4. Clinical Guidelines for Liver Transplantation (PDF) - British ...

Guidebook for the Solid Organ Transplant Programme Chapter 4
4.2.5 TRANSPLANT PROCEDURE CONT.
iii. Back table preparation
Before the liver is transplanted into the recipient, it is prepared in a separate location in the
operating room. This is called the “back table preparation". The liver is inspected, perhaps
biopsied, the anatomy is confirmed and any abnormalities, injuries or unusual findings detected
and dealt with. The liver is modified to fit the recipient’s anatomy if necessary and the vessels
and bile duct are optimized for transplant.
iv. Transplantation
Once the liver has been prepared in the back table, the diseased liver is removed and the
transplant itself begins. There are two commonly used recipient procedures. One is the
standard orthotopic procedure, which is generally used for patients with tumors and whole
organ transplants, where the vena cava, the large vein that goes to the heart, is removed with the
diseased liver. A second technique, termed “piggyback” technique is when the recipient’s vena
cava is left intact, the liver is removed from the cava and the hepatic veins are sewn to the
hepatic veins of the donor liver, leaving the patient’s vena cava as well as the transplanted vena
cava intact. The first step of the recipient procedure is the anastomosis, the suprahepatic vena
cava first, followed by the infrahepatic vena cava.
The liver can be either washed out with cold lactated Ringers solution or some IV solution that
washes out the potassium and preservative solution, or the patient’s portal blood can be run
through the liver and allowed to run out the vena cava from below through a vent until such
time that the liver has been washed out with the patient’s own blood. This blood is usually
saved in a cell saver system, which scavenges any blood that is allowed to leave the body and is
re-transfused once the red cells have been washed. This cuts down the need for allogeneic blood
transfusions.
Once the vena cava has been reconstructed, the portal vein is reconstructed, which when
completed allows for reperfusion of the liver. The next procedure is to reconstruct the hepatic
artery, which is done is various ways, generally not leaving too short of an artery or too
redundant an artery. Good flow through the portal vein and hepatic artery is mandatory for
survival of the organ. The quality of the storage can be assessed by the stiffness of the liver, the
rapidity of preservation and the fact that the liver may make bile in the early reperfusion period.
Livers that contain a lot of fat or were in storage for a prolonged period of time may function
poorly at first. In the third stage of the operation, the bile duct is reconnected. If the biliary
system of the recipient is adequate an intraoperative cholangiogram may be done to assess for
major bile leaks or obstruction.
The donor bile duct is sewn to the recipient bile duct so that the sphincter mechanism in the
distal end is still intact. Sometimes a small stent is placed across the sphincter of Oddi to reduce
the chance of a bile leak. The stent usually floats out on its own in the postoperative period but
may have to be removed endoscopically.
Chapter 4 – Clinical Guidelines for Liver Transplantation – July, 2010 Page 10
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