Background: Living-donor liver transplantation using a right-lobe graft has increased the frequency of hilar anatomical variations despite its advantage of a larger graft volume. Methods: Sixty-seven living-donor liver transplantations using right-lobe grafts are reviewed, regarding the surgical anatomy of hilar vascular and biliary systems. Results: The portal anatomy was classified into four types. The incidence of double portal vein was 6.0% (n = 4), and for such cases a unified orifice (n = 1) or a Y-graft (n = 3) was used for reconstruction. The arterial system was classified into five types. The incidence of arterial complications was 6.0% (n = 4), all of which occurred in cases where the graft artery was connected to the recipient's right hepatic artery. The biliary system was classified into four types. The incidence of a double bile duct was 7.5% (n = 5), and that of a unified one was 29.8% (n = 20). Hepaticojejunostomy was more prone to biliary sepsis (25.0%) and bile leakage (18.8%) than duct-to-duct connection (0 and 2%, respectively). Conclusion: Hilar anatomical variations in right-lobe living-donor liver transplantation could be managed after preoperative detailed evaluation of the graft and intraoperative appropriate surgical decision and techniques.
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