Orthotopic liver transplant (OLT) is an operation that involves recipient hepatectomy with resection of the inferior vena cava (IVC) from above the renal veins to the diaphragm. After removing the diseased recipient liver, the donor liver is placed in the recipient and 4 main vascular anastomoses are performed in addition to the restoration of continuity of the bile duct. Interruption of caval flow during the anhepatic phase results in a reduction in venous return to the heart and a decrease in renal perfusion, as well as splanchnic hyperemia secondary to portal clamping.
In 1968, Calne and Williams described the preservation of the IVC.1,2 In this technique, known as piggyback, during liver implantation, the venous continuity is restored by creating a venous cuff from the recipient hepatic veins (all 3 hepatic veins, or the right hepatic vein and middle hepatic vein, or the middle hepatic vein and left hepatic vein) with an end-to-side anastomosis between the donor IVC and recipient IVC. In the piggyback technique, only a partial clamp is applied across the recipient IVC. This avoids the decrease in venous return and avoids the accumulation of potassium and lactic acid below the clamp, which can cause hypotension when the clamp is released in the conventional technique. The other potential advantages of the piggyback technique include avoiding the need for dissection of the retrocaval space, resulting in decreased blood loss. Nevertheless, it does not avoid the splanchnic hyperemia secondary to portal clamping.3,4 A modified technique of piggyback including a temporary portocaval shunt (TPCS) was first described by Tzakis et al.1 The preservation of both portal and caval blood flows throughout the procedure maintains hemodynamic stability and avoids congestion of intestines, which can lead to renal failure due to sequestration of fluid into a third space. This technique is particularly useful for patients with fulminant hepatitis who lack adequate portosystemic collaterals in the splanchnic area.
A published meta-analysis showed that surgical time is not affected by the creation of the TPCS.4 The time spent performing TPCS is regained with an easier hepatectomy with a fully devascularized organ and shorter final hemostasis. Most studies showed no significative differences regarding hospital stay and global postoperative complications between the piggyback method with a temporary portocaval shunt versus the piggyback method without a temporary portocaval shunt.
In patients undergoing cava-sparing liver transplantation with TPCS, after dissecting and ligating the hepatic artery and the bile duct, the portal vein is dissected from the duodenal level to the bifurcation (Fig. 60-1).
The infrahepatic vena cava is exposed enough from the caudate lobe to easily allow the anastomosis (Fig. 60-2).
A Satinsky clamp is placed transversally on the IVC and then the distal end of the portal vein is anastomosed in an end-to-side fashion to the infrahepatic vena cava with a 6/0 polypropylene suture (Fig. ...