REVIEW
The Liver Transplant Operation
Charles Miller, Teresa Diago Uso
The first liver transplantation was performed by Thomas
Starzl in Denver, Colorado, in 1963.1 Over the past 50
years, the field has experienced tremendous medical and
surgical advancement, with 1- and 5-year survival
approaching 90% and 75%, respectively, in most series.
Successful transplantation involves a fascinating complex of
donor and recipient factors, which represent the focus of
this review.
Donor Factors
Donor quality is one of the most important determinants
of peritransplantation and posttransplantation organ func-
tion. Donors can be defined as standard criteria donors
(i.e., good quality donors) or extended criteria donors,
which may include steatotic livers, older donors, donors
with positive serology, split livers, and donors after cardiac
death (DCD). Other factors that affect organ quality are
mechanism of death, hemodynamic instability that requires
pressor support, and electrolyte derangement (sodium level
at procurement >160 mmol/L). All of these factors along
with predicted ischemia times are among the important var-
iables that can help with the initial decision of whether or
not to pursue the procurement of a liver. Ischemia time can
be divided into cold ischemia time (CIT) and warm ische-
mia time (WIT). CIT begins when the liver is cooled with
cold perfusion solution during organ procurement and ends
when the organ is placed in the transplant field for implan-
tation. The time from removal of the liver from ice until
vascular reperfusion represents the WIT. During this period,
the liver warms slowly to a temperature of 12.5 C while the
caval and portal vein anastomoses are performed.2 CIT and
WIT of 6 to 12 hours and 30 to 60 minutes, respectively,
are acceptable, with shorter times being necessary when
transplanting marginal donors to maximize early graft func-
tion. Matching donor and recipient characteristics is another
Abbreviations: CIT, cold ischemia time; DCD, donors after cardiac death; IVC, inferior vena cava; WIT, warm ischemia time.
From the Cleveland Clinic, Liver Transplant Program, Department of General Surgery Cleveland, OH.
Potential conflict of interest: Nothing to report.
View this article online at wileyonlinelibrary.com
C 2013 by the American Association for the Study of Liver Diseases
V
doi: 10.1002/cld.232
192 Clinical Liver Disease, Vol 2, No 4, August 2013
important aspect of preoperative planning. For instance,
older donors (>60 years) transplanted to hepatitis C virus
recipients are associated with more aggressive posttrans-
plantation hepatitis C virus recurrence,3 and a suboptimal
organ (fatty livers, old grafts, or DCD organs) transplanted
to a very sick patient often results in poor transplantation
outcome.4
DCDs are donors who do not meet the criteria for brain
death and must be pronounced dead after life support has
been terminated and after a variable agonal phase (which
should not exceed 30 minutes) and ultimately irreversible
cessation of circulation. Livers procured from DCDs are
more susceptible to primary nonfunction and chronic bili-
ary complications, probably due to the hypoperfusion dur-
ing the agonal phase. These are all important concepts
when considering donor and recipient factors in the delicate
phase of organ acceptance and transplantation.
Recipient Factors
Recipient Hepatectomy and Preparation for Implanta-
tion. Hepatectomy of the native liver is the first step of
the operation. This can be a challenging procedure due to
the intimate anatomical relationship of the liver with the
retrohepatic inferior vena cava (IVC) in the setting of coa-
gulopathy and portal hypertension. A history of previous
upper abdominal surgery can make the operation even
more hazardous.
Hepatectomy can be performed using one of two techni-
ques: the conventional technique or the piggyback tech-
nique. In the conventional technique, the native
retrohepatic IVC is removed en bloc with the liver. The
donor vena cava (always procured along with the liver) is
anastomosed in an end-to-end fashion to both the suprahe-
patic and infrahepatic IVC to recreate the original anatomi-
cal situation (Fig. 1.A,B). In the piggyback technique, the
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FIGURE 1. Liver transplantation: the conventional technique. (A) The native retrohepatic vena cava is removed en bloc with the liver. (B) The donor IVC is anasto-
mosed in an end-to-end fashion to the recipient suprahepatic and infrahepatic IVC.
FIGURE 2. Liver transplantation: the piggyback technique. The donor
suprahepatic IVC is anastomosed in an end-to-side fashion to the common
cuff of the recipient hepatic veins. The retrohepatic donor vena cava is ligated.
liver is completely dissected from the IVC, which is there-
fore preserved and only partially clamped at completion of
the hepatectomy. A common cuff is created by joining the
three hepatic vein orifices together, and the donor suprahe-
patic cava is anastomosed in an end-to-side fashion to the
common cuff of recipient hepatic veins (Fig. 2.). The retro-
hepatic donor vena cava (i.e., the cul-de-sac) is ligated. One
of the major advantages of this technique is that the venous
return is preserved during the anhepatic phase. Further-
more, only one IVC anastomosis is performed, shortening
the anhepatic phase time. This is the only technique possi-
ble when the IVC is not present in the graft (i.e., in living
donors and split livers).
193 Clinical Liver Disease, Vol 2, No 4, August 2013
The Liver Transplant Operation Miller and Diago Uso
The conventional technique requires complete occlusion
of the vena cava. Consequently, some surgeons prefer to
use a veno-venous bypass during the anhepatic phase to
avoid hemodynamic instability caused by total caval occlu-
sion. Many other surgeons rarely if ever use the bypass tech-
nique, however, and rely on advanced anesthesia techniques
and a more rapid implantation to achieve the same results.
The conventional technique does not require the sometimes
tedious dissection of the caudate lobe from the vena cava,
making the hepatectomy easier and faster. The decision
between the conventional technique or the piggyback tech-
nique is most often made according to a surgeon’s experience
and personal preference.5,6 In our program, we use the con-
ventional technique in 40% to 50% of cases, mostly without
the use of veno-venous bypass. No study in the literature has
proven superiority of one technique over the other.
Portal Vein Anastomosis. After completing the IVC anas-
tomosis, portal vein anastomosis is performed in an end-to-
end fashion and the liver is reperfused. Reperfusion is one
of the most critical parts of transplantation. This can be
characterized by profound hemodynamical instability (bra-
dycardia and hypotension) and is the result of the sudden
introduction in the systemic circulation of cold and
cytokine-rich graft effluent. To avoid profound reperfusion
syndrome, the liver is flushed with room temperature saline
and then with systemic blood from either the portal vein or
the IVC to wash and warm the graft just prior to formal
reperfusion.
Some degree of portal vein thrombosis may be present in
up to 13% of transplants.7 This must be dealt with via sim-
ple portal thrombectomy or secondarily with portal vein
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 R E V I E W The Liver Transplant Operation Miller and Diago Uso

FIGURE 3. Hepatic artery anatomy. (A) Anatomy of the standard hepatic artery. (B) Replaced (accessory) right hepatic artery from the superior mesenteric artery.
(C) Replaced (accessory) left hepatic artery from the left gastric artery.

replacement with venous grafts (typically the donor iliac

vein is used as a conduit) interposed between the donor
portal vein and a recipient splanchnic vein (portal vein,
superior mesenteric vein, coronary vein, or a large porto-
systemic collateral). In selected cases, especially when there
is a well-developed spleno-renal shunt, the left renal vein
can be used as an excellent source of portal inflow.

Hepatic Artery Anastomosis. The most common and

durable approach to hepatic artery reconstruction is an end-
to-end anastomosis between the donor’s celiac axis and the
recipient’s common hepatic artery just at the confluence
with the gastroduodenal artery (Fig. 3.A). Depending on
surgeon preference and anatomical factors (e.g., arterial var-
iants, vessel diameter, living donor grafts), the level of the
reconstruction may vary.
The most common deceased donor arterial anatomical
variant is the presence of a right arterial branch originating
from the superior mesenteric artery (15% of cases) (Fig.
FIGURE 4. Hepatico-jejunostomy with a defunctionalizated Roux-en-Y
3.B).8 Different back table techniques are used to recon- intestinal loop.
struct this variant; the focus of the reconstruction is to
allow for only one simple anastomosis in the recipient. The
easiest and most common reconstruction technique is the
anastomosis of the separate right hepatic branch to the identified and reconstructed at the back table. For severe
stump of the donor gastroduodenal artery. injuries that defy attempts at reconstruction, it is good to
In the case of a left accessory hepatic artery (10% of remember that the replaced left hepatic artery is usually an
cases),8 this branch takes off from the donor’s left gastric accessory artery, and ligation or thrombosis should not cre-
artery (Fig. 3.C). This is preserved during donor surgery, ate drastic consequences, as there are rich collaterals within
and the arterial anastomosis is performed as described the umbilical fissure. The replaced right hepatic artery is
above between the donor’s celiac axis (therefore proximal to usually the only arterial supply to the right lobe and proxi-
the accessory artery) and the recipient’s common hepatic mal bile duct, and lack of patency can have far more severe
artery. The use of running versus interrupted suture in the manifestations of biliary leak, biliary stricture, and right
arterial anastomosis is usually subject to the diameter of the lobe ischemia with abscess.
vessel (interrupted used for smaller vessels). In case of poor recipient arterial inflow that may be
During procurement, these accessory arteries may go caused by celiac stenosis or inadvertent damage to the com-
unrecognized and become injured. Most injuries can be mon hepatic artery during hepatectomy, an interpositional

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FIGURE 5. Living donor liver transplantation. (A) Right lobe graft. (B) Left lobe remnant.
arterial graft (usually the iliac artery of the donor) is placed
between the infrarenal or supraceliac aorta and the donor
celiac axis.
Every effort should be made during the operation to
assure early and late hepatic artery patency. Early hepatic
artery thrombosis necessitates thrombectomy and recon-
struction if it is identified before hepatic necrosis ensues; if
not, and the liver is severely damaged, it may require early
retransplantation. When hepatic artery thrombosis occurs
later, it may be first recognized when the patient presents
with fever and hepatic abscess. Although this may also ulti-
mately require retransplantation, many grafts can be sal-
vaged with conservative supportive therapy aimed at taking
advantage of the development of collaterals that can supply
adequate perfusion and oxygenation to allow for hepatic
parenchymal healing. Careful study of triphasic computed
tomography scans and duplex ultrasound images often
reveal patent intrahepatic arterial branches despite the pres-
ence of a main hepatic artery thrombosis.
Biliary Anastomosis. Following the vascular anastomosis
and the establishment of good hemostasis is the donor chole-
cystectomy and biliary reconstruction. The preferred anasto-
mosis is duct-to-duct between the donor and recipient
common bile ducts. When there is unacceptable duct size
mismatch or the recipient bile duct is unusable (primary
sclerosing cholangitis), a hepatico-jejunostomy with a defunc-
tionalizated Roux-en-Y intestinal loop is performed (Fig. 4.).
References
1. Starzl TE, Marchioro TL, Vonkaulla KN, Hermann G, Brittain RS, Waddell
WR. Homotransplantation of the liver in humans. Surg Gynecol Obstet
1963;117:659–676.
195 Clinical Liver Disease, Vol 2, No 4, August 2013
The Liver Transplant Operation Miller and Diago Uso
The duct-to-duct anastomosis is usually performed without
the use of a T-tube. Although once very popular, removal of
T-tubes was found to be associated with a high rate of mor-
bidity due to insertion site leak that often required emergent
hospitalization and endoscopic retrograde cholangiopancrea-
tography and stenting. As anastomotic techniques became
more refined, internal stents and T-tubes fell into disfavor.9
Living Donor Factors
The imbalance between organ supply and demand has
pushed the transplant community to look at ways to expand
the donor pool. Living donor liver transplantation is one
option, despite its indisputable ethical and surgical chal-
lenges (Fig. 5.A,B). This type of transplantation can be per-
formed between an adult donor and either a pediatric or
adult recipient. Because donor safety is of paramount
importance, only healthy donors in which the future liver
remnant will be more than 35% are candidates for this pro-
cedure. The technical challenges of the donor and recipient
operation are beyond the scope of this review; suffice it to
say, however, that the basis of the techniques have evolved
and have been refined from those used in deceased donor
transplantation described above.10
CORRESPONDENCE
Charles Miller, M.D., Liver Transplant Program, Department of General
Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195.
E-mail: millerc8@ccf.org
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