Alternative Techniques

"Piggyback Procedure"

The recipient hepatectomy can be altered to leave the recipient retrohepatic IVC in situ. Thus, during the hepatectomy, the caudate venous branches are ligated and divided individually as the IVC is separated from the liver. Occasionally accessory hepatic veins are encountered particularly to the right lobe and eventually the liver remains attached to the IVC only by the hepatic veins. The hepatic veins can then be either clamped and the ostia used for the IVC anastomosis (Fig. 9.4A), or suture ligated and another site on the recipient IVC used for anastomosis. The donor IVC is then anastomosed to the recipient IVC in a piggyback fashion by performing either an end-to-side or side-to-side IVC-to-IVC anastomosis. Once the IVC anastomosis is completed, the infrahepatic IVC is used as outflow of portal venous blood (instead of cold Ringer's lactate) in an effort to wash out preservation solution from the liver and following this, the infrahepatic IVC is ligated. The remaining structures are anastomosed in standard fashion (Figure 9.4B).

"Split Liver Procedure"

Recently, the use of split livers has become routine for selected donor livers for most liver recipients. The liver is typically 'split' along the falciform ligament separating the left lateral segment (Couinaud segments II and III) from the remaining liver. The main hilar vascular and biliary structures are retained with the right side of the liver. The left lateral segment is typically transplanted into a child and the remaining liver transplanted into an adult. The transplant procedure for a split liver is identical to that for a whole liver with the exception that hemostasis at

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