Liver transplantation with piggyback anastomosis using a linear stapler: a case report

Stapled Anastomosis for Side-to-Side Cavo-Cavostomy in Orthotopic Liver Transplantation

In liver transplantation, a side-to-side anastomosis is one of the commonly performed techniques of the inferior vena cava reconstruction. The authors report a case of an application of an endoscopic vascular linear stapler for a side-to-side caval anastomosis during deceased-donor liver transplantation. The back table procedure was performed in a standard fashion for a side-to-side anastomosis. The linear vascular stapler was introduced during the temporary clamping of the recipient's inferior vena cava and the anastomosis was created without problems. Suturing of the resulting defect completed the anastomosis. The use of the stapler resulted in a shortening of the anastomosis time. The staple line after the reperfusion of the graft was completely sealed. The patient's postoperative course was uncomplicated and post-operative ultrasound and computed tomography confirmed the patency of the anastomosis. This case demonstrates a novel approach to a side-to-side caval reconstruction during liver transplantation that enables a shortening of the implantation time and may improve the quality of anastomoses.

One-shot side-to-side anastomosis (OSSSA) with stapler for cavo-cavostomy in liver transplantation: the first step towards a fully mechanized liver transplant?

BACKGROUND

In literature, a variety of caval reconstruction techniques for liver transplantation have been reported. The piggyback technique preserves the recipient's caval vein which is directly anastomosed to donor's inferior vena cava (IVC) allowing for the reduction of hemodynamic compromise during liver transplantation.

METHODS

Herein, we present our standardized step-by-step technique for the realization of a caval one-shot side-to-side anastomosis (OSSSA) using a linear stapler. A Satinsky vascular clamp is placed in a top down direction to realize a longitudinal partial clamping of the recipient IVC. A 1-cm venotomy is then performed on the anterior wall of the recipient IVC to permit the easy introduction of the vascular stapler arm in order to perform the mechanical anastomosis. Portal vein, hepatic artery, and biliary anastomosis are then completed in standard fashion.

CONCLUSIONS

Compared to the manual one, this mechanical anastomosis permits to reduce operative time, caval and portal vein clamping, warm ischemia time, and visceral congestion.

RESULTS

In our opinion, this is a rapid, easy, safe, and reproducible technique to perform the side-to-side cavocaval anastomosis during liver transplantation in selected patients when a manual anastomosis may be technically challenging.

An Alternative Surgical Technique of Native Hepatectomy in Liver Transplantation

Background

Orthotopic liver transplantation has become the procedure of choice for end-stage liver disease. There are 3 commonly used methods of vena cava anastomosis. Here, we report a new technique for native hepatectomy.

Material/Methods

The data of 12 patients who underwent orthotopic liver transplantation using a new surgical technique were retrospectively collected for analysis. The new separation and reconstruction surgical technique mainly involved the second portal isolation and hepatectomy that followed. We performed recipient liver resection without the occlusion of the inferior vena cava, which was then followed by classic, piggyback, modified piggyback, or side-to-side orthotopic liver transplantation. The graft function index and complications were collected after transplantation.

Results

The length of the anhepatic phase was 30.92±9.1 min. Alanine transaminase (ALT) levels were 138 to 2027 U/L, with a median of 361.5 U/L. The ALT levels of all patients gradually decreased to normal levels 7 to 10 days after surgery. Only 2 recipients had elevated levels of ALT higher than 1000 U/L. Four of 12 patients did not require red blood cell transfusion during surgery. Four patients appeared to have early allograft dysfunction, while others recovered smoothly.

Conclusions

This new surgical technique may shorten the anhepatic phase and decrease blood loss volume, aiding the success of liver transplant surgery. It can be used for most patients and does not increase the risk of complications or impair prognosis.

Circumferential Fence With the Use of Polyethylene Terephthalate (Dacron) Vascular Graft for All-in-One Hepatic Venous Reconstruction in Right-Lobe Living-Donor Liver Transplantation

Integration of hepatic vein tributaries with a diameter ≥ 5 mm into the drainage system in right-lobe living-donor liver transplantation (LDLT) is of vital importance for graft function. Recently, the most commonly emphasized hepatic venous reconstruction model is the all-in-one reconstruction model. In the final stage of this model that aims to form a common large opening, allogeneic vascular grafts are almost always used to construct a circumferential fence. To date, no other study has reported the use of polyethylene terephthalate (Dacron) vascular graft as a circumferential fence in LDLT. We aimed to present the 1st 4 cases of circumferential fences created with Dacron vascular graft. Four right-lobe grafts weighing 522-1,040 g were used. A polytetrafluoroethylene vascular graft was used for the integration of segment 5 vein and segment 8 vein into the drainage model, whereas a Dacron graft was used to creating a circumferential fence. The patency of hepatic outflow evaluated with the use of multidetector computerized tomography at postoperative day 7. Venous outflow obstruction was not detected in any cases. This study suggested that owing to its flexible structure the polyethylene terephthalate vascular graft can be an alternative to allogeneic vascular grafts in forming circumferential fence.

Caval reconstruction techniques in orthotopic liver transplantation

There are several caval reconstruction techniques currently in use for orthotopic liver transplantation. These include caval replacement or the conventional technique, performed with or without venovenous bypass, piggyback technique with anastomosis with two or three hepatic veins with or without cavotomy and modifications of the piggyback technique including end-to-side and side-to-side cavocaval anastomosis. There are few randomized controlled trials comparing the use of these techniques and our knowledge of their comparability is based on a few multi- and many single-center retrospective and prospective reviews. Although there are advantages and disadvantages for each technique, it is advisable that the surgeon perform the technique with which they have the most the experience and at which they are the most skilled as excellent outcomes can be obtained with any of the caval reconstruction options discussed.