Table 9.13. Potential indications for venous-venous bypass

1. Severe retroperitoneal collateralization

2. Poor preoperative renal function

3. Hypotension following test clamping of the vena cava despite adequate volume loading

4. Intestinal or mesenteric edema

5. Fulminant hepatic failure

6. Inexperience with the procedure

(For more details on anesthetic considerations of liver transplantation including monitoring of coagulation please refer to Chapter 13.)

The hepatic artery anastomosis is typically performed between the recipient hepatic artery, at the junction of the gastroduodenal artery, and the donor celiac axis using a Carrel patch. Approximately 15 to 20 percent of the time, abnormal arterial anatomy is identified in the donor liver consisting of either an aberrant left hepatic artery emanating from the left gastric artery of the donor, which does not require any particular reconstruction, or an aberrant right hepatic artery originating from the superior mesenteric artery. This latter type of arterial anatomy requires arterial reconstruction on the back bench which most commonly consists of implanting the origin of the aberrant vessel onto the donor splenic artery so that the celiac axis can be used as a single inflow. Occasionally, the inflow from the recipient hepatic artery is inadequate either because of inadequate flow or as a result of abnormal arterial anatomy in the recipient. Donor iliac arteries are routinely harvested as part of the donor procedure and these can be used to construct a conduit between the recipient infrarenal aorta and the donor hepatic artery or celiac axis. This conduit can also be made to originate from the supraceliac aorta, although infrarenal reconstruction is more commonly used. The conduit can be brought to the hilum by creating a tunnel behind the pancreas, but can also be placed anteriorly through the transverse mesocolon.

Once the liver is arterialized and the hepatic artery demonstrates satisfactory flow, hemostasis is achieved, and the bile duct reconstruction is performed using end-to-end choledochocholedochostomy over a T-tube stent. Several variations of this anastomosis have been used. Recently the necessity for a T-tube has been

0 0

Post a comment