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  • Highly unstable individuals with liver failure who:

    • Are candidates for liver transplantation

    • Have no immediately available liver grafts for transplantation

    • Have severe physiologic derangements

      • Unresponsive to therapy

      • Entirely attributable to their liver failure

  • Causes of liver failure:

    • Fulminant hepatic failure associated with massive necrosis

    • Acute graft failure associated with massive necrosis

    • Primary graft nonfunction

    • Massive trauma with exsanguination

    • Spontaneous hepatic rupture

    • Massive uncontrolled hemorrhage

    • Other

  • “Toxic liver syndrome”

    • Total liver necrosis

    • Cardiovascular shock

    • Renal failure

    • Likely respiratory failure

  • Need for:

    • Vasopressor support

    • Renal replacement therapy

    • Mechanical ventilation

  • The decision to proceed with emergency total hepatectomy as the first of a 2-stage transplant procedure should take into consideration:

    • High mortality associated with:

      • Current condition

      • Anhepatic state

    • Whether total hepatectomy will bring enough stability to justify transplantation

    • Extent and reversibility of multiorgan failure

    • Presence of sepsis

    • Neurologic status

  • Intensive medical management is required to maintain some stability during the anhepatic phase.

  • In instances where a liver graft becomes available, it should be determined that the recipient is stable enough to tolerate the implantation.


  • Total hepatectomy is performed according to the technique chosen for liver transplantation.

  • We prefer to preserve the retrohepatic IVC.

  • Once the liver is removed, the suprahepatic veins are oversewn (Figs. 76-1 and 76-2).

  • A temporary portocaval shunt is then constructed (Figs. 76-3 and 76-4).

  • In instances where the retrohepatic IVC is removed, an external venovenous bypass can be instituted.

  • Hemostasis should be carefully monitored, since during the anhepatic phase no hepatic coagulation factors are produced and all support is via infused products.

  • When a liver graft is available and the recipient considered suitable for transplantation, implantation is undertaken according to the surgeon’s technique of choice.


The native liver has been removed, and the confluence of the hepatic veins into the IVC is being sutured (green arrow).


The hepatic veins have been completely oversewn (green arrow). The retrohepatic IVC (blue arrows) has been preserved in its entirety.


The portal vein (yellow arrow) has been anastomosed in an end-to-side fashion (white arrow) onto the IVC (blue arrow).


Finalized temporary portocaval shunt for emergency hepatectomy. The hepatic veins have been oversewn (green arrow) and the portal vein (yellow arrow) anastomosed in an end-to-side fashion (white arrow) onto the IVC (blue arrow).


Guirl  MJ, Weinstein  JS, Goldstein  RM, Levy  MF, Klintmalm  GB. Two-stage total hepatectomy and liver transplantation for acute deterioration of chronic liver disease: A new bridge to transplantation. Liver Transpl. 2004;10(4):564–570.  [PubMed: 15048803] ...

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