Ex-Situ Modified Segment 2 Graft After Left Lateral Sector Procurement in Pediatric Liver Transplantation: Farewell to Delayed Abdominal Closure?

Abstract

<h4>Background</h4>The left lateral sector (LLS) from an adult donor is often the preferred option to provide a graft in pediatric liver transplantation (pLT). It can result, however, in a challenge when transplanting small recipients given the size mismatch, jeopardizing the abdominal wall closure. The existing options in this scenario are closing with a temporary mesh (delayed abdominal closure) or the surgical modification of the graft, either a non-anatomical reduction (NAR) or an anatomical segmentectomy.<h4>Methods</h4>We present our experience altering ex-situ the LLS and producing a Modified Segment 2 graft (MS2 or almost complete S3 exeresis) with the intention to reduce the incidence of temporary mesh closure.<h4>Results</h4>From January 2014 to 2024, 206 pLT were done, including 67 recipients less than 10 kg with an initial donor weight-recipient weight ratio of 9 (DWRWR). 42 were full-LLS, 15 were NAR, and 10 were MS2. The MS2 generated the smallest grafts (median of 195 g), allowing it to reduce the initial Graft Weight-Recipient Weight Ratio (GWRWR) below 3.5. All but one patient in the MS2 had a primary abdominal wall closure, a goal not obtained when using the full-LLS or NAR. Postoperative outcomes for MS2 were no different when compared with other grafts.<h4>Conclusion</h4>In our experience, when transplanting recipients less than 10 kg, ex-situ MS2 grafts can be produced safely and it facilitates primary abdominal wall closure, avoiding any further extra surgical procedure to achieve final abdomen closure.