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(See Plate 171.) The selective distal splenorenal shunt may be indicated in the patient with cirrhosis of the liver without ascites but with evidence of a major hemorrhage from gastroesophageal varices. The incidence of encephalopathy may be reduced in comparison with other types of portosplenic shunts.

These patients require detailed evaluation of both hepatic and renal function. Severe ascites contraindicates the procedure. A needle biopsy of the liver evaluates the basic hepatic disease as well as determines the possibility of acute inflammation caused by alcoholic hepatitis or chronic aggressive hepatitis and cirrhosis. The operation is delayed indefinitely if acute alcoholic hepatitis is found. Except in emergency situations, the hepatic disease should be considered stable before the shunting procedure is planned.

Preoperative angiography is essential to establish the presence or absence of portal venous flow to the liver, as well as to obtain a gross estimate of the volume of portal venous perfusion of the liver. The preoperative angiogram also determines the patency and anatomic relationships of the mesenteric, splenic, and portal veins.

In addition, catheterization and visualization of the left renal vein are essential. These procedures permit a preoperative evaluation of the structural relationships and reveal any abnormalities or unusual anatomic variations that would make the proposed shunt impossible.

(See Plate 172.)

(See Plate 172.)

The surgeon should be familiar with the anatomy of the portal system as well as the veins draining the stomach (Figure 1). Maximum exposure is essential. A long midline incision extending from the xiphoid to well below the navel may be used (Figure 2). The incision may be made to the right of the navel, and the umbilical vein and round ligament to the liver ligated and divided. A long bilateral curved incision extending from the midrectus on the right to well out into the left flank may be preferred, with the left side of the patient elevated 10 to 15 degrees.

Gentle and limited exploration of the opened abdomen is indicated to avoid possible hemorrhage from delicate torn vascular adhesions. The region of the needle puncture for a splenoportogram is inspected for evidence of continued bleeding. Some type of hemostatic material may be required to control the oozing site. A biopsy of the liver should be taken.

The gastrocolic omentum is detached from the transverse colon, including the flexures, without ligating the gastroepiploic vessels. This ensures good access to the pancreas and, in turn, the splenic and renal veins. Adhesions ...

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