Two‐stage explantation of a cirrhotic liver for liver transplantation in a patient with a coronary bypass using a right gastroepiploic artery

The right gastroepiploic artery (RGEA) has been considered a fair alternative choice for a coronary bypass graft. However, after such nonanatomical anastomosis, it is difficult to plan abdominal surgery without endangering the critical arterial supply. To date, gastrectomies and pancreatoduodenectomies have been reported in patients with RGEA grafts for coronary bypass. We recently performed living donor liver transplantation (LDLT) in a patient who had previously undergone coronary bypass surgery using RGEA 3 years before the LDLT. This is the first case of LDLT after coronary bypass using RGEA. We report our two-stage explantation of the cirrhotic liver without any injury to the RGEA. The patient was a 63-year-old man suffering from end-stage liver failure and persistent cholangitis due to primary sclerosing cholangitis in May 2007. LDLT was indicated, and preoperative angio-computed tomography was performed and revealed that the patent RGEA graft was located on the left lobe of the cirrhotic liver (Fig. 1A). The LDLT was scheduled on May 28, 2007, with the attendance of a cardiac surgeon and full monitoring of cardiac function, including transesophageal ultrasound. Laparotomy showed that the RGEA was on the left lobe of the cirrhotic liver (Fig. 1B). In order to liberate the RGEA, the left lateral segmentectomy was performed first with the Cavitron ultrasonic surgical aspirator system (CUSA; Valley-Lab, Boulder, CO) and saline-linked cautery (Dissecting Sealer DS 3.0, Tissue Link Medical, Inc., Dover, NH) with minimal blood loss (Fig. 1B,C). Subsequently, the remnant right lobe of the liver was explanted without a spastic event of the RGEA being caused; a left lobe graft from a living donor was then implanted. The RGEA was placed on the dorsal side of the graft because this was the natural position of the RGEA (Fig. 1D). No cardiac event occurred throughout the LDLT, with total blood loss of 1900 g during a total operative time of 1015 minutes. The patient’s postoperative course was uneventful, and he was discharged from our hospital on the thirty-first day after the LDLT. As of this writing, he has been doing well for 8 months since the LDLT. Performing LDLT in patients after previous abdominal surgery is a therapeutic challenge. In particular, the gastroepiploic artery used for coronary arterial bypass is a cumbersome entity because damage to the artery can cause significant consequences for the patient, including cardiac infarction. We performed two-stage explantation of the liver because it was impossible to mobilize the cirrhotic liver with the RGEA in place as the RGEA was present on the left lobe of the liver. After we recognized the situation through a preoperative three-dimensional recon-