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Vol.18, No. 7July 1996
Surgical Techniquesfor ExtravascularOcclusion of Intrahepatic Shunts
 Washington State University 
Karen M. Swalec Tobias, DVM, MS
University of Georgia
Clarence A. Rawlings, DVM, PhD
I
ntrahepatic portosystemic shunts are congenital vascular anomalies that arefound primarily in large-breed dogs.
1
Surgical occlusion of portosystemicshunts is the therapy of choice for improving the quality of life and increas-ing the life span of affected animals. Location of intrahepatic portosystemicshunts can be determined by exploratory laparotomy, ultrasonography, portog-raphy, or nuclear scintigraphy.
2
Because of the location of the intrahepatic por-tosystemic shunt, direct ligation may be difficult. Other surgical options includeligation of the portal vein branch supplying the shunt, ligation of the hepaticvein branch draining the shunt, or temporary inflow occlusion and intravascularclosure of the shunt or associated hepatic vein.
3,4
This article reviews the perti-nent anatomy and surgical approaches for extravascular occlusion of intrahepat-ic portosystemic shunts and the veins supplying or draining intrahepatic shunts.
ANATOMY OF THE LIVER
The canine liver consists of six lobes and three divisions (Figure 1). The leftlateral and left medial lobes make up the left division; the right medial andquadrate lobes, which lie on either side of the gallbladder, compose the centraldivision; and the right lateral and caudate lobes form the right division. Thecaudate lobe is subdivided into the caudate and papillary processes, which re-ceive portal blood supply from the vessels of the right and left divisions, respec-tively.
5–7
The right lateral and caudate lobes surround a portion of the caudalvena cava as it courses cranially in the dorsal abdomen.
6
The liver is attached tothe diaphragm, primarily by the left triangular ligament (Figure 2); the righttriangular ligament is smaller and provides less support.
7
Caudal to the liver, the portal vein is ventral to the caudal vena cava, epiploic
Continuing Education Article
V
FOCAL POINTKEY FACTS
#
Knowledge of anatomy ofthe liver and its associatedvasculature is critical for locatingand isolating intrahepaticportosystemic shunts.
I
If not readily visible during surgery,intrahepatic portosystemic shuntsmay be located by palpation,ultrasonography, catheterization viathe portal vein, or measurement ofportal pressure changes duringdigital vascular occlusion.
I
Intraoperative hepaticparenchymal hemorrhage isdecreased with blunt dissectionor use of an ultrasonic aspirator.
I
Intrahepatic portosystemicshunts of the left hepatic divisionare occluded by direct ligation ofthe portosystemic shunt or byligation of the left hepatic vein.
I
Intrahepatic portosystemicshunts of the central and righthepatic divisions are oftenoccluded by ligation of theassociated portal vein branch.
 
foramen, and hepatic artery. Its tributaries, from caudalto cranial, include the cranial mesenteric, caudalmesenteric, splenic, and gastroduodenal veins. The por-tal vein branches are fairly consistent in number and lo-cation (Figure 1). The right main branch of the portalvein supplies the right division of the liver, except forthe papillary process of the caudate lobe.
6,7
The rightmain branch may be partially or completely surround-ed by hepatic tissue when it divides to form the rightlateral and caudate portal branches. The larger leftmain branch gives off a central branch to the right me-dial lobe and a small papillary branch to the papillary lobe before dividing into left lateral, left medial, and quad-rate branches.
7
Branches of the hepatic artery and bileducts are usually located on the ventral surface of theportal vein, although some branches may befound dorsal to the portal vein.
7
Dogs usually have six to eight hepaticveins that form a partial spiral aroundthe caudal vena cava
6
(Figure 2).The left hepatic vein drainsthe left division of the liverand is the largest, mostcranially located hepaticvein.
5,7
The left hepaticvein enters the left later-al surface of the caudalvena cava near the vis-ceral surface of the di-aphragm.
6
One third toone half of the vein’s cir-cumference is in close con-tact with hepatic parenchyma.The left hepatic vein can beseen more readily by incisingthe left triangular ligament(Figure 3). The central divi-sion of the liver may bedrained by one or two hep-atic veins. These veins enterthe ventral surface of thecaudal vena cava caudomedi-al to the left hepatic vein and may be completely surrounded by he-patic parenchyma at their insertions.
7
Hepatic veins draining the right division of the liver join the caudal vena cava on its right ventrolateral sur-face and are completely surrounded by hepatic tissue.
6,7
GENERAL SURGICAL PRINCIPLESIdentification of the Shunt
Intrahepatic portosystemic shunts are approached via aventral midline celiotomy.Median or paramedian ster-notomy and incision of thediaphragm can also be per-formed to increase exposure.Intrahepatic portosystemicshunts may be seen if they arenot completely surroundedby hepatic parenchyma (Fig-ure 2). Intrahepatic portosys-temic shunts and hepatic orportal vein branches that areassociated with the portosys-temic shunts are usually dilat-ed and have turbulent bloodflow. If the portosystemicshunt is not visible, lobes
Small Animal
The Compendium 
July 1996
LIVER ANATOMY
I
SURGICAL APPROACHES
Figure 1—
 Anatomy of the liver (visceral surface), hepaticartery, and portal vein in the dog. The six lobes of the liverare the caudate lobe, which is subdivided into the caudate(
CC 
) and papillary (
PC 
) processes; left lateral lobe (
LL 
);left medial lobe (
LM 
); quadrate lobe (
Q 
); right mediallobe (
RM 
); and right lateral lobe (
RL 
). The gallbladder(
G 
) lies between the quadrate and right medial lobes.
a 
=artery,
v 
= vein.
Key Facts AboutIntrahepatic Shunts
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Large-breed dogsprimarily affected
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Left side of livermore often affected
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Postligationcomplication rate =77%
I
Postligationmortality rate =11% to 25%
 
should be palpated to determine whether there is an easi-ly compressible area (typical of an aneurysm) associated with an intrahepatic shunt.
8
The abdominal viscerashould be monitored during this palpation because ve-nous distention and increased portal pressure can devel-op if the portosystemic shunt is obstructed.Intraoperative ultrasonography has been used duringexploratory surgery to locate portosystemic shunts thatare not readily visible. A sterilized ultrasound transduc-er is gently rested on the liver surface and irrigated withphysiologic saline, as needed. A needle and suture may then be passed around the portosystemic shunt withultrasonographic guidance to avoid perforating theshunt.
9
 Another method of locating intrahepatic portosys-temic shunts is to place a purse-string suture in the por-tal vein and insert a large-bore catheter or tube throughthe purse-string into the vein and advance it throughthe shunt (Figure 4). The catheter can also be passedthrough a splenic vein to avoid placement of the portalvein purse-string suture. Proper placement of thecatheter is verified by palpating the tip in the caudalvena cava cranial to the liver. Palpation of the intravas-cular catheter will identify the intrahepatic location of the portosystemic shunt and the hepatic and portalveins draining and supplying the shunt, respectively.
10
Identification of the shunt may be confirmed by measuring changes in portal pressure. A mesenteric orportal vein is catheterized, and baseline portal pressureis measured with a water manometer zeroed to the levelof the portal vein or with a pressure transducer. Normalportal pressure is approximately 8 to 13 cm H
2
O (6 to10 mm Hg); portal pressure in dogs with portosystemicshunts may be 0 to 12 cm H
2
O.
2,11
The suspected shunt or its associated portal veinbranch is digitally occluded without inhibiting flowthrough the portal vein or its remaining branches. Dig-ital occlusion of the left hepatic vein may be similarly attempted; the surgeon must be careful not to simulta-neously obstruct the caudal vena cava. A rapid rise inportal pressure occurs with occlusion of the portosys-temic shunt or its associated portal vein branch or he-patic vein; minimal changes are seen with compressionof other portal branches or hepatic veins. Occasionally,
The Compendium 
July 1996Small Animal
SHUNT IDENTIFICATION
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ULTRASONOGRAPHY
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PURSE-STRING SUTURES
Figure 2—
 Anatomy of the liver (diaphragmatic surface) and the hepatic veins. The hepatic veins form a partial spiral aroundthe ventral surface of the caudal vena cava near the diaphragm. After incising the left triangular ligament, the left mediallobe is retracted to the right and the interlobar area is examined for a portosystemic shunt draining into the hepatic vein of the left lateral or left medial liver lobe.
RL 
= right lateral lobe,
RM 
= right medial lobe,
GB 
= gallbladder,
LM 
= left mediallobe,
Q 
= quadrate lobe,
LL 
= left lateral lobe,
Lig 
= ligament.
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