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single confluence to ensure proper venous drainage of the graft. Alternately, a new caval orifice can be created more inferiorly on the vena cava orienting the liver more medially, and allowing the portal vein ends to come together with less tension. Fine absorbable monofilament sutures are used for the venous anastomosis. The artery is anastomosed using fine interrupted nonabsorbable sutures and an operating microscope in infants10 or when the donor vessels are small such as in living donor transplants.

Reperfusion Phase

After reperfusion, a number of metabolic changes occur. Calcium requirements decrease or stop, the serum bicarbonate level rises and potassium may fall. Additionally, PTT may go up. The coagulopathy may require additional fresh frozen plasma, but more aggressive coagulation factor replacement with cryoprecipitate is not advisable unless bleeding is life threatening. Over correction of the coagul-opathy seen after reperfusion may lead to hepatic arterial thrombosis.

During this last phase, the Roux loop is constructed if necessary, and the bile duct anastomosis is completed.

Children usually require biliary reconstruction using a Roux loop of bowel. The choledochojejunostomy is done over a stent in cases of very small ducts in order to ensure that the back wall is not accidentally included in the front wall reconstruction. In cases of grafts from living donors or where the liver is split, separate ducts from segments 2 and 3 may be encountered which require individual attachment to the bowel.

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