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Transplantation - Practical Manual of Abdominal Organ Transplantation - 2002

Transplantation - Practical Manual of Abdominal Organ Transplantation - 2002

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Published by: basyony1970 on Feb 29, 2012
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The remaining attachments to the liver can be divided rapidly once the liver
has been completely devascularized. The liver is then sharply excised (Fig. 10.3),
leaving an upper caval cuff at the diaphragm that includes the open orifices of the
hepatic veins, a lower caval cuff above the renal veins, and the bare area that was
behind the rightlobe of the liver. The bare area is oversewn for hemostasis (Fig.
10.4), and the vena cavalcuff is fashioned for anastomosis.
The implantation of the liver follows a strict routine. The suprahepatic vena
cava is anastomosed first. With this completed, the vena cava is anastomosed
below the liver; a venting catheter is left within the cava through the lower caval

100

Cosme Manzarbeitia and Sukru Emre

anastomosis, which is left untied until after reperfusion. The recipient portal vein
is now decannulated. The donor and recipient portal veins are then anastomosed in
a manner that redundancy and kinking are avoided. The liver is then flushed free of
preservation solution prior to reopening the circulation by infusion of a crystalloid
solution via the portal veinduring the infrahepatic vena caval anastomosis or with
portal blood subsequent to the portal anastomosis. After reperfusion, the caval
clamps are opened, restoring normal flow. A rapid inspection for hemostasis is
made, and attention is turned to the hepatic artery. We have found that the routine
use of the common hepatic artery at the level of the gastroduodenal is the most
common source of adequateinflow, and avoids a duodenal steal phenomenon. The
anastomosis is performed in an end-to-end fashion,sewing the common hepatic
artery to the celiac artery of the donor. To confirmadequacy of the arterial
reconstruction,flow is measured with an electromagnetic flow meter at the com-
pletion of the vascular anastomoses. If flow is found to be inadequate, the artery is
scrutinized to determine the reason and any problems are corrected. If there is any

101

The Liver Transplant Procedure

doubt as to the adequacy of the inflow, an aortohepatic graft should be fashioned
by utilizing donor iliac artery. Grafts can be also used to lengthen the vessels for
anastomosis as interposition arterial or venousgrafts (Fig. 10.5). The graft is then
sewn end-to-end to the celiac axis of the donor liver.

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