TECHNIQUE OF LIVER TRANSPLANTATION Deceased donor

TECHNIQUE OF LIVER TRANSPLANTATION Deceased donor liver transplantation

A reverse-L or a Mercedes-Benz (transverse abdominal inci - - sion with a midline extension) incision is usually made and the diseased liver is mobilised. As a result of portal hypertension, the recipient hepatectomy (removal of damaged liver) is often - the most di ffi cult part of the operation, especially if there has been previous upper abdominal surgery . The common bile duct is divided, as are the hepatic arteries. The inferior vena cava is mobilised above and below the liver; the portal vein is - clamped and divided, and the vena cava is divided above and below , allowing the recipient liver to be removed. This ‘classical’ technique ( Figure 89.1a ) allows quick removal of the recipient liver without the need to free the liver from the cava by tying all the short and named hepatic veins (i.e. caval ‘preservation’ technique). Occlusion of the vena cava and portal vein results in a reduction in cardiac output and may necessitate the use of venovenous bypass, albeit not commonly . The bypass circuit delivers blood from the inferior vena cava and/or portal vein, back to the heart via a cannula inserted into the internal jugu - lar vein. This improves venous return to the heart and provides haemodynamic stability during the operation. The portal limb of the bypass also reduces portal hypertension and congestion of the bowel during the implantation phase and potentially can reduce blood loss. After total he patectomy the implantation starts by plac - ing the liver graft in the orthotopic position. The supra- and infrahepatic caval anastomoses are the first to be performed. The liver is flushed through the portal vein with normal saline a t room temperature to remove the preservative solution with the e ffl uent draining out through the lower caval anastomo - sis, which is left incomplete until the flushing. The portal vein anastomosis is then completed and the graft is reperfused. The hepatic artery anastomosis can sometimes be done first to reperfuse the liver with arterial blood followed by the por - tal vein anastomosis . Figure 89.2 shows a cirrhotic liver and the deceased donor liver after transplantation. Finally , biliary drainage is re-established usually by a duct-to-duct anastomosis ( Figure 89.3a ). In recipients with biliary atresia where the bile duct is absent or in those with PSC where the bile duct is dis eased, the donor bile duct is reconstructed through a Roux en-Y hepaticojejunostomy ( Figure 89.3b ). An alternative and more commonly performed technique is the ‘caval preservation’ technique, which allows the recipient liver to be remo ved without cross-clamping the vena cava, thus avoiding venovenous bypass. The donor liver here is implanted using a ‘piggyback’ technique onto the confluence of the three Cesar Roux , 1857–1934, Professor of Surgery and Gynaecology , Lausanne, Switzerland, described this method of forming a jejunal conduit in 1908. hepatic veins in the recipient ( Figure 89.1b ) or using a side-to - - side cavo-cavoplasty (joining donor and recipient cava side to - side) ( Figure 89.1c ). Optimal perioperative management is crucial to a success - ful outcome and presents a major challenge. These pa tients are often very sick preoperatively , especially those transplanted for ALF . Blood loss during and after the transplantation procedure can be very considerable , and management of coagulopathy is particularly important. Coagulation is assessed repeatedly

(a) LHV Diaphragm Recipient IVC (b) LHV Donor IVC MHV RHV Diaphragm Recipient IVC Figure 89.1 Pictorial representation of inferior vena cava (IVC) reconstruction in a deceased donor live transplantation. replacement technique in which the recipient’s retrohepatic IVC is replaced with donor IVC. of the three hepatic veins in the recipient is used to anastomose with the top end of the donor IVC. the side of the donor IVC is joined with the side of the recipient IVC. LHV, left hepatic vein; MHV, middle hepatic vein; RHV, right hepatic vein. (a) Figure 89.2 Adult deceased donor liver transplantation. (a) Recipient cirrhotic liver; hepatic artery. MHV RHV Donor IVC Recipient IVC (c) LHV MHV Donor IVC Diaphragm Recipient IVC RHV (a) A ‘classical’ caval (b) A ‘piggyback’ technique in which the con /f_l uence (c) ‘Side-to-side cavo-cavoplasty’ in which (b) (b) whole liver graft after reperfusion with the portal vein and

throughout the transplantation period and corrected with appropriate clotting factors, if required. Many centres rou tinely use point-of-care ‘viscoelastic monitoring’ such as thromboelastography (TEG) or rotational thromboelastome try (ROTEM) to perform dynamic assessment of coagulation. The deceased donor liver transplant (DDLT) grafts come from either donation after brain death (DBD) donors or donation after circulatory death (DCD) donors. The latter are considered ‘extended criteria’ donors o wing to greater ischaemia associated with donor hypoxia/death, higher risk of graft dysfunction, higher risk of vascular and biliary complications and poor long-term outcomes. Although LT has established itself as a life-saving treatment, the limited availability of deceased donor liver grafts has urged the transplant community to devise newer techniques and strategies to reduce the gap between organ demand and supply . The various options to increase organ availability are: LDLT , split and reduced-size LT , use of extended criteria donors (ECDs), auxiliary LT , domino LT and the paired-exchange programme. Summary box 89.3 Types of L T (based on source of liver allograft) /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Silvano Raia , b. 1930, Emeritus Professor at the Faculty of Medicine, Sao Paulo, Brazil, performed the first living donor liver transplantation in a child. Russell Strong , contemporary , Emeritus Professor of Surgery , University of Queensland, Princess Alexandra Hospital, Australia. He successfully performed a living donor liver transplant of the left lateral segment of a Japanese mother’s liver into her 18-month-old son in 1989. Both were alive and well 27 years later (2016); the recipient graduated and is practising as a physiotherapist.

Liver Stomach Figure 89.3 Pictorial representation of the standard deceased donor liver transplant with a ‘classical’ caval replacement technique. graft after completion of all anastomoses, in order of performance: (1) suprahepatic cava; (2) infrahepatic cava; (3) portal vein; (4) hepatic artery; (5) bile duct. (b) A Roux-en-Y reconstruction where the donor bile duct is anastomosed to the loop of jejunum. The rest of the anastomoses and order of performance are the same. DDLT, which includes DBD (70–80%) and DCD (20–30%) LDLT – this can be adult to adult or adult to child Split and reduced-size LT ECDs Auxiliary LT Domino LT Paired-exchange programme Liver Inferior vena cava Portal vein Bile duct Hepatic artery (a) A liver