Liver implantation

Recipient hepatectomy:

• Bilateral subcostal incision (2-3cm lower if patient has ascites) with midline extension (right more laterally)
• Divide and ligate round ligament
• Divide falciform ligament towards suprahepatic vena cava
• Place mechanical retractor
• Left coronary and triangular ligaments divided
• Reflect segments II and III to right and gastrohepatic ligament divided
• CHA divided and clamped with bulldog (need to clamp common hepatic artery first to avoid a dissection due to preserved high flow)
• Cystic duct and artery are divided (high)
• PV dissected
• Right lobe and IVC mobilised (take down coronary and triangular ligaments, and divide peritoneum longitudinally along IVC - complete separation of the posterior aspect of retrohepatic IVC from retroperitoneum
• Now ready for removal - vascular clamps on PV, infrahepatic and suprahepatic IVC
• Haemostasis of bare area

Veno-venous bypass:

• In general, indicated in patients with haemodynamic instability after clamping, with fulminant liver failure to reduce volume overload, and with nondialysis-dependent hepatorenal syndrome.

Back table:

• Remnant diaphragm removed
• Suprahepatic IVC isolated
  • Phrenic vein openings ligated
  • Adrenal vein openings ligated
• Portal vein isolated to level of bifurcation and canulated for later flush with ice-cold ringers
• Entire arterial axis skeletonised
• Avoid dissection above the level of the GDA - potential injury to proper hepatic artery

Implantation

• Create a common suprahepatic vena cava by dividing venous bridges in the recipient
• Stay sutures for liver at opposite corners with 3-0 prolene
• Anastomose suprahepatic IVC 3-0 prolene
• Flush with chilled LR or UW solution
• Anastomose infrahepatic IVC 4-0 prolene
• PV anastomosis
  • Avoid redundant length by trimming donor PV
  • Running 6-0 prolene
• HA reconstruction - usually end-to-end, depends on anatomy
• Biliary reconstruction
  • Prefer choledocho-choledochostomy but Roux-en-Y biliodigestive anastomosis also permissible
  • End-to-end with 5-0 or 6-0 PDS

Split liver

• Most commonly a left lateral graft (segments 2 and 3) along with right trisector graft (1, 4 to 8)
• Can also split into two full hemilivers
• Splitting can be done in situ or ex situ