Chapter 58: Recipient Hepatectomy

INTRODUCTION

Recipient hepatectomy has been considered the most difficult stage of the entire liver transplant procedure. The removal of the diseased liver from the recipient can be a challenge, and the degree of difficulty is related to different factors, like age; congenital malformations (situs inversus, portal hypoplasia, or agenesis); previous procedures (previous Kassai, biliary surgeries or drainage, previous laparotomies); acute or chronic liver disease; presence of portal hypertension; portal vein thrombosis; or previous transjugular intrahepatic portosystemic shunt (TIPS); portosystemic shunts; degree of coagulopathy; or a previous transplant, among others.¹

There is no single best method to remove the diseased native liver.² The strategy to be used in each patient should be part of the multidisciplinary discussion after successfully overcoming the evaluation, and it is important to set the necessary steps to successfully perform the engraftment.

We will provide in this chapter the basic steps for a standard hepatectomy in an adult patient, which will be considered the basic procedure to be known and understood. We will add the technical aspects that need to be managed in order to perform a caval-preserving hepatectomy, a pediatric hepatectomy, and a living donor or a split transplant. A partial hepatectomy is only required during the auxiliary partial orthotopic liver transplantation (APOLT).³

The standard recipient hepatectomy can be divided into (1) surgical approach; (2) hepatic hilar dissection; (3) mobilization of the liver and management of the cava and hepatic veins; and finally, (4) venous clamping, venous transection, and hepatectomy.

Unique technical aspects to perform hepatectomies in the presence of spontaneous portosystemic shunts, portal vein thrombosis (PVT), TIPS, or in cases like retransplantation, domino, living donor, or splits are included in “Special Considerations and Pitfalls” as the last part of this chapter.

SURGICAL APPROACH

The incision aims to provide an adequate surgical exposure, which is mandatory to perform a safe procedure. The standard surgical approach for an adult liver transplantation is the bilateral subcostal incision with an upper midline extension (named by Sir Roy Calne as the “Mercedes” incision);⁴ in some centers the extended subcostal incision with the upper midline extension, also called the “J” access or “hockey stick,” is preferred (Fig. 58-1). In pediatric patients the most used incision is the bilateral subcostal one (Fig. 58-2).

The transection of the muscular layers follows the skin pattern (Fig. 58-3), showing the aspect of the complete abdominal wound opening. The abdominal retractor is then placed (Fig. 58-4). The teres ligament ...