Overview
Definition:
The hepatectomy phase of liver transplantation refers to the critical surgical period where the diseased native liver (or explant) is removed from the recipient, and the graft liver is prepared for implantation
This phase is marked by meticulous dissection, control of major vascular and biliary structures, and management of potential bleeding and hemodynamic instability.
Epidemiology:
Liver transplantation is performed for end-stage liver disease (ESLD) from various etiologies including cirrhosis (alcoholic, viral hepatitis, NASH), hepatocellular carcinoma (HCC), and acute liver failure
The demand for liver transplants consistently outstrips the availability of donor organs, making efficient and safe surgical execution paramount.
Clinical Significance:
This phase is arguably the most technically demanding and hemodynamically challenging part of a liver transplant
Mastery of recipient hepatectomy directly impacts patient outcomes, minimizes operative morbidity and mortality, and reduces the incidence of early graft dysfunction
It is a core competency for transplant surgeons preparing for DNB and NEET SS examinations.
Indications For Transplant
Esld Criteria:
MELD score of 15 or higher for cirrhosis
Specific criteria for alcoholic hepatitis, NASH cirrhosis, and primary biliary cholangitis
Contraindications include uncorrected coagulopathy, active sepsis, and severe cardiopulmonary disease.
HCC Criteria:
Milan criteria (single lesion <= 5 cm or up to 3 lesions each <= 3 cm)
Expanded criteria based on downstaging and specific tumor biology
Importance of multidisciplinary tumor board review.
Acute Liver Failure:
Indications include coagulopathy (INR > 1.5 unresponsive to vitamin K) and hepatic encephalopathy in the absence of pre-existing liver disease
Consideration for hyperacute, acute, and subacute forms.
Preoperative Assessment And Preparation
Patient Evaluation:
Comprehensive assessment of comorbidities: cardiac, pulmonary, renal, and endocrine function
Nutritional status evaluation
Infectious disease screening (CMV, EBV, Hepatitis viruses).
Donor Liver Evaluation:
Assessment of donor liver quality: steatosis, steatohepatitis, size matching, cold ischemic time
Use of machine perfusion techniques to assess graft viability.
Anesthesia Considerations:
Advanced hemodynamic monitoring: arterial lines, central venous catheters, pulmonary artery catheter (if indicated)
Management of coagulopathy and thrombocytopenia
Fluid management strategies and blood product availability.
Recipient Hepatectomy Technique
Surgical Approach:
Standard subcostal or Mercedes-Benz incision for optimal exposure
Careful dissection of the falciform ligament and round ligament
Identification and preservation of the infrahepatic inferior vena cava (IVC).
Vascular Dissection And Control:
Mobilization and control of the suprahepatic and infrahepatic IVC
Careful dissection and ligation of hepatic veins draining into the IVC
Identification and isolation of the portal vein and hepatic artery
Control of these vessels is crucial to minimize blood loss.
Biliary Dissection And Explantation:
Dissection of the common hepatic duct or common bile duct
Division of the bile duct
Careful inspection for accessory ducts or anomalies
Careful dissection around the porta hepatis to avoid injury to surrounding structures.
Explantation And Hemostasis:
Systematic removal of the native liver, meticulously controlling bleeding from the raw liver surfaces and from the caval stumps
Use of topical hemostatic agents and meticulous suture ligation
Management of potential torrential bleeding from caval lacerations or hepatic vein avulsions.
Intraoperative Management And Challenges
Hemodynamic Instability:
Frequent fluid shifts, vasopressor requirements, and potential for distributive shock
Aggressive fluid resuscitation and judicious use of vasoactive agents
Rapid blood product replacement (RBCs, FFP, platelets, cryoprecipitate) based on thromboelastography (TEG) or rotational thromboelastometry (ROTEM).
Bleeding Management:
High risk of torrential hemorrhage due to portal hypertension, coagulopathy, and the friable nature of the diseased liver
Use of intraoperative cell salvage
Identification and management of accessory hepatic arteries and veins
Potential need for temporary caval shunting.
Ischemia Reperfusion Injury:
This occurs during the reperfusion of the graft
Strategies to minimize include early reperfusion, meticulous graft preparation, and judicious use of crystalloids and colloids
Monitoring for signs of early graft dysfunction.
Post Hepatectomy Care And Graft Reperfusion
Graft Preparation:
Once explanted, the graft liver is prepared for implantation
This involves trimming and vascular anastomoses
The hepatectomy phase concludes with the final steps of explant removal and initial steps of graft preparation.
Initial Reperfusion:
The moment the vascular clamps are released on the newly anastomosed portal vein and hepatic artery
This is followed by reperfusion of the IVC, and then the hepatic veins
Close monitoring of blood pressure, heart rate, and graft appearance (color, turgor).
Complications Of Hepatectomy
Hemorrhage:
Major bleeding from vascular structures, raw liver surface, or caval lacerations
Requires aggressive resuscitation and prompt surgical re-exploration if uncontrolled.
Hemodynamic Collapse:
Profound hypotension and shock due to massive blood loss, vasodilation, and reperfusion injury
Requires aggressive management with fluids, vasopressors, and blood products.
Caval Injury:
Lacerations to the infrahepatic or suprahepatic vena cava can lead to catastrophic bleeding
Meticulous dissection and prompt repair are essential
Temporary caval shunting may be required.
Bile Duct Injury:
Though more common during the anastomosis phase, inadvertent injury during hepatectomy can occur
Careful identification and preservation of the bile duct are paramount.
Key Points
Exam Focus:
Critical structures to identify and control during hepatectomy: IVC (supra/infrahepatic), portal vein, hepatic artery, hepatic veins
Understanding hemodynamic management strategies
Recognizing and managing torrential bleeding
The concept of caval shunting.
Clinical Pearls:
Maintain meticulous dissection planes to minimize bleeding
Have blood products and cell saver ready
Aggressively manage hemodynamic instability with a low threshold for vasopressors
Think about outflow obstruction from hepatic vein confluence
Communicate continuously with the anesthesia team.
Common Mistakes:
Inadequate control of vascular structures before division
Underestimation of blood loss and delayed resuscitation
Failure to recognize and manage caval injuries promptly
Insufficient attention to hemodynamic monitoring and fluid management
Poor visualization leading to injury of surrounding structures.