The classic technique of liver transplantation can be divided into 4 phases:
Implantation (anhepatic phase)
The patient is placed in the supine position with the arms fully abducted and exposed to the mid-thigh, allowing access to the groin. The right internal jugular vein is cannulated with a 12F wire-reinforced cannula by the anesthetic team.
The abdomen is opened via a reverse “L” incision: the transverse incision is extended far enough laterally to allow exposure of the hilum and inferior vena cava (IVC), usually extending beyond the lateral border of the rectus. The midline incision is usually longer than the lateral one, depending on body habitus, and the upper limit is achieved when the suprahepatic IVC is visualized. The xyphoid process is usually excised (Fig. 59-1). Care is taken to control the abdominal wall vessels with ties (2.0 silk) or Ligasure. After peritoneal division, ascitic fluid is sampled for microbiology and the remaining ascites is aspirated. The upward retractor is placed.
The round ligament is divided close to the liver, using artery clips. The fat pad adjacent to the falciform ligament is then dissected up close to the hepatic veins and removed. The round ligament can be used as a point of traction in order to expose the porta hepatis. The lower abdominal wall retractor is secured in place.
Assessment and staging of the liver is performed in cases of hepatocellular carcinoma (HCC) and primary sclerosing cholangitis (PSC). Any tissue suspicious for metastatic disease is biopsied. The arterial anatomy is assessed, looking specifically for an anomalous left hepatic artery arising from the left gastric artery (after opening the gastrohepatic ligament with Ligasure) or an anomalous right hepatic artery arising from the superior mesenteric artery (SMA).
Liver mobilization is the initiated by dissecting toward the hepatic veins and suprahepatic vena cava (Fig. 59-2). The left triangular ligament is exposed after placing a pack under the left lateral sector and is divided with cautery from lateral to medial, ending at the lateral border of the left hepatic vein/left phrenic vein (Fig. 59-3). In order to better expose the left hepatica vein and IVC, the remnant of the ligamentum venosum can be divided (Fig. 59-4).
Suprahepatic vena cava approach.
Left triangular ligament division (note the pack behind the left lateral sector).
Opening the lesser sac and exposing the caudate lobe.