Editing Liver transplant (section)

== Approach to an orthotopic piggyback liver transplant ==

* Mercedes Benz incision
* Hepatectomy
** Division ligamentous attachments, CBD, CHA, HV and PV
* Implantation
* IVC anastomosis
* PV reconstruction
** Usually performed end to end
** Main thing is to avoid kinking/stenosis
** Allow for a 'growth factor' when tying off the circumferential running suture - because it will expand slightly when flow is returned
** Getting the length right is important - if too much donor length is used, kinking will occur
** May need to do PV thrombectomy if PV thrombosis is present
* Arterial reconstruction
** Usually direct end to end anastomosis between donor and recipient HA
** Carrel patch should be used to decrease hepatic artery thrombosis
** Poor hepatic artery inflow will cause a problem - may need to dissect more proximal to it. Maybe use a donor iliac artery graft to do an accessory conduit direct form aorta.
* Biliary anastomosis
** Direct duct to duct vs Roux-en-Y hepaticojejunostomy/choledochojejunostomy
** Duct to duct is preferable if recipient duct is normal - allows access via ERCP and preserves native anatomy
*** If there is a significant size discrepancy, side to side anastomosis can be used
** Roux-en-Y is used for a retransplant or for PSC, although the latter is now controversial, and duct to duct anastomosis may still be appropriate
** T-tubes should not be routinely used for biliary anastomosis