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Surgical techniques in hepatobiliary surgery and in liver transplantation have evolved to the point where safe vascular reconstruction of both inflow and outflow structures can be achieved with low associated morbidity and mortality.

High-volume hepatopancreatobiliary (HBP) surgery centers perform these procedures often, generating additional training for managing vascular pedicles, the vena cava, and the suprahepatic veins, as well as for selective and intermittent use of clamping, etc.

The surgical techniques described in this chapter on vascular reconstruction in liver transplantation may be applied to optimize inflow and outflow for different anatomic variants, thus decreasing, or even eliminating, postoperative complications.

Of course, complications may arise during the operation, which is often the source of many of the problems observed after surgery. Herein, we describe the most common pitfalls linked to venous reconstruction and propose potential solutions.

Living-donor liver transplant is especially challenging and has forced surgeons to perfect even further their techniques and strategies, as well as develop new skills to resolve issues of inflow and outflow to the liver.

Positioning of the right suprahepatic vein (RSHV), anastomoses, and outflow of the accessory hepatic veins from segments 5, 6, and 8 are key to secure liver regeneration to avoid organ congestion and “small-for-size syndrome” and decrease postoperative morbidity.

For deceased-donor whole organ liver transplant we detail 2 techniques: the standard orthotopic procedure and the caval-sparing or piggyback techniques. For living-donor liver transplant, different types of vascular anatomy may be present:

  • Portal trifurcation

  • Accessory suprahepatic veins from segment 6

  • Accessory suprahepatic veins from segments 5 or 8 and from 5 and 8

  • Accessory veins from segment 7



Liver transplant. Standard hepatectomy. The main problems confronted by the surgical team during receptor hepatectomy relate to hemodynamic instability resulting from manipulation of the vena cava, renal hypoperfusion, and bleeding due to coagulopathy. Cross-clamping of splanchnic blood flow and of the inferior vena cava reduces cardiac output and hemodynamic instability. These alterations were the main causes of perioperative deaths during the 1980s. Since then, use of extracorporeal venovenous bypass circulation systems has eliminated hemodynamic problems linked to total vascular exclusion.



In 1989 Thomas Starzl described the caval-sparing or piggyback technique for liver transplantation hepatectomies, significantly improving patient hemodynamic stability and decreasing blood loss and transfusion requirements.


Ultrasound of an end-to-side anastomosis in the piggyback technique.


Under normal conditions, the rate of blood flow ...

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