Liver Transplant – Recipient mayo stand and back table surgery setup

A liver transplant surgery is a procedure in which a diseased liver is removed and replaced with a healthy liver from a donor. It is typically done to treat liver failure or other severe liver conditions that cannot be managed with medication or other treatments. The surgery involves carefully detaching and reattaching important structures like the vena cava, portal vein, hepatic artery, and common bile duct, using specialized surgical instruments and techniques. Recovery from a liver transplant can be a long and complex process, but successful transplant can greatly improve a patient’s quality of life and overall health.

Positioning
Supine

Drapes
Folded towels or utility drapes, laparotomy drape or the equivalent to an “open belly” drape that your facility has, Ioban

Step 1: Removing the Diseased Liver
The first and most crucial part of the surgery is removing the recipient’s diseased liver. The surgeon will assess the liver and decide on the best approach for removal. To detach the liver from surrounding tissue and liver attachments, the surgeon will isolate and transect important structures like the inferior vena cava, portal vein, hepatic artery, and common bile duct. Depending on surgeon preference, Crawford clamps may be used on the inferior vena cava, and mini DeBakey clamps on the portal vein. An Ethicon stapler (or equivalent) may also be used.

Step 2: Attaching the New Liver
After the old liver is removed, the new healthy liver will be sewn into place. The surgeon will first connect the vena cava and portal veins using 3-0 and 4-0 Prolene. Long Debakey pickups, vascular needle holders, and long suture scissors will be used while suturing. Next, arterial flow will be established by re-connecting the hepatic arteries using 7-0 Prolene. The common bile ducts will then be reconnected using 6-0 PDS. Hemostats or mosquito clamps with booties should be available to tag suture.

Step 3: Checking for Bleeding and Warming the Cavity
Once all the major structures are reattached, new blood will be cycled through the liver (reprofusion), and the surgeon will watch for any bleeding. Warm saline will be poured into the cavity to bring it up to natural body temperature. Two drains will also be placed using the Mayo scissors to cut the drains and 2-0 Nylon to suture them in place.

Step 4: Closing the Incision
Finally, the surgeon will ensure that all bleeding has been stopped, and the incision can be closed. Usually, a stapler is used on the skin. As a surgical technologist, it is essential to have all the necessary instruments at hand and be able to anticipate the surgeon’s needs throughout the procedure.

Tips and tricks
Always have clip appliers ready. Some surgeons will prefer the disposable ones over the reusable ones, but common sizes are the small and medium clips.

Several sizes of free silk ties should be available to tie off any small attachments. It is also a good idea to have at least 2 asepto bulb syringes on your field for irrigation, and don’t forget your fluid warmer!

The Surgery Sparknotes

1. Prepare #10 blade and extended tip for bovie
2. Isolate and transect important structures of diseased liver
3. Attach new liver by connecting vena cava, portal veins, hepatic arteries, and common bile ducts using appropriate sutures and clamps
4. Check for bleeding, warm the cavity, and place two drains
5. Close incision using a stapler