*Purpose: In Eastern countries Budd Chiari syndrome (BCS) is most often caused by the membranous obstruction of the vena cava (MOVC). During living donor liver transplantation (LDLT), recipient inferior vena cava (IVC) should be preserved. So, when LDLT is contemplated for BCS, management of IVC is of primary concern. There are several options for managing MOVC in LDLT, including replacement or patch plasty of the occluded IVC with either synthetic or allogeneic graft. The authors applied a new technique that the IVC segment including MOVC and right hepatic vein (RHV) is excised altogether and reconstructed (Fig) in a case of LDLT for MOVC-induced BCS complicated by cirrhosis and HCC and report here with video.

*Methods: Briefly, after completion of recipient hepatectomy, right diaphragm is opened and right atrium was clamped as well as IVC just above the right renal vein. Through the RHV opening, MOVC could be identified. The fibrotic obstructed IVC segment, located at the level of the diaphragm, was resected in a diagonal fashion, shaping the lowermost RHV wall matched the lowest point of the defect (Fig). The gap between the upper and lower IVC was about 1 cm long in the posterior side and the posterior IVC wall could be primarily closed with 5/0 Prolene running suture. The defect in the anterior wall was diamond shaped and 4 cm long and 2 cm wide. Upper half and left half of this anterior defect in IVC wall was closed with an allograft patch. So there remained an opening of 2 cm long at the anterior IVC wall defect, corresponding to the previous RHV site. After putting the graft in the abdomen, a slit incision extending downward from the remnant opening (inferior tip of the previous RHV) was made in the recipient IVC for RHV anastomosis. RHV anastomosis was done with 5/0 Prolene suture.

*Results: Postoperatively, 4cm long thrombus extending from the left renal vein to the IVC was identified on a routine CT checked 4 days after the operation and Warfarin have been given until now, 10 months after the operation. She stayed for 28 days after the operation because of backpain (radiculopathy) and far-distance to home.

*Conclusions: When managing IVC web in LDLT for membranous obstruction of vena cava, , IVC web can be easily located and excised by making a diagonal incision in the IVC extending upward and bilaterally from the inferior tip of RHV. The ensuing RHV anastomosis can be constructed widely as a one-step procedure. The control of right atrium can be done trans-diaphragmatic approach.

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