The standard procedure of orthotopic liver transplant is the preferred surgical method. This technique should be used any time a liver malignancy is growing next to the inferior vena cava (IVC). The standard technique is the simplest of the procedures to perform, and it takes the shortest amount of time. The introduction of the venous-venous bypass has made the training of many surgeons possible and has dramatically decreased the intraoperative mortality experienced during the early days of liver transplantation. Before the introduction of the venous-venous bypass, survival rates were low in the setting of hemodynamic instability (Shaw et al. 1984). Patients were especially vulnerable during the anhepatic phase due to decreased venous return to the heart and hypertension in portal and systemic vessels upon clamping of the IVC and the portal vein (Shaw et al. 1984). The venous-venous bypass shunts blood flow from the portal and caval systems in the lower part of the body into the internal jugular vein, bypassing the inferior vena cava. This shunt provides the surgical team with time to implant the allograft without subjecting the patient to a decreased venous return to the heart during a complete occlusion of the IVC.

The preferred incision of choice is known as the Mercedes-Benz. It consists of a bilateral, subcostal incision with an upper midline extension made with electrocautery. Once the peritoneum is entered, the ascitic fluid, if present, is drained. Specimens are sent for culture and sensitivity studies. The round ligament of the liver is divided between 0 silk ties, and the falciform ligament of the liver is divided with electrocautery. At this stage, the xiphoid process is removed using electrocautery and heavy scissors. Subsequently, the midline peritoneum is tucked to the fascia with interrupted 2/0 silk stitches. This maneuver facilitates reopening of the midline if needed. In fact, by bringing the peritoneum up to the fascia, the intensity of the adhesions is limited in that area. In addition to that, covering the stump of the xiphoid process with peritoneum prevents injuries during the mobilization of the cirrhotic liver and the implantation of the allograft. A wet folded lap is placed on the tip of the spleen to avoid splenic injury caused by the retractor’s blades. To provide adequate exposure, the surgeon uses a combination of the self-retaining rib-grip (Stieber) and the Iron Intern retractors. The operation begins with an exploratory laparotomy. This phase is particularly important and aims to rule out possible contraindication to transplantation. Contraindication is most commonly lymph node metastasis from primary liver cancers. Subsequently, the elements of the hepatic hilum are skeletonized. First, the common bile duct is isolated and transected between 2/0 silk ties. A sample of bile is collected and sent for culture. This is the second and last standard culture obtained during liver transplantation. Patients undergoing liver transplantation are often colonized with bacteria that can cause infection postoperatively under the effect of the immunosuppressive treatment. Therefore, knowing which bacteria, if any, are colonizing the bile duct and the peritoneal cavity can help expedite antibiotic treatment while waiting for the final culture results. Next, the hepatic artery is divided between 2/0 silk ties. It is a good practice for the surgeon to alert the anesthesiologist before the silk is tied off on the artery. This provides the anesthesiologist enough time to draw the last arterial blood sample while the native liver is perfused with systemic blood flow. In fact, the lactate clearing activity of the liver is predominantly controlled by the blood flow coming from the hepatic artery. Lastly, the portal vein is skeletonized. At this stage we proceed to dissect the hepatic artery proximally to 1 cm below the takeoff of the gastroduodenal artery (GDA). The distance of 1 cm generally provides enough room to place a surgical clamp on the common hepatic artery and to rotate the vessels when performing the anastomosis.

At this stage, the access sites for the venous-venous bypass are prepared. The return cannula is placed in the right internal jugular vein by the anesthesia team after induction of general anesthesia and before prepping the surgical field. The IVC cannula is placed percutaneously through the left groin using a Seldinger technique. Although the left groin is preferred, the right groin can be used if needed. Of note, the IVC is accessed through the iliac-femoral vessels. To safely place the portal vein cannula, the portal vein skeletonization is first maximized to obtain the longest possible vessel trunk. Then, a large surgical clamp is applied distally on the portal vein as far as possible in the porta hepatis, while the proximal end of the vessel is clamped between fingers. The portal vein is divided as close as possible to the clamp in the porta hepatis. To facilitate the cannulation of the portal vein, three tonsils are applied on the edge of the vessel to keep it open. The cannula is secured in place by two wet umbilical tapes. Both cannulas are tested and flushed with a heparinized saline solution. The portal and femoral vein cannulas are connected with a Y connector, and the bypass cannula is connected to the patient, as shown in Fig. 2. The bypass is started and the flow is maintained above 1 l per minute. Below this speed, the patient is subject to thrombosis (Shaw et al. 1984). If the volume flow rate slows to below 1 l/min, it may be a sign of hypovolemia or malpositioning of the portal vein cannula. In the first case, administration of fluid boluses can increase the bypass flow rate. At times, low flow results from a cannula facing the wall of one of the vessels, typically at the juncture of the splenic and superior mesenteric veins. To increase the flow in this case, the surgeon must maneuver the cannula away from the wall of the vessel. However, if the flow rate cannot be increased above 1 L/min, the patient is required to go off bypass.

The distal stump of the portal vein is oversewn with Prolene 3/0. The infra-hepatic IVC is skeletonized and cross-clamped with an adult angle Potts clamp. The left triangular ligament is divided with electrocautery, and the gastrohepatic ligament is divided between 2/0 silk ties. The right triangular ligament is divided with electrocautery. The suprahepatic IVC is encircled and clamped with a German clamp. The liver is removed from the field using blunt and sharp dissection. As soon as the native liver is removed from the surgical field, the right adrenal vein is tied off using a 0 silk tie, which is passed around the area where this vessel merges with the IVC. Further hemostasis is obtained in the bare area of the liver by two running 2/0 Prolene sutures: one vertically placed in the IVC area and one from the tip of the right triangular ligament forward as shown in Fig. 3. These two running sutures are not always necessary. At times, proper hemostasis of the bare area can be achieved with argon beam coagulation.

Achieving hemostasis by oversewing the bare area tends to decrease the size of the retro-hepatic area, allowing for transplantation of a smaller liver. This change in size of the right upper quadrant of the abdomen should be kept in mind when using large livers that might not fit the anatomical area. In that case, different hemostatic techniques should be considered.

The cuffs of the supra- and infra-hepatic IVC are prepared, and the new liver is brought into the operative field. It is helpful to position two 4/0 silk sutures on the upper left of the suprahepatic IVC cuff. By pulling these two sutures cranially, a better exposure of the posterior wall of the anastomosis is achieved. The suprahepatic IVC anastomosis is done in an end-to-end fashion using running 3/0 Prolene sutures. Subsequently, the infra-hepatic IVC anastomosis is completed in an end-to-end fashion using running 4/0 Prolene sutures. Once the posterior wall of the infra-hepatic IVC anastomosis is completed, the liver is flushed with 1 l of chilled (4 °C) lactated Ringer’s (LR) solution. The allograft is flushed through a cannula that was secured in the portal vein at the time of the back-table preparation. The practice of flushing the liver with chilled LR intends to remove as much University of Wisconsin® solution (UW) as possible from the allograft. UW is rich in potassium. If the UW is not removed from the allograft, a load of potassium would reach the right atrium at the time of reperfusion. This process may be responsible for deadly cardiac arrhythmias. At this stage, in preparation for the portal vein anastomosis, the portal cannula of the venous-venous bypass is clamped with a tubing clamp. The portal cannula is removed from the portal vein, and the portal vein is clamped with a pediatric angled Potts clamp. The surgeon should clamp the tip of the portal vein cannula with a large Kocher clamp to prevent air embolism in the case of failure of the tubing clamp. In preparation for the portal vein anastomosis, three wet lap sponges are placed between the right hemidiaphragm and the dome of the liver. The right arm of the rib-grip retractor is lowered by three complete turns. The combination of these two maneuvers shortens the distance between the donor and recipient’s portal vein stumps. This prevents the creation of a long portal vein that could kink and therefore cause vessel thrombosis in the postoperative time. The donor’s portal vein is then shortened to a sufficient length to obtain a straight and nonredundant anastomosis. The portal vein anastomosis is completed end-to-end with running 6/0 Prolene sutures. When the running suture is tied, a generous growth factor is left behind so the anastomosis can expand at reperfusion and stenosis can be prevented. The laps are removed from the field and the rib-grip retractor is placed in its original position. There are two ways of proceeding at this time. One way is to perfuse the liver solely with portal blood and to reconstruct the hepatic artery once reasonable hemostasis is achieved. The second option consists of reconstructing all of the vessels before reperfusing the allograft. This second option is the one favored. However, in order to safely proceed with four-vessel reconstruction before reperfusion, the total implantation time cannot exceed 1 h. In addition, reperfusing allografts with portal as well as systemic blood can cause more hemodynamic instability that should be taken in account by the anesthesiology team. The four-vessel technique is completed as follows. The GDA is tied off with two 2/0 silk ties. The use of two separate sutures guarantees better control of this vessel. The common hepatic artery is clamped with a spoon clamp, and the recipient’s hepatic artery is opened. A cuff of the recipient’s hepatic artery is prepared at the level of the GDA patch. The donor’s hepatic artery is shortened and beveled in the opposite direction, and a straight and nonredundant anastomosis is made end-to-end using running 7/0 Prolene sutures. Once the anterior wall of the hepatic artery anastomosis is completed, the anesthesia team is alerted that the allograft will be reperfused in approximately 3 min. This gives the anesthesiologist enough time to prepare the drugs needed to counteract possible hemodynamic instability after reperfusion and to record the last potassium level before reperfusion. At this stage the liver is reperfused. The hepatic artery, the portal vein, the infra-hepatic IVC, and the suprahepatic IVC clamps are removed in sequence. It is possible to keep the suprahepatic IVC clamp on until the liver is fully reperfused. In this case, the liver outflow runs into the bypass machine before reaching the heart rather than going directly into the right atrium. This maneuver prevents a potentially fatal, arrhythmogenic potassium load.

If the patient is stable after packing the operative field, it is suggested to go off bypass. After all cannulas are removed, the blood in the circuit can be recuperated in the cell saver. The next step of the operation is to achieve hemostasis. It is customary to proceed in a clockwise fashion starting from the anterior wall of the suprahepatic IVC, moving toward the medial side wall of the same vessel, to the infra-hepatic IVC on its medial aspect, to the hepatic hilum, and lastly to the lateral walls of the infra- and suprahepatic IVC. There are several areas not mentioned above that are addressed while moving in the clockwise direction, namely, the falciform ligament on both sides (donor and recipient), the left triangular ligament on both sides, the hepatogastric ligament on the recipient’s side, and the right triangular ligament on the donor’s side. Generally, these areas are addressed with argon beam coagulation. Packing during hemostasis is exceptionally important because pressure alone has been shown to be one of the most effective methods of achieving hemostasis, and because it maintains hemostasis while the anesthesiologist progressively corrects any coagulopathy based on the results of thromboelastography (Kang et al. 1985).

The last step of the operation is the bile duct reconstruction that will be discussed in a separate paragraph.

This same operation can be performed without venous-venous bypass when the degree of portal hypertension is such that cross-clamping the IVC would not cause a significant reduction in the blood flow return to the right heart. Hemodynamic stability in this case can be achieved by maintaining the patient’s electrolyte and volume status (Starzl et al. 1968).

The bile duct continuity can be achieved with several techniques. It is preferential to perform an end-to-end choledochocholedochostomy over a T tube. First, the donor’s duct is explored. This is done with a bile duct probe. With this maneuver, the distance between the stump of the donor’s duct and the bifurcation in the right and left duct is assessed. Next, cholecystectomy is carried out in an antegrade fashion using electrocautery. The cystic artery is transected to check for good blood flow from the hepatic artery. The cystic artery is then tied off with a 2/0 silk tie when satisfactory pulsating blood flow is identified. The gallbladder is removed from the surgical field. Hemostasis is achieved in the bed of the gallbladder with argon beam coagulation. The cystic duct is then opened flat with electrocautery to avoid possible mucocele formation in the postoperative time. The stump of the bile duct is trimmed by 1 or 2 mm until arterial bleeding is noted from the edge of the duct. The bleeding vessels are always located in the medial and lateral corner of the bile duct stump; hemostasis is achieved with one transfixed stitch per arterial vessel. Different types of stitches can be used, such as 4/0 silk or 6/0 PDS. At this stage, two 4/0 silk stitches are placed on the lateral and medial corner of the donor’s bile duct stump. The recipient’s duct is opened, explored, and trimmed. Although this anastomosis can be performed with or without a T tube, T tube use is preferred. The T tube gives easy access to the bile duct if a cholangiogram is needed in the postoperative time. Other uses of the T tube include: macroscopic evaluation of the bile characteristics and bile collection for culture in case of postoperative infections. Thick dark bile is considered to be normal. Bile that is light in color, and less dense than normal, is typical in primary non-function or acute cellular rejection. Nine 5/0 PDS sutures are used to complete the anastomosis. Two stitches are placed in the posterior wall, three on each side, and one on the anterior wall. A purse string is placed around the exit site of the T tube. Lastly, the anastomosis is checked for leakage by injecting heparinized saline solution through the T tube first, and air, while the anastomosis is submerged in water, second.