Midline incision from suprasternal notch or xiphoid process to pubis
Balfour to expose abdomen +/- sternal retractors if chest is opened
Explore for contraindications to explant, and evaluate liver (size and parenchymal quality)
Look for sharp edges, smooth surface with appearance of scratching marks, and brownish surface colour
Abdominal dissection
Divide round ligament between two heavy silk ties
Take down falciform ligament to confluence of hepatic vein/suprahepatic vena cava
Divide left coronary and triangular ligaments
Reflect left lateral sements (II and III) towards donors right side to access gastrohepatic ligament (inspect this carefully for a replaced or accessory left hepatic artery - 10% of donors - if present, divide ligament above and below the artery)
Retroperitoneal dissection
Reflect ascending colon medially
Ascending colon and D2 are mobilised and reflected to the left
Mobilise remaining small intestine cephalad until left renal vein is visible (look out for SMA, left renal artery and pancreas)
Isolate IMV at ligament of Treitz. This is distally ligated then canulated for precool perfusion
Expose distal abdominal aorta above level of the bifurcation for canulation and clamping
Reflect small intestine and ascending colon into abdomen to expose porta hepatis
Tie off CBD distally with 2-0 silk and half-way incised just above the tie, then wash out via a transcystic flush until the effluent is clear
Expose supracoeliac aorta, and encircle with umbilical tape
Systemically heparinize with 300-500 IU/kg for 3 minutes
Ligate aorta at bifurcation and insert cardiac catheter. Cross-clamp supracoeliac.Transect suprahepatic vena cava at caval-atrial junction. Liver can be covered with ice.
