Donor evaluation and selection: rigorous multistep process - 1) ABO compatibility, voluntariness, psychosocial assessment; 2) liver function tests, hepatitis screening, autoimmune markers, alpha-1 antitrypsin; 3) imaging - CT volumetry (residual liver volume must be ≥30-35% in donor), CTA/MRA for arterial and portal anatomy, MRCP or intraoperative cholangiography for biliary anatomy; 4) liver biopsy if steatosis suspected (>20-30% steatosis disqualifies); 5) cardiac (stress echo if >40 yr), pulmonary (PFT), renal evaluations. Donor age 18-55, BMI <30, no significant comorbidity, normal liver function and architecture. Recipient must meet transplant criteria with MELD score and tumor staging (HCC within Milan criteria).
Surgical technique (right hemihepatectomy): donor positioned supine, midline or J-shaped incision (or laparoscopic/robotic in expert centers). Steps - 1) cholecystectomy and intraoperative cholangiography to map biliary anatomy; 2) hilar dissection - identification and isolation of right hepatic artery, right portal vein, right hepatic duct; 3) division of short hepatic veins to vena cava; 4) parenchymal transection along principal scissura (Cantlie line) using ultrasonic dissector + bipolar + clips, with intermittent Pringle maneuver; 5) division of right hepatic vein, right portal vein, right hepatic artery, and right hepatic duct in sequence at end of dissection; 6) graft removal, perfusion with preservation solution, transfer to recipient OR; 7) donor closure with hemostasis verification. Operative time 6-10 hours, blood loss 300-800 mL.
Donor outcomes and complications: hospital stay 7-10 days, return to full activity 6-12 weeks. Complications (35-40% in RH, 15-20% in LLS) - biliary leak/stricture (5-10%), wound infection (3-5%), bleeding requiring transfusion (5-10%), bowel obstruction (1-3%), pleural effusion (10-20%), DVT/PE (1-2%), incisional hernia (5-10%), psychological distress, transient liver dysfunction. Donor mortality - RH 0.2-0.5%, LLS <0.1%. Liver regeneration - donor regenerates to 75-80% of original volume by 6 months, full function by 1 year. Long-term donor outcomes are excellent with normal liver function and quality of life. Comprehensive informed consent with explicit discussion of risks, alternative recipient options (deceased donor), and right to withdraw at any time before incision is mandatory.