Surgical Techniques of Orthotopic Liver Transplantation in Adults J. Hauss Surgical Techniques of Orthotopic Liver Transplantation in Adults J. Hauss
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Surgical Techniques of
Orthotopic Liver Transplantation in AdultsJ. Hauss
Surgical Techniques of
Orthotopic Liver Transplantation in AdultsJ. Hauss
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Access for Liver Transplantation
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Mobilisation of the right liver and
isolation of the lower vena cava
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Detachment of the upper vena cava
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Division of the posterior peritoneum
along the left margin of the vena cava
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The upper vena cava is encircled
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VenoVeno--VenousVenous BybassBybass
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History of veno-venous bypass
- in early experiments of LTX in a non-cirrhoticdog model it was discovered that clamping ofthe 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 systemwas developed**
* Moore FD et al. 1959, Transplant Bull** Starzl TE et al. 1960 Surg Gynecol Obstet
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History of veno-venous bypass
- the Pittsburgh group reported in 1984 a 10%intraoperative mortality rate as a result of hemo-dynamic instability during the anhepatic phase*
- VVB consisting of heparin bonded tubing and acentrifugal pump was developed** and its efficacy
was confirmed***
* Shaw BW Jr et al. 1984 Ann Surg** Griffith B et al. 1985 Surg Gynecol Obs*** Shaw BW Jr et al. 1987 Tpl Proc
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Preparation of access
for veno-venous bypass
- Isolation of saphenous vein at its outlet from thefemoral vein and ligation of collaterals
- Isolation of the axillary vein at the apex of theaxilla for 3-4cm
- Isolation of the portal vein close to the bifurcation
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CanCannnulationulation forfor venoveno--venous bypasvenous bypas
saphenoussaphenous veinvein
axillaryaxillary veinvein
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Cannulation for veno-venous bypass
- the circuit is filled with saline solution and connectedto the bypass pump
- the axillary vein is cannulated first
- the common iliac vein is cannulated through thesaphenous vein
- and lastly the portal vein is interrupted close to thebifurcation
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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
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Disadvantages of veno-venous bypass
- increases operative and warm ischemic times
- transient hypothermia (bradycardia, hypotensionand coagulopathy)
- cannula and incision-related morbidity (vein thrombus,pulmonary or air ebolism, hematoma, lymphocele,
plexus nerve injury)- hemodilution
- increases cost
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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 SurgeryJugan E et al. 1996 Transplantation ** Wall WJ et al. 1987 TransplantationShaw BW et al. 1984 Ann Surg *** Chari RS et al. 1998Am College of Surge
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Recommended indications for the
selective use of VVB
- preexisting cardiac disease (EF<30%)
- anesthesiologist not familiar with caval clamping
- hemodynamic instability during hepatectomyor portal or caval clamping
- major bleeding during hepatectomy (> 10 units)
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when bypass is installedand hepatectomy is completed...
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Hemostasis of retro-hepatic space
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Anastomosis of the upper vena cava
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Anastomosis of the lower vena cava
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Anastomosis of portal vein 1
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Anastomosis of portal vein 2
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Anastomosis of the hepatic artery 1
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Arterial variations
A t i l t ti
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Arterial reconstruction
accessory right hepatic artery in the dono
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Arterial reconstruction backtable 1
accessory right hepatic artery
splenicstump
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gastroduodenal stump
Arterial reconstruction backtable 2
accessory right hepatic artery
A i l i b k bl 3
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Arterial reconstruction backtable 3
accessory right hepatic artery
donor iliac artery
Arterial reconstruction
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Arterial reconstruction
replaced right hepatic artery in the donor
A t i l t ti b kt bl 1
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Arterial reconstruction backtable 1
replaced right hepatic artery
celiac trunkwith aortic pat
end-toend onceliac trunk
A t i l t ti b kt bl 2
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Arterial reconstruction backtable 2
replaced right hepatic arterya replaced hepatic
artery is preservedwith AMS
1
2
33
1
2
A t i l t ti
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Arterial reconstruction
savenous vena to aorta
1. aortal
anastomosis
Arterial reconstruction
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Arterial reconstruction
savenous vena to aorta 2
2. Hepatic artery
anastomosis
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Anastomosis of the
bile duct
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End to end biliary anastomosis 2
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End-to-end-biliary anastomosis 2
discrepancies in duct diameter
biliaroplasty
End to end biliary anastomosis 3
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End-to-end biliary anastomosis 3
small ducts
biliaroplastyon both ends
End to end biliary anastomosis 4
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End-to-end biliary anastomosis 4
one very large duct
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Placement of T tube
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Placement of T-tube
Side to side biliary reconstruction
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Side-to-side biliary reconstruction
Bili d i
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- most centres have adopted a direct end-to-endanastomosis of the bile duct*
- in a prospective randomized controlled study comparingend-to-end with side-to-side anastomosis no statisticalsignificant difference was found in biliary complications**
Biliary duct anastomosis
* Sherman et al. 1995 Transplantatio
** Davidson et al. 1997 Brit J Surgery
Final view
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normal anatomy
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Bile duct and hepatic artery are
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p y
interrupted, right portal branch encircled
Accessory hepatic veins are ligated
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Accessory hepatic veins are ligated
the right hepatic vein is exposed
The liver is displaced upwards
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and the anterior vena cava is freed
Incision of posterior peritoneal layer
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c s o o poste o pe to ea aye
and exposure of the left vena cava
Clamping of the right hepatic vein trunk
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Clamping of the right hepatic vein trunk
Ligation of the right portal branch
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Ligation of the right portal branch
Middle and left hepatic vein are
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clamped and the liver is removed
Preparing a wide common orifice
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p g
Wide common orifice,
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appropriate for caval anastomosis
Completion of superior caval
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anastomosis, flushing of portal vein
Subhepatic caval stump is closed
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p p
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Portal vein thrombosis
Portal vein thrombectomy
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Portal vein thrombectomy
or isolation of the spleno-mesenteric
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confluence after mobilisation ofpancreatic head
Venous jumping graft with donor
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iliac vein anastomosed with recipientmesenteric vein
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Cavo-portal transposition 1
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free completely retrohepatic cava
Cavo-portal transposition 2
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Hepatectomy with long distal vena cava
Cavo-portal transposition 3.
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1.
3.
2
supra hepatic cava
flush portal vein
close lower cava
Cavo-portal transposition 4.
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Anastomosis recipient vena cavaand the graft portal vein