Orthotopic Liver Transplantation
This complex surgery involves the total hepatectomy of the diseased native liver and the subsequent implantation of a donor liver into the same anatomical position. The procedure requires multiple vascular anastomoses, including the vena cava, portal vein, and hepatic artery, along with biliary reconstruction.
Surgical instruments
11 on this table — tap a photo to zoom, the name for its full card.
The case
Spark notes
The 30-second rundown — scan this outside the room.
- Anesthesia and Positioning: Patient is put under general anesthesia and positioned on their back with arms extended.
- Incision and Exposure: A large incision is made in the upper abdomen to expose the liver.
- Liver Mobilization: The surgeon divides ligaments and blood vessels to mobilize the liver.
- Dissection: The hepatic artery, portal vein, and bile ducts are dissected.
- Hepatectomy: The diseased liver is removed by dividing the blood vessels and bile ducts that connect it to the body.
- Graft Preparation: The healthy liver is trimmed and prepared for implantation.
- Implantation: The graft is implanted by connecting the blood vessels and bile ducts to those of the recipient.
- Hemostasis: The surgeon ensures there is no bleeding from the surgical site and that blood flow is adequate.
- Closure: The incision is closed with sutures or staples, and sterile dressings are applied to the wound.
Walkthrough
What the surgeon does — and what to have in your hand before they ask.
Anesthesia and Positioning
The first step in an Orthotopic Liver Transplantation is to put the patient under general anesthesia and position them on their back with their arms extended (supine). This position allows the surgical team to have access to the abdomen.
Incision and Exposure
A large incision is made with a #10 knife blade on a #3 knife handle in the upper abdomen to expose the liver. This incision allows the surgical team to have a clear view of the liver and access to the blood vessels and ducts that need to be dissected and divided during the surgery. Common instruments to use during dissection are hemostats, right angles, and a variety of scissors such as Tenotomys or Metz.
Liver Mobilization
The surgeon carefully mobilizes the liver by dividing the ligaments and blood vessels that connect it to the surrounding structures. This step allows the liver to be lifted and moved to give the surgical team better access to the blood vessels and ducts that need to be dissected and divided.
Dissection of the Hepatic Artery, Portal Vein, and Bile Duct
The surgeon dissects the hepatic artery, portal vein, and bile ducts, which are the blood vessels and ducts that supply the liver with blood and bile. This step is critical to the success of the transplant as it ensures that the graft has proper blood flow and biliary drainage. Crawford clamps and pediatric vascular clamps are commonly used during this portion, along with a variety of silk tie sizes, vessel loops, and sometimes a 45 or 60 Ethicon stapler for veins. 6-0 BVI is commonly used on veins, and 7-0 Prolene on arteries.
Hepatectomy
The diseased liver is removed by dividing the blood vessels and bile ducts that connect it to the body. This step requires precision and care to avoid damage to surrounding organs and structures.
Graft Preparation
The healthy liver (graft) is carefully prepared for implantation, which includes trimming it to the appropriate size and reconnecting the hepatic artery, portal vein, and bile ducts. This step ensures that the graft is the correct size for the recipient and that it has the proper blood flow and biliary drainage.
Implantation
The graft is implanted by connecting the blood vessels and bile ducts to those of the recipient, using surgical sutures to create a secure connection. This step requires precision and care to ensure that the graft has proper blood flow and biliary drainage.
Hemostasis
The surgeon ensures that there is no bleeding from the surgical site and that blood flow to the liver is adequate. This step is critical to the success of the transplant and requires careful monitoring and management.
Closure
The incision is closed with sutures or staples, and sterile dressings are applied to the wound. This step is important to prevent infection and promote healing. Common sutures used are 3-0 and 4-0 SH Prolene, 5-0 C1Prolene, and 6-0 PDS.
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