Surgical Techniques Surgical Techniques of of Orthotopic Liver Transplantation in Adults Orthotopic Liver Transplantation in Adults

J. J. Hauss 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

Veno-Venous Bybass

History of veno-venous bypass

- in early experiments of LTX in a non-cirrhotic dog model it was discovered that clamping of the 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 system was 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 hemodynamic instability during the anhepatic phase* - VVB consisting of heparin bonded tubing and a centrifugal pump was developed** and its efficacy was confirmed***
* Shaw BW Jr et al. 1984 Ann Surg ** Griffith B et al. 1985 Surg Gynecol Obst *** Shaw BW Jr et al. 1987 Tpl Proc

Preparation of access for veno-venous bypass

- Isolation of saphenous vein at its outlet from the femoral vein and ligation of collaterals - Isolation of the axillary vein at the apex of the axilla for 3-4cm - Isolation of the portal vein close to the bifurcation

Cannulation for veno-venous bypass

axillary vein

saphenous vein

Cannulation for veno-venous bypass

- the circuit is filled with saline solution and connected to the bypass pump - the axillary vein is cannulated first - the common iliac vein is cannulated through the saphenous vein - and lastly the portal vein is interrupted close to the bifurcation

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, hypotension and 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 Surgery ** Wall WJ et al. 1987 Transplantation Jugan E et al. 1996 Transplantation Shaw BW et al. 1984 Ann Surg

*** Chari RS et al. 1998 Am College of Surgeons

Recommended indications for the selective use of VVB

- preexisting cardiac disease (EF<30%) - anesthesiologist not familiar with caval clamping - hemodynamic instability during hepatectomy or portal or caval clamping - major bleeding during hepatectomy (> 10 units)

when bypass is installed and 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 portal vein 3

Anastomosis of the hepatic artery 1

Anastomosis of the hepatic artery 2

Arterial variations

Arterial reconstruction accessory right hepatic artery in the donor

Arterial reconstruction backtable 1 accessory right hepatic artery

splenic stump

Arterial reconstruction backtable 2 accessory right hepatic artery

gastroduodenal stump

Arterial reconstruction backtable 3 accessory right hepatic artery

donor iliac artery

Arterial reconstruction replaced right hepatic artery in the donor

Arterial reconstruction backtable 1 replaced right hepatic artery

end-to end on celiac trunk celiac trunk with aortic patch

Arterial reconstruction backtable 2 replaced right hepatic artery

a replaced hepatic artery is preserved with AMS

2 3 3 1 1

Arterial reconstruction savenous vena to aorta

1. aortal anastomosis

Arterial reconstruction savenous vena to aorta 2

2. Hepatic artery anastomosis

Arterial jumping graft with donor iliac artery tunneled through the transverse mesocolon

Anastomosis of the bile duct

End-to-end biliary anastomosis 1

End-to-end-biliary anastomosis 2 discrepancies in duct diameter

biliaroplasty

End-to-end biliary anastomosis 3 small ducts

biliaroplasty on both ends

End-to-end biliary anastomosis 4 one very large duct

Placement of T-tube
Transverse limb of T-tube is opend longitudinally

Placement of T-tube

Side-to-side biliary reconstruction

Biliary duct anastomosis

- most centres have adopted a direct end-to-end anastomosis of the bile duct* - in a prospective randomized controlled study comparing end-to-end with side-to-side anastomosis no statistical significant difference was found in biliary complications**

* Sherman et al. 1995 Transplantation ** Davidson et al. 1997 Brit J Surgery

Final view normal anatomy

The Piggy-Back Technique

Bile duct and hepatic artery are interrupted, right portal branch encircled

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 and exposure of the left vena cava

Clamping of the right hepatic vein trunk

Ligation of the right portal branch

Middle and left hepatic vein are clamped and the liver is removed

Preparing a wide common orifice

Wide common orifice, appropriate for caval anastomosis

Completion of superior caval anastomosis, flushing of portal vein

Subhepatic caval stump is closed

Portal vein thrombosis

Portal vein thrombectomy

or isolation of the spleno-mesenteric confluence after mobilisation of pancreatic head

Venous jumping graft with donor iliac vein anastomosed with recipient mesenteric vein

Complete porto-splenic thrombosis

Cavo-portal transposition 1 free completely retrohepatic cava

Cavo-portal transposition 2 Hepatectomy with long distal vena cava

Cavo-portal transposition 3. 1.
supra hepatic cava

flush portal vein

2.

3.

close lower cava

Cavo-portal transposition 4. Anastomosis recipient vena cava and the graft portal vein

Recommended reading
Books: Mazziotti and Cavallari: Techniques in Liver Surgery Greenwich Medical Media Molmenti and Klintmalm Atlas of Liver Transplantation Saunders