chart review, multivariate logistic regression analysis adjusted for confounding factors was performed to confirm that ALBI, ICG-R15, and LHL15 are independent risk factors for PHLF. Results: ICG-R15 and LHL15 were moderately correlated ( r = −0.61). However, the correlation with LHL15 weakened when ICG-R15 was about ³20. Weak correlations were observed between LHL15 and ALBI score ( r = −0.269) and ALBI score and ICG-R15 ( r = 0.339). Of 413 patients, 66 (19%) developed PHLF (grade A: n = 20, grade B: n = 44, grade C: n = 2). Multivariable logistic regression analyses, mALBI grade ( P = .014) and ICG-R15 ( P < .001) were significant independent risk factors for PHLF. Subgroup analysis showed that ICG-R15 <19, major hepatectomy, and mALBI grade and ICG-R15 ³19, major hepatectomy, and LHL15 were significant independent risk factors for PHLF ( P =.036,.020,.043, and.013, respectively). Conclusion: LHL15 and mALBI grade would be complementary to ICG-R15 for predicting PHLF risk.

The optimal approach for the safe implementation and education of robotic pancreaticoduodenectomy (RPD) remains unclear. Prolonged operation time may cause surgeon fatigue and result in perioperative complications. To solve this issue, our department adopted task division by the console surgeon turnover between resection and reconstruction in 2022. This study retrospectively investigated consecutive patients who underwent RPD from November 2009 (initial introduction of RPD) to December 2023. The analysis excluded patients who underwent concomitant resection of other organs. The cases performed by a single console surgeon (single approach) were compared with those performed by two or more console surgeons (multiple approach). This study analyzed 85 consecutive RPD cases, including 51 with the single approach and 34 with the multiple approach. The operation time was significantly shorter (832 vs. 618 min, p < 0.001), and the postoperative major complication was less frequent (45

Robotic surgery has technical advantages including high optical magnification and articulation of forceps. However, the surgical field tends to be narrow due to the high magnification, and the forceps have no tactile sensation. A case of severe intraoperative bleeding from the splenic artery during robotic distal pancreatectomy is presented, with a video. A man in his 80s with a cystic tumor located at the pancreatic tail underwent robotic distal pancreatectomy. During mobilization of the pancreatic tail by an inferior approach, the root of the splenic artery was injured by the joints of the robotic instruments located outside the surgical field and the bleeding became uncontrollable under the robotic operation. It is important to always be aware of what the forceps are in contact with outside the surgical field. While dissecting the left subdiaphragmatic area in robotic distal pancreatectomy, the root area of splenic artery tends to be outside the surgical field. More attention should be paid to the positional relationship between the forceps trajectory and the major blood vessels by checking the surgical field from a distant view on a regular basis.

Pancreatic tumor enucleation is a procedure that can preserve pancreatic function and is sometimes performed using a minimally invasive approach. Recently, a single-port robotic platform called da Vinci SP has been developed. However, the technical details of pancreatic tumor enucleation using da Vinci SP have not been reported to date. We report a male patient in his 70s who underwent robotic SP pancreatic tumor enucleation for a pancreatic neuroendocrine tumor. The dissection between the tumor and pancreatic parenchyma was performed using the double bipolar technique. The operative time was 139 min, and the estimated blood loss was 4 mL. The patient had an uneventful recovery and was discharged on the sixth day after the surgery. Robotic SP pancreatic tumor enucleation appears to be a feasible procedure with lower invasiveness and better cosmesis.

Surgical techniques and outcomes of minimally invasive anatomic liver resection (AR) using the extrahepatic Glissonian approach for hepatocellular carcinoma (HCC) are undefined. In 327 HCC cases undergoing 185 open (OAR) and 142 minimally invasive (MIAR; 102 laparoscopic and 40 robotic) ARs, perioperative and long-term outcomes were compared between the approaches, using propensity score matching. After matching (91:91), compared to OAR, MIAR was significantly associated with longer operative time (643 vs. 579 min, p = 0.028); less blood loss (274 vs. 955 g, p < 0.0001); a lower transfusion rate (17.6% vs. 47.3%, p < 0.0001); lower rates of major 90-day morbidity (4.4% vs. 20.9%, p = 0.0008), bile leak or collection (1.1% vs. 11.0%, p = 0.005), and 90-day mortality (0% vs. 4.4%, p = 0.043); and shorter hospital stay (15 vs. 29 days, p < 0.0001). On the other hand, laparoscopic and robotic AR cohorts after matching (31:31) had comparable perioperative outcomes. Overall and recurrence-free survivals after AR for newly developed HCC were comparable between OAR and MIAR, with potentially improved survivals in MIAR. The survivals were comparable between laparoscopic and robotic AR. MIAR was technically standardized using the extrahepatic Glissonian approach. MIAR was safe, feasible, and oncologically acceptable and would be the first choice of AR in selected HCC patients.

Although tumor size (TS) is known to affect surgical outcomes in laparoscopic liver resection (LLR), its impact on laparoscopic major hepatectomy (L-MH) is not well studied. The objectives of this study were to investigate the impact of TS on the perioperative outcomes of L-MH and to elucidate the optimal TS cutoff for stratifying the difficulty of L-MH. This was a post-hoc analysis of 3008 patients who underwent L-MH at 48 international centers. A total 1396 patients met study criteria and were included. The impact of TS cutoffs was investigated by stratifying TS at each 10-mm interval. The optimal cutoffs were determined taking into consideration the number of endpoints which showed a statistically significant split around the cut-points of interest and the magnitude of relative risk after correction for multiple risk factors. We identified 2 optimal TS cutoffs, 50 mm and 100 mm, which segregated L-MH into 3 groups. An increasing TS across these 3 groups (≤ 50 mm, 51–100 mm, > 100 mm), was significantly associated with a higher open conversion rate (11.2

Purpose Anatomic isolated liver segmentectomy 8 (ILSeg8) for malignancies remains technically challenging. The feasibility, safety, and oncologic validity of laparoscopic ILSeg8 are undefined, and thus were evaluated in comparison with the open approach. Methods This study enrolled 35 open and 29 laparoscopic ILSeg8 cases of hepatocellular carcinoma ( n = 47), metastatic liver tumors ( n = 16), and intrahepatic cholangiocarcinoma ( n = 1) at our institution. The surgical techniques were based on the pre-hepatectomy extrahepatic Glissonian pedicle control, followed by cranial-to-caudal parenchymal dissection from the hepatic vein root side. The short- and long-term outcomes after ILSeg8 were retrospectively evaluated and compared between the open and laparoscopic approaches using 1:1 propensity score matching (PSM). Results Both before and after PSM, the laparoscopic ILSeg8 group had significantly less blood loss, lower postoperative serum bilirubin level, and a shorter postoperative hospital stay than the open group. The overall survival rates were comparable between the laparoscopic and open groups before ( P = 0.017) and after ( P = 0.043) PSM, with the similar recurrence-free survival rates between the groups. In a multivariable analysis of the cohort before PSM ( n = 64), the laparoscopic approach was identified to be an independent factor for favorable overall survival (hazard ratio = 0.20, P = 0.039). Conclusion Laparoscopic ILSeg8 using the extrahepatic Glissonian approach and hepatic vein root at first parenchymal dissection was feasible, safe, and oncologically acceptable. In ILSeg8 for malignancy, the laparoscopic approach potentially confers short-term advantages over the open approach with comparable long-term outcomes in select patients.

COVID-19 due to SARS-CoV-2 spread from China in December 2019 and is still a worldwide problem in August 2022.The seventh wave of the epidemic has arrived in Japan, and the number of infected patients is increasing.We report here our experience with a case of COVID-19 1 month after living donor liver transplantation.A 69-year-old female with decompensated cirrhosis due to nonalcoholic steatohepatitis underwent living donor liver transplantation.The donor was her 43-year-old daughter, and the graft was from the right lobe of the liver.The patient had postoperative bile leak and underwent reoperation on postoperative day 4, but otherwise, the postoperative course was generally good.The recipient's blood type was B Rh+ and the donor's blood type was A Rh+.The patient was immunosuppressed with FK, MMF, and steroids after surgery.On postoperative day 32, the patient developed a sore throat, hoarseness, and low-grade fever.PCR test was positive for SARS-CoV-2, and the patient was diagnosed with COVID-19.Respiratory failure was not observed, and the patient was considered mild illness.Remdesivir 200 mg/ day was administered for 3 days, and the dose of MMF was reduced to half.FK and steroids were continued at the same dose, however, FK was measured daily at trough level.Symptoms disappeared 3 days after the onset of the disease, and the trough level of FK passed without significant change.With the spread of COVID-19 infection, the number of cases of COVID-19 after transplantation is likely to increase, and accumulation and analysis of medical data is desirable.

BACKGROUND/PURPOSE:Surgical outcomes and utility of robotic liver resection (RLR) are undefined. METHODS:We retrospectively studied perioperative and long-term outcomes of the single-center 120 RLRs including non-anatomic (NAR, n = 58) and anatomic (AR, n = 62) resections. To evaluate the feasibility and safety of RLR, perioperative outcomes of RLR (n = 103) were compared to those of open (OLR, n = 495) or laparoscopic (LLR, n = 451) resection in liver-only resections without reconstruction, using 1:1 propensity score matching (PSM). The changing trends from the earlier to the later RLR cases were assessed. Long-term outcomes were compared between RLR and LLR. RESULTS:Various types of RLR with different surgical difficulties were performed, with mostly comparable postoperative morbidity between AR and NAR, or among AR subtypes. In segmentectomy and sectionectomy cases, perioperative outcomes significantly improved in the later period. In comparison between PSM-selected OLR and RLR cases (87:87), RLR had significantly longer operative time, less blood loss, and shorter hospital stay. PSM-selected LLR and RLR cases (91:91) showed comparable perioperative outcomes. Overall and recurrence-free survivals after RLR for newly diagnosed hepatocellular carcinoma and colorectal metastasis were comparable to those after LLR. CONCLUSIONS:RLR is applicable to various types of liver resection with acceptable perioperative and long-term outcomes in select patients.

Background: Conventional open distal pancreatectomy with en bloc celiac axis resection (DP-CAR) using the ventral approach is technically challenging, highly invasive, and not easy to ensure ample dorsal surgical margins. Hence, we describe a novel minimally invasive strategy for DP-CAR using the retroperitoneal-first laparoscopic approach (Retlap), i.e., Retlap DP-CAR, for locally advanced pancreatic body cancer (LAPC), and assess its utility. Methods: Retlap DP-CAR was performed in 10 patients with LAPC that was categorized as either unresectable (UR-LA, n = 4) or borderline (BR-A, n = 6). Neoadjuvant chemotherapy was applied on 8 patients and upfront surgery on 2. Retlap was used to create a working space in the retroperitoneal cavity between the pancreatic body and the left kidney and confirm technical resectability, such as securing the celiac axis and preserving the superior mesenteric artery in an early operative stage. Retlap DP-CAR was laparoscopic in 8 patients and robotic in 2. Surgical procedures are directly manipulated from the dorsal side of the pancreas and tumor, facilitating confirmation of technical resectability and obtaining ample dorsal margins in a no-touch isolation approach. Once technical resectability was confirmed, the procedure was converted to the ventral approach for completing DP-CAR.Results: Median operating time and blood loss during Retlap were 271 min and 10 mL, respectively, while median resection time and intraoperative blood loss were 582 min and 412 mL, respectively. Tumor-free resection margins were obtained in all cases. The major morbidity rate (C-D > IIIa) was 10%. No mortality was recorded within 90 days. Median overall survival was 53.8 months [95% confidence interval 32.7-75.0].Conclusions: Retlap DP-CAR is a novel minimally invasive procedure for resecting LAPC located close to the celiac axis. It is both safe and feasible, enables determination of technical resectability, achieves dorsal surgical mar-gins, and can improve outcomes and QOL in patients with LAPC.

Background: Minimally invasive pancreaticoduodenectomy (MIPD), including laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD), is technically demanding because of pancreaticojejunostomy (PJ). Postoperative pancreatic fistula (POPF) is the most serious complication of MIPD and open pancreaticoduodenectomy (OPD). Contrary to expectations, conventional PJ in MIPD did not improve POPF rate and length of hospital stay. High POPF rates are attributed to technical issues encountered during MIPD, which include motion restriction and insufficient water tightness. Therefore, we developed wrapping double-mattress anastomosis, the Kiguchi method, which is a novel PJ technique that can improve MIPD. Herein, we describe the Kiguchi method for PJ in MIPD and compare the outcomes between this technique and conventional PJ in OPD. Methods: The current retrospective study included 83 patients in whom the complete obstruction of the main pancreatic duct by pancreatic tumors was absent on preoperative imaging. This research was performed from September 2016 to August 2020 at Fujita Health University Hospital. All patients were evaluated as having a soft pancreatic texture, which is the most important factor associated with POPF development. Briefly, 50 patients underwent OPD with conventional PJ (OPD group). Meanwhile, 33 patients, including 15 and 18 who had LPD and RPD, respectively, underwent MIPD using the Kiguchi method (MIPD group). After a 1:1 propensity score matching, 30 patients in the OPD group were matched to 30 patients in the MIPD group. Results: The patients' preoperative data did not differ. The grade B/C POPF rate was significantly lower in the MIPD group than in the OPD group (6.7% vs 40.0%, p = 0.002). The MIPD group had a significantly shorter median length of hospital stay than the OPD group (24 vs 30 days, p = 0.004). Conclusion: The novel Kiguchi method in MIPD significantly reduced the POPF rate in patients without complete obstruction of the main pancreatic duct.

Background Acute obstruction of the hepatic vein (HV) or the portal vein (PV), particularly when it occurs during liver surgery, is potentially fatal unless repaired swiftly. As surgical interventions for this problem are technically demanding and potentially unsuccessful, other treatment options are needed. Case presentation We report two cases of acute, surgically uncorrectable HV or PV obstruction during liver resection or living donor liver transplantation (LDLT), which was successfully treated with urgent intraoperative placement of endovascular stents using interventional radiology (IVR). In Case 1, a patient with colonic liver metastases underwent a non-anatomic partial hepatectomy of the segments 4 and 8 with middle hepatic vein (MHV) resection. Additionally, the patient underwent an extended right posterior sectionectomy with right hepatic vein (RHV) resection for tumors involving RHV. Reconstruction of the MHV was needed to avoid HV congestion of the anterior section of the liver. The MHV was firstly reconstructed by an end-to-end anastomosis between the MHV and RHV resected stumps. However, the reconstruction failed to retain the HV outflow and the anterior section became congested. Serial trials of surgical revisions including re-anastomosis, vein graft interposition and vein graft patch-plasty on the anastomotic wall failed to recover the HV outflow. In Case 2, a pediatric patient with biliary atresia underwent an LDLT and developed an intractable PV obstruction during surgery. Re-anastomosis with vein graft interposition failed to restore the PV flow and elongated warm ischemic time became critical. In both cases, the misalignment in HV or PV reconstruction was likely to have caused flow obstruction, and various types of surgical interventions failed to recover the venous flow. In both cases, an urgent IVR-directed placement of self-expandable metallic stents (SEMS) restored the HV or PV perfusion quickly and effectively, and saved the patients from developing critical conditions. Furthermore, in Cases 1 and 2, the SEMS placed were patent for a sufficient period of time (32 and 44 months, respectively). Conclusions The IVR-directed, urgent, intraoperative endovascular stenting is a safe and efficient treatment tool that serves to resolve the potentially fatal acute HV or PV obstruction that occurs in the middle of liver surgery.

Potential conflict of interest: Nothing to report. TO THE EDITOR: The outflow congestion of liver grafts is potentially life‐threatening in living donor liver transplantation (LDLT) using the right liver graft (RLG) devoid of the middle hepatic vein (MHV) or the right posterior section graft (RPSG). To prevent congestion of the right anterior section of an implanted RLG, it is crucial to reconstruct donor MHV tributaries using vascular grafts. Congestion of the right hepatic vein (RHV) due to an anastomotic stricture or trunk twisting can also be prevented by effective venoplasty using vascular grafts. Among such grafts, cryopreserved homologous vein grafts are common,(1) but they are limited in availability and long‐term patency. Although prosthetic graft use has increased,(2) these grafts have risks of infection and thrombosis formation. In this context, the procurement of autologous vascular grafts from the recipient liver (which will be discarded) is a viable option from technical, economical, and patient safety–related standpoints. Although autologous portal vein grafts (PVGs) have been reported,(3) we considered recovering autologous hepatic vein grafts (AHVGs) as another source of vascular grafts. Herein, we present our techniques for procuring AHVGs by ex situ and in situ methods and describe the AHVG and patient outcomes in 4 patients receiving LDLTs. The study was conducted in accordance with the Declaration of Helsinki (2000) and approved by the institutional research board (HM19‐064). Informed consent was obtained from all patients. Surgical Techniques for the Recovery of AHVG The Ex Situ Method After liver explantation, the RHV trunk was dissected as a vein graft out of the explant, with the branches being meticulously ligated and divided (Fig. 1). To prevent injury to the vein wall, we carefully dissected between the RHV trunk wall and the surrounding liver parenchyma, from the RHV root‐side stump. This preserved the fibrous tissue on the vein wall. The obtained graft was checked for leakage with a saline infusion.FIG. 1: The ex situ (A and B, patient 1) and in situ (C‐E, patient 2) methods for recovering the RHV trunk as an AHVG. (A) Dissection between the liver parenchyma and the vein wall of the RHV (arrow) of the explanted liver. (B) The AHVG (RHV graft) was used as an interposition graft between the donor V5 and the recipient IVC. (C) Schematic illustration of the in situ splitting of the recipient liver parenchyma for recovering the RHV graft. Note that the right portal vein (RPV), RHA, LHA, and common bile duct (CBD) were already divided, though the LPV, LHV, and MHV were left open. The root of the RHV was taped, and its trunk was exposed from the root side along with its major tributary from the segment 7 (V7). Minor venous branches were treated by pinching with bipolar coagulation. (D) An RHV graft (10 cm long) in conjunction with a V7 piece (2 cm long) was recovered as an AHVG. It was divided into the proximal and distal parts, and each piece was used as a separate vein graft. (E) The V7 stump of the proximal part of the RHV graft was anastomosed to the donor V8, and the trunk of the proximal part of the RHV graft was longitudinally opened and worked as an anterior wall patch for the anastomosis between the donor RHV orifice and IVC. The distal part of the RHV graft was used as an interposition graft between the donor V5 and PVG, which was anastomosed to the IVC.The In Situ Method During hilar dissection and hepatectomy in the recipient, the left portal vein (LPV) and the 3 major hepatic veins were retained. Then, the recipient RHV was exposed and isolated from its root side by transecting the liver parenchyma in the cranial‐to‐caudal direction using ultrasonic shears and a bipolar coagulator (Fig. 1C). During the procedure, the right liver inflow was blocked to reduce blood loss, but the LPV and the left hepatic veins (LHVs) and MHV were kept open to retain blood flow to the left liver (Fig. 1C). Adequate manual compression of the RHV root with the surgeon’s left fingers was useful for the outflow control (Fig. 1C). We were able to obtain RHV grafts of any desired length up to approximately 10 cm. When necessary, a significant V7 could be procured in conjunction with the RHV trunk (Fig. 1D). The AHVG procurement was followed by a total hepatectomy. An Example Patient Using the AHVG A 59‐year‐old male with end‐stage nonalcoholic steatohepatitis (NASH) underwent an LDLT using an RLG (Table 1, patient 2). As complex hepatic vein reconstructions (HVRs) of the RHV, V5, and V8 were necessary, we recovered both AHVG and PVG. An RHV trunk (10 cm long) in conjunction with a V7 piece (2 cm long) was procured en bloc as an AHVG using the in situ method (Fig. 1D). An autologous PVG was also procured in situ. The obtained AHVG was divided into 2 pieces, each of which was used separately (Fig. 1D,E). The donor liver had separate V5 and V8 orifices that needed to be reconstructed. The V7 stump of the proximal AHVG was anastomosed to the donor V8 orifice, and the posterior wall of the longitudinally opened AHVG was anastomosed to the anterior wall of the donor RHV (Fig. 1E). This composite graft worked as the anterior wall patch for the RHV reconstruction. Separately, the distal AHVG was used as an interposition graft between the donor V5 and PVG that was anastomosed to the vena cava (Fig. 1E). TABLE 1 - Summary of 4 LDLT Patients Using AHVG Patient 1 Patient 2 Patient 3 Patient 4 Patient age, years 56 59 55 18 Sex Male Male Male Female Indication CLC NASH PBC BA MELD score 13 11 17 9 PT‐INR 1.37 1.27 0.96 0.98 PC, ×104/mm3 3.6 1.8 13.4 21.2 Liver graft type RLG RLG RPSG RPSG Liver graft weight, g 681 553 436 372 Actual GRWR, % 0.83 0.83 0.67 0.54 Method of AHVG recovery Ex situ In situ In situ In situ AHVG (length) RHV (3 cm) RHV (10 cm) with adjoining V7 (2 cm) RHV (8 cm) with adjoining V7 (3 cm) RHV (5 cm) Time needed for AHVG recovery, minutes 46 22 18 30 EBL during AHVG recovery, mL NA 5 10 30 Warm ischemia time, minutes 66 70 92 101 Cold ischemia time, minutes 197 179 90 109 Anhepatic phase, minutes 274 229 151 175 Pattern of AHVG usage Interposition (V5) Proximal part: Interposition and AWP (RHV with V8) Interposition and AWP (RHV with V7) AWP (RHV) Distal part: Interposition (V5) Outcomes Patency of AHVG (duration) V5: Patent (18 months) RHV: Patent (7 months) RHV: Patent (51 months) RHV: Patent (31 months) V8: Patent (7 months) V7: Narrowed (2 months) V5: Patent (7 months) Postoperative complications PVT, BD stricture Bile leak, TMA Stricture of V7 ACR Survival (duration) Dead (18 months) Dead (7 months) Alive (51 months) Alive (31 months) Cause of death Suicide Sepsis NA NA Results Details of the AHVGs and outcomes of the 4 patients are shown in Table 1. In our series, 3 males and 1 female between 18 and 59 years of age with the indicated liver diseases underwent LDLTs using AHVGs. There were 2 patients who underwent transplantation with RLGs, whereas the other 2 underwent transplantation with RPSGs. The ex situ method was used in 1 patient, whereas the in situ was used in the other 3. The length of the procured RHV trunks ranged from 3 to 10 cm. In 2 patients, the adjoining V7 was recovered with the RHV trunk. The time needed for AHVG recovery did not exceed 30 minutes in the in situ patients and was 46 minutes in the ex situ patient. The estimated blood loss (EBL) in the in situ patients was minimal. The anhepatic phase during LDLT was 274 minutes in the ex situ patient and 151, 175, and 229 minutes in the in situ patients. The AHVGs were used for interposition in patient 1 and partly in patient 2. In patient 3 and partly in patient 2, the AHVGs were used for combined interposition and wall patch venoplasty. In patient 4, the AHVG was used for wall patch plasty. Postoperative patency of HVRs using AHVGs evaluated by computed tomography (CT) and changes in representative serum biomarkers are presented in Fig. 2. Of the 7 HV anastomoses using pieces of AHVGs (n = 7: V5 in patient 1; RHV, V8, and V5 in patient 2; RHV and V7 in patient 3; and RHV in patient 4), 6 were patent for 7‐51 months after LDLT. However, the V7 reconstruction in patient 3 presented a stricture at 2 months (Fig. 2D). Therefore, the patency rates on a patient basis were 75% at 6 months (patients 1, 2, and 4) and 50% (patients 1 and 4) at 12 months, respectively. The biomarkers showed an acceptable recovery, except for sustained high total bilirubin (TB) and low albumin levels in patient 2, due to bile leak and infection (Fig. 2E). Of the patients, 2 died of causes unrelated to HVRs, and the remaining 2 have been alive for 31 and 51 months, respectively.FIG. 2: Postoperative CT findings in patients (A) 1, (B) 2, and (C and D) 3 and (E) changes in representative serum biomarkers until posttransplant month 3 in all patients. (A) In patient 1, the interposition RHV graft for reconstruction of donor V5 was patent (arrows). (B) In patient 2, the RHV and V8 conduit reconstruction using the proximal part of the RHV graft was patent (arrowheads). (C) In patient 3, the RHV and donor V7 were patent at 1 month after transplantation (arrows); (D) however, occlusion of the donor V7 was found at 2 months (single arrow), and the RHV reconstruction was patent (arrows). (E) Changes in the serum levels of TB, PT‐INR, and albumin in all 4 patients.Discussion Although this is a small patient series, our findings suggest that AHVGs can be successfully procured by both ex situ and in situ methods and that they are applicable even to multiple or complex HVRs in LDLT. There are few reports on AHVG in LDLT. One study describes MHV tributary reconstructions using the recipient MHV preserved in situ, not as an isolated vein graft.(4) To the best of our knowledge, the in situ procurement of isolated AHVGs has not been previously reported. Such limited use of AHVGs may stem from the belief that safely isolating hepatic veins from cirrhotic livers is difficult and that the vein wall is too thin to be used for HVR. In our method, however, the RHV trunk can be isolated with a thick wall by attaching the fibrous tissue around it. This tissue (“Laennec’s capsule”) essentially covers the liver parenchyma(5) and can be intentionally preserved on the RHV wall by exposing it from the root side (Fig. 1). Furthermore, the RHV grafts available by our methods can be long and, whenever necessary, obtained with significant V7 branches. Such vein grafts are useful in multiple or complex HVRs. For instance, they can be used as multiple split pieces, as in patient 2. In our cohort, 6 of the 7 anastomoses using AHVGs were patent for more than 6 months, and the 6‐ and 12‐month patency rates on a patient basis were 75% and 50%, respectively. Because this is a small patient series, any conclusions regarding AHVG patency are unlikely to be drawn. Therefore, further accumulation of data on patients undergoing systematic and standardized ultrasound or CT surveillance to document patency rates at 6 and 12 months is warranted in future studies. Patient outcomes, including laboratory data, seemed satisfactory, and the 2 deaths were unrelated to HVR. When comparing the ex situ and in situ methods, we consider that the latter may be superior to the former in terms of technical simplicity, procedural time, and the length of the anhepatic phase. The former requires meticulous ligation of tributaries as well as leak tests and wall repair. In the latter, the division of venous branches is completed in an acceptable length of time with minimal blood loss, mostly by bipolar coagulation. Ultrasonic aspirators could be another useful device for vein exposure. Furthermore, the ex situ recovery after explantation lengthens the anhepatic phase, while the in situ procurement does not require additional anhepatic time because the LPV flow is maintained during the procedure. In recipients with hepatocellular carcinoma (HCC), tumor cell implantation on AHVGs is a potential concern. Patient 1 received a hepatectomy at 1.5 pretransplant years because of HCC, which did not recur until his death 18 months after transplant. A study on LDLTs using the native MHV trunks for HVRs in 14 patients with nonruptured HCC reported no posttransplant tumor recurrence.(4) Nevertheless, even in well‐selected recipients with HCC, the possibility of spreading microscopic tumor cells on the hepatic vein wall must be considered. Therefore, our current opinion is that AHVGs should not be procured from livers carrying overt malignancy. In conclusion, an AHVG is a viable vascular graft that is safely recoverable and usable in HVR during LDLT. Further studies are necessary to confirm the safety and efficacy of using AHVGs. Their use may serve to expand the source of vascular grafts and decrease the need to sacrifice nonhepatic vessels from LDLT recipients or donors, thereby increasing their safety.