title: Split-liver full-left full-right: proposal for an operative protocol.
abstract: BACKGROUND
  Worldwide, organ shortage is a major limiting factor to transplantations. One possible way to face graft scarcity is splitting full livers into hemilivers; this procedure would allow transplantation in 2 adult recipients with the use of a single organ from a deceased donor.
  
  
  OBJECTIVE
  The goal of this study was to describe an adult-to-adult split liver operative protocol and share it between centers interested in exploring this procedure.
  
  
  METHODS
  A literature review was first conducted to elaborate on the present protocol; second, selection criteria for suitable deceased donors were identified. The technical aspects of performing the procurement were also analyzed; finally, the recipient selection criteria and the transplantation criteria were determined.
  
  
  RESULTS
  The donor characteristics should be consistent with the following: age≤55 years; weight≥70 kg; body mass index<28 kg/m2; intensive care unit stay<7 days; sodium level<160 mEq/L if the intensive care unit stay is >2 days; maximum transaminase value 3 times normal; hemodynamic stability; negative for hepatitis B surface antigen, hepatitis C virus, and human immunodeficiency virus; macrosteatosis<20%; macroscopic adequacy; and absence of anatomic anomalies requiring complex reconstruction. The procurement hospital should provide the preoperative computed tomography scan, liver dissector, and the intraoperative ultrasound. Indication for in situ or ex situ splitting depends on the hepatic vein outflow anatomy. Graft-to-recipient weight ratio should be ≥1%, and the graft-to-recipient spleen size ratio should be ≥0.6. United Network for Organ Sharing status 1 and 2A recipients are excluded, as are patients with transjugular intrahepatic portosystemic shunts. Hemiliver transplants are performed as in living-donor liver transplantation, and portal hyperflow is corrected by splenic artery ligation, splenectomy, and portal infusion of vasoactive drugs.
  
  
  CONCLUSIONS
  The present protocol was proposed to test the validity of the full-left full-right split liver procedure. A retrospective analysis found that 130 transplantations were suitable for this procedure according to the present protocol in the period January 1, 2008, through December 31, 2011 (65 donors). We believe that these numbers could be greatly increased once this procedure is proven feasible and safe within the proposed criteria.
authors.affiliation: Chirurgia Generale e dei Trapianti, Ospedale Niguarda, Milano, Italy. Electronic address: fabio.ferla@ospedaleniguarda.it.
authors.forename: F
authors.initials: F
authors.lastname: Ferla
authors.affiliation: Chirurgia Generale e dei Trapianti, Ospedale Niguarda, Milano, Italy.
authors.forename: A
authors.initials: A
authors.lastname: Lauterio
authors.affiliation: Chirurgia Generale e dei Trapianti, Ospedale Niguarda, Milano, Italy.
authors.forename: S
authors.initials: S
authors.lastname: Di Sandro
authors.affiliation: Chirurgia Generale e dei Trapianti, Ospedale Niguarda, Milano, Italy.
authors.forename: I
authors.initials: I
authors.lastname: Mangoni
authors.affiliation: Chirurgia Generale e dei Trapianti, Ospedale Niguarda, Milano, Italy.
authors.forename: C
authors.initials: C
authors.lastname: Poli
authors.affiliation: Chirurgia Generale e dei Trapianti, Ospedale Niguarda, Milano, Italy.
authors.forename: G
authors.initials: G
authors.lastname: Concone
authors.affiliation: Chirurgia Generale e dei Trapianti, Ospedale Niguarda, Milano, Italy.
authors.forename: C
authors.initials: C
authors.lastname: Cusumano
authors.affiliation: Chirurgia Generale e dei Trapianti, Ospedale Niguarda, Milano, Italy.
authors.forename: A
authors.initials: A
authors.lastname: Giacomoni
authors.affiliation: Chirurgia Generale, Ospedale San Martino, Genova, Italy.
authors.forename: E
authors.initials: E
authors.lastname: Andorno
authors.affiliation: Chirurgia Generale e dei Trapianti, Ospedale Niguarda, Milano, Italy
authors.forename: L
authors.initials: L
authors.lastname: De Carlis
authors.affiliation: Chirurgia Generale e dei Trapianti, Ospedale Niguarda, Milano, Italy.
authors.forename: L
authors.initials: L
authors.lastname: De Carlis Luciano
mesh_terms: D000328:Adult; D000367:Age Factors; D001835:Body Weight; D046148:Donor Selection; D005260:Female; D006801:Humans; D007558:Italy; D016031:Liver Transplantation / Q000379:methods*; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D012189:Retrospective Studies; D014019:Tissue Donors / Q000600:supply & distribution