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Surgical Techniques of

Orthotopic Liver Transplantation in AdultsJ. Hauss

Surgical Techniques of

Orthotopic Liver Transplantation in AdultsJ. Hauss



Access for Liver Transplantation



Mobilisation of the right liver and

isolation of the lower vena cava



Detachment of the upper vena cava



Division of the posterior peritoneum

along the left margin of the vena cava



The upper vena cava is encircled



VenoVeno--VenousVenous BybassBybass



History of veno-venous bypass

- in early experiments of LTX in a non-cirrhoticdog model it was discovered that clamping ofthe portal vein or inferior vena cava resulted in

death of the animal within 30minutes*

- a temporary portocaval shunt combined with a

passive femoral-to-jugular venous bypass systemwas developed**

* Moore FD et al. 1959, Transplant Bull** Starzl TE et al. 1960 Surg Gynecol Obstet



History of veno-venous bypass

- the Pittsburgh group reported in 1984 a 10%intraoperative mortality rate as a result of hemo-dynamic instability during the anhepatic phase*

- VVB consisting of heparin bonded tubing and acentrifugal pump was developed** and its efficacy

was confirmed***

* Shaw BW Jr et al. 1984 Ann Surg** Griffith B et al. 1985 Surg Gynecol Obs*** Shaw BW Jr et al. 1987 Tpl Proc



Preparation of access

for veno-venous bypass

- Isolation of saphenous vein at its outlet from thefemoral vein and ligation of collaterals

- Isolation of the axillary vein at the apex of theaxilla for 3-4cm

- Isolation of the portal vein close to the bifurcation



CanCannnulationulation forfor venoveno--venous bypasvenous bypas

saphenoussaphenous veinvein

axillaryaxillary veinvein



Cannulation for veno-venous bypass

- the circuit is filled with saline solution and connectedto the bypass pump

- the axillary vein is cannulated first

- the common iliac vein is cannulated through thesaphenous vein

- and lastly the portal vein is interrupted close to thebifurcation



Advantages of veno-venous bypass

- less cardiovascular instability- allows longer anhepatic phase

- minimizes fluid requirements and pulmonary edema- splanchnic decompression -minimal intestinal edema

- minimizes endotoxemia- reduces impairment of renal function



Disadvantages of veno-venous bypass

- increases operative and warm ischemic times

- transient hypothermia (bradycardia, hypotensionand coagulopathy)

- cannula and incision-related morbidity (vein thrombus,pulmonary or air ebolism, hematoma, lymphocele,

plexus nerve injury)- hemodilution

- increases cost



Bypass or not to bypass....

- no difference in blood product administration*- no survival benefit at 180 days due to improved

renal function at 30 days**- overall VVB related complications range

from 10 - 30%***

* Kuo PC et al. 1995 SurgeryJugan E et al. 1996 Transplantation ** Wall WJ et al. 1987 TransplantationShaw BW et al. 1984 Ann Surg *** Chari RS et al. 1998Am College of Surge



Recommended indications for the

selective use of VVB

- preexisting cardiac disease (EF<30%)

- anesthesiologist not familiar with caval clamping

- hemodynamic instability during hepatectomyor portal or caval clamping

- major bleeding during hepatectomy (> 10 units)



when bypass is installedand hepatectomy is completed...



Hemostasis of retro-hepatic space



Anastomosis of the upper vena cava



Anastomosis of the lower vena cava



Anastomosis of portal vein 1



Anastomosis of portal vein 2





Anastomosis of the hepatic artery 1





Arterial variations

A t i l t ti



Arterial reconstruction

accessory right hepatic artery in the dono



Arterial reconstruction backtable 1

accessory right hepatic artery

splenicstump



gastroduodenal stump



A i l i b k bl 3





donor iliac artery





replaced right hepatic artery in the donor

A t i l t ti b kt bl 1




replaced right hepatic artery

celiac trunkwith aortic pat

end-toend onceliac trunk

A t i l t ti b kt bl 2




replaced right hepatic arterya replaced hepatic

artery is preservedwith AMS

1

2

33

1

2

A t i l t ti




savenous vena to aorta

1. aortal

anastomosis





savenous vena to aorta 2

2. Hepatic artery

anastomosis





Anastomosis of the

bile duct



End to end biliary anastomosis 2



End-to-end-biliary anastomosis 2

discrepancies in duct diameter

biliaroplasty




End-to-end biliary anastomosis 3

small ducts

biliaroplastyon both ends




End-to-end biliary anastomosis 4

one very large duct



Placement of T tube



Placement of T-tube

Side to side biliary reconstruction



Side-to-side biliary reconstruction

Bili d i



- most centres have adopted a direct end-to-endanastomosis of the bile duct*

- in a prospective randomized controlled study comparingend-to-end with side-to-side anastomosis no statisticalsignificant difference was found in biliary complications**

Biliary duct anastomosis

* Sherman et al. 1995 Transplantatio

** Davidson et al. 1997 Brit J Surgery

Final view



normal anatomy



Bile duct and hepatic artery are



p y

interrupted, right portal branch encircled

Accessory hepatic veins are ligated



Accessory hepatic veins are ligated

the right hepatic vein is exposed

The liver is displaced upwards



and the anterior vena cava is freed

Incision of posterior peritoneal layer



c s o o poste o pe to ea aye

and exposure of the left vena cava

Clamping of the right hepatic vein trunk



Clamping of the right hepatic vein trunk

Ligation of the right portal branch



Ligation of the right portal branch

Middle and left hepatic vein are



clamped and the liver is removed

Preparing a wide common orifice



p g

Wide common orifice,



appropriate for caval anastomosis

Completion of superior caval



anastomosis, flushing of portal vein

Subhepatic caval stump is closed



p p



Portal vein thrombosis

Portal vein thrombectomy



Portal vein thrombectomy

or isolation of the spleno-mesenteric



confluence after mobilisation ofpancreatic head

Venous jumping graft with donor



iliac vein anastomosed with recipientmesenteric vein



Cavo-portal transposition 1



free completely retrohepatic cava

Cavo-portal transposition 2



Hepatectomy with long distal vena cava

Cavo-portal transposition 3.



1.

3.

2

supra hepatic cava

flush portal vein

close lower cava

Cavo-portal transposition 4.



Anastomosis recipient vena cavaand the graft portal vein

