Research ArticleClinical Studies
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Modified Subtraction Technique for the Middle Hepatic Vein Tributary and Glissonean Pedicle in Right Lobe Graft Procurement

KOSEI TAKAGI, TOMOKAZU FUJI, KAZUYA YASUI, TAKEYOSHI NISHIYAMA, YASUO NAGAI, SHOHEI YOKOYAMA, YUZO UMEDA and TOSHIYOSHI FUJIWARA
In Vivo January 2026, 40 (1) 349-354; DOI: https://doi.org/10.21873/invivo.14198

Abstract

Background/Aim: The procurement of right lobe grafts while preserving the middle hepatic vein (MHV) tributaries (V5 and V8) just before graft retrieval is technically challenging. Moreover, the safe isolation of the hepatic duct from the Glissonean pedicle is essential in living donor hepatectomy. To date, few studies have reported surgical techniques for preserving the MHV tributaries during right lobe graft procurement.

Patients and Methods: This report presents our modified subtraction technique for managing the MHV tributaries and Glissonean pedicle during right lobe graft procurement. First, a subtraction technique for the MHV tributaries was initiated by isolating the right Glissonean pedicle. The lower tip of the tape was placed behind the caudate lobe and passed behind the right hepatic vein. Each end of the tape was then passed behind V5 and V8, followed by dissection of the remaining liver parenchyma between them. Subsequently, a subtraction technique for the Glissonean pedicle was applied to safely isolate the right hepatic duct and hilar plate.

Results: Between September 2011 and May 2025, seven donors underwent right lobe graft procurement using the subtraction technique for the middle hepatic vein tributaries. The mean operative time was 381 min with an estimated blood loss of 217 ml. Using the subtraction technique, all middle hepatic vein tributaries were preserved just before graft retrieval.

Conclusion: This study presents subtraction techniques used during living donor hepatectomy. The technique may facilitate liver parenchyma dissection while preserving MHV tributaries just before graft retrieval and isolating the Glissonean pedicle.

Keywords:

Introduction

Liver transplantation is a well-established approach for the curative treatment of liver decompensated cirrhosis and hepatocellular carcinoma (1, 2). The right lobe of the liver is commonly used as a graft in adult living donor liver transplantation (LDLT). To ensure donor safety, the middle hepatic vein (MHV) should be preserved in the donor’s remnant left liver. In LDLT using the right lobe as a graft, the need for hepatic vein reconstruction –including MHV tributaries (V5 and V8)– has been discussed to prevent venous congestion and outflow obstruction in the anterior sector of the graft (3). However, preserving MHV tributaries just before graft retrieval is technically challenging. Moreover, few studies have described the surgical techniques for preserving MHV tributaries during right lobe graft procurement (4). Herein, we present our modified subtraction technique for managing the MHV tributary and Glissonean pedicle during right lobe graft procurement.

Patients and Methods

Indications for hepatic vein reconstruction of MHV tributaries in right lobe graft procurement. Precise evaluation of anatomical variations and volumetric analysis was performed using a computed tomography image analysis system (Synapse Vincent; Fujifilm Medical, Tokyo, Japan) (5). Our standard protocol excludes the MHV from the right lobe graft during procurement. Therefore, hepatic vein reconstruction of MHV tributaries should be considered when the MHV drains a significant portion of segments V and VIII. Reconstruction criteria included MHV tributaries (V5 or V8) greater than 5 mm or a drainage volume exceeding 10% of the graft volume (6, 7).

Surgical techniques of a subtraction technique for the MHV tributary. After a midline laparotomy, the right lobe was fully mobilized, and the right hepatic vein (RHV) was encircled. Following cholecystectomy, hilar dissection was performed to isolate the right hepatic artery (RHA) and right portal vein (RPV). The right Glissonean pedicle (RGP), including the RHA and RPV, was encircled at this stage. Intraoperative ultrasound confirmed the MHV tributaries. Liver parenchymal dissection along Cantlie’s line was performed using a cavitron ultrasonic surgical aspirator, without Pringle’s maneuver. The major MHV tributaries (V5 and V8) were carefully dissected and encircled and were preserved until graft harvest.

A subtraction technique was then applied to dissect the liver parenchyma. First, a hanging tape was placed behind the RGP (Figure 1A). Its lower tip was positioned behind the caudate lobe and passed behind the RHV (Figure 1B). Each side of the tape was passed behind V5 (Figure 1C) and V8 (Figure 1D), and the remaining parenchyma between V5 and V8 was dissected (Figure 1E). This technique enabled effective traction and easier division of the liver parenchyma, especially near the caudate lobe.

Figure 1.
Figure 1.

Subtraction technique for the MHV tributary. A) A hanging tape was initially placed behind the right Glissonean pedicle. B) The lower tip of the tape was placed behind the caudate lobe and passed behind the right hepatic vein. C) The tape was passed behind V5. D) The tape was passed behind V8. E) The remaining liver parenchyma between V5 and V8 was then dissected.

Surgical technique: subtraction technique for the Glissonean pedicle. Safe isolation of the hepatic duct and hilar plate from the Glissonean pedicle is critical in living donor hepatectomy. The subtraction technique was employed to encircle the right hepatic duct (RHD) and hilar plate. A tape encircling the RGP was passed behind the RPV (Figure 2A) and RHA (Figure 2B), allowing safe encirclement of the RHD (Figure 2C).

Figure 2.
Figure 2.

Subtraction technique for the Glissonean pedicle. A) After encircling the right Glissonean pedicle, a tape was passed behind the right portal vein. B) The tape was subsequently passed behind the right hepatic artery, C) allowing safe isolation of the right hepatic duct and hilar plate.

Intraoperative cholangiography was used to evaluate the biliary anatomy, and the RHD and hilar plate were divided. After heparinization, the RHV, MHV tributaries (V5 or V8), RHA, and RPV of the graft were clamped and divided, and the graft was retrieved.

Bench surgery for venous reconstruction. Venous reconstruction may utilize autologous interposition grafts or synthetic grafts such as expanded polytetrafluoroethylene (e-PTFE). Suitable autologous grafts include the inferior mesenteric vein, gonadal vein, and falciform ligament. If available, deceased donor cryopreserved grafts (e.g., iliac artery or vein) may also be used (6). The MHV tributaries and grafts were anastomosed using continuous 6-0 Prolene sutures (Figure 3). Common techniques include end-to-end or end-to-side anastomosis. A simplified one-orifice venoplasty may also be effective for MHV tributary reconstruction (Figure 4) (8).

Figure 3.
Figure 3.

Bench surgery for venous reconstruction. Autologous interposition grafts or e-polytetrafluoroethylene grafts can be used. In this case, the gonadal vein was used for V5 with end-to-end anastomosis and for V8 with end-to-side anastomosis.

Figure 4.
Figure 4.

Simplified one-orifice venoplasty technique for reconstructing MHV tributaries. An interposition graft was anastomosed to the anterior side of the right hepatic vein anastomosis.

Results

Between September 2011 and May 2025, 97 donors underwent the right lobe graft procurement at out institution. The subtraction technique for the middle hepatic vein tributaries (V5 and V8) was used in seven cases out of 97. The characteristics of the donors were summarized in Table I. There were three men and four women with a mean age of 45 years. The mean operative time was 381 min with an estimated blood loss of 217 ml. Using the subtraction technique, all middle hepatic vein tributaries were preserved just before graft retrieval. Regarding postoperative outcomes, only one donor developed organ space surgical site infection. The mean postoperative length of stays was 14 days. The middle hepatic vein tributaries were reconstructed using autologous grafts from donors or recipients during bench surgery.

View this table:
Table I.

Donor characteristics who underwent the right lobe graft procurement using the subtraction technique for the middle hepatic vein tributaries.

Discussion

The present study describes our modified subtraction technique for the MHV tributary and Glissonean pedicle in right lobe graft procurement. Using this technique, liver parenchyma dissection can be performed while preserving the MHV tributary just before graft retrieval. Moreover, the subtraction technique for the Glissonean pedicle enables safe isolation of the hepatic duct and hilar plate before division.

Given that MHV reconstruction in right lobe LDLT has demonstrated efficacy with excellent outflow drainage and favorable recipient outcomes, MHV tributaries –especially those >5 mm– should be reconstructed (9). While previous studies have focused on the surgical techniques and outcomes of MHV reconstruction (6-9), few have addressed the procurement techniques for right lobe grafts that include preserving the MHV tributaries (4).

The subtraction technique offers several advantages, including easier parenchymal dissection behind the MHV tributaries and reduced compression of the surrounding tissue. Blind dissection of the caudate lobe without adequate traction may result in bleeding or bile leakage. Accordingly, the usefulness of the liver hanging maneuver has been reported (10). However, care must be taken to avoid venous injury during retraction of the hanging tape. The subtraction technique is also effective for isolating the Glissonean pedicle and may help avoid incidental injuries to the hepatic artery and portal vein.

Conclusion

Our subtraction technique for the MHV tributary and Glissonean pedicle may be useful during right lobe graft procurement. Indications for hepatic vein reconstruction of MHV tributaries should be carefully considered based on anatomical factors. This technique may assist in dissecting the liver parenchyma while preserving the MHV tributary and safely isolating the Glissonean pedicle.

Footnotes

  • Authors’ Contributions

    Conception and design: Kosei Takagi. Analysis and interpretation: Kosei Takagi, Tomokazu Fuji, Kazuya Yasui, Takeyoshi Nishiyama, Yasuo Nagai, Shohei Yokoyama, Yuzo Umeda. Drafting of the manuscript: Kosei Takagi. Critical revision of the manuscript: Toshiyoshi Fujiwara. All Authors have approved the final version of the article.

  • Conflicts of Interest

    The Authors declare no conflicts of interest regarding this study.

  • Funding

    The Authors declare that they received no funding for this report.

  • Artificial Intelligence (AI) Disclosure

    No sections involving the generation, analysis, or interpretation of research data were produced by generative AI. All scientific content was created and verified by the authors. Furthermore, no figures or visual data were generated or modified using generative AI or machine learning–based image enhancement tools.

  • Received October 4, 2025.
  • Revision received October 16, 2025.
  • Accepted October 17, 2025.

This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY-NC-ND) 4.0 international license (https://creativecommons.org/licenses/by-nc-nd/4.0).

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Modified Subtraction Technique for the Middle Hepatic Vein Tributary and Glissonean Pedicle in Right Lobe Graft Procurement
KOSEI TAKAGI, TOMOKAZU FUJI, KAZUYA YASUI, TAKEYOSHI NISHIYAMA, YASUO NAGAI, SHOHEI YOKOYAMA, YUZO UMEDA, TOSHIYOSHI FUJIWARA
In Vivo Jan 2026, 40 (1) 349-354; DOI: 10.21873/invivo.14198
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