Liver Transplantation: Operative Techniques and Medical Management

Chapter 54: Back-Table Preparation of the Liver for Implantation

Luis Campos de la Borbolla; Damian Clement; Alexia McCann-Molmenti; Ernesto Pompeo Molmenti

INTRODUCTION

The liver is prepared for implantation (usually in a back table of the operating room where the transplant takes place) by:

Removing unnecessary tissues
Preparing the vessels and biliary ducts for the future anastomoses
Making sure there are no defects in the vessels or biliary ducts
Identifying any potential lesions and/or injuries

The sterile bag containing the liver and cold preservation fluid is placed within a basin with ice Figure 1.

FIGURE 54-1

The procured liver is in a cold preservation fluid bath within a plastic bag contained in a basin with ice.

An image shows the procured liver in a cold preservation fluid bath within a plastic bag contained in a basin with ice.

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IVC

Stay sutures are placed on the proximal and distal ends of the inferior vena cava (IVC) Figures 2, 3, and 4. The triangular, coronary, and falciform ligaments are transected, allowing for the removal of the diaphragm.

Venous branches (including phrenic, right adrenal, and lumbar veins) are tied and/or oversewn. A bulb syringe may be used to infuse preservation fluid (or alternatively air) through one end of the IVC (while clamping the other end) to detect any leaks. The entire length of the procured IVC is preserved, and any trimming is performed at the time of implantation.

FIGURE 54-2

Stay sutures are placed on the proximal (blue arrow) and distal (green arrow) ends of the IVC.

An image of a procured liver graft shows stay sutures placed on the proximal (blue arrow) and distal (green arrow) ends of the IVC.

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FIGURE 54-3

Sometimes unexpected findings are encountered, such as this bridge (pink arrow) between the walls of the IVC.

An image of a liver graft shows a bridge (pink arrow) between the walls of the IVC, which is an unexpected finding.

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FIGURE 54-4

The liver has been positioned with its ventral surface lying down and the retrohepatic IVC facing upward. The proximal end of the IVC is inspected. The right (red arrow), middle (pink arrow), and left (blue arrow) hepatic veins can be identified.

An image shows the proximal end of the IVC being inspected with the liver positioned with its ventral surface lying down and the retrohepatic IVC facing upward.

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PORTAL VEIN

A cannula (preferably with a blunt edge) is placed in the portal vein and secured with a tie Figure 5. Tissues surrounding the portal vein are removed (at least around its free end) to allow for its subsequent anastomosis to its recipient counterpart. Branches are tied and/or oversewn.

FIGURE 54-5

A cannula (yellow arrow) has been placed within the portal vein (blue arrow) and its surrounding tissues removed. Small branches are tied and/or suture-ligated.