The recipient operation consists of hepatectomy of the native liver followed by implantation of the donor liver. The native hepatectomy can be difficult, especially in patients with previous upper abdominal operations and severe portal hypertension. The ligamentous attachments of the liver are systematically taken down followed by skeletonization of the hilar structures, namely the bile duct, hepatic artery, and portal vein, in preparation for implantation of the new liver. The retroperitoneal (bare) area is taken down last since most of the blood loss can result from this dissection. Finally, the inferior vena cava (IVC) is encircled below the liver having divided the adrenal vein, and above the liver allowing enough room between the diaphragm and the origin of the hepatic veins for a vascular clamp to be comfortably placed. At this 'point of no return', the bile duct is ligated and divided, as is the hepatic artery. Vascular clamps are then placed on the portal vein and the IVC below and above the liver and the liver is removed by transecting the portal vein and the IVC and removing the retrohepatic IVC with the liver.
At this point, hemostasis is achieved as well as possible. Occasionally, the bare area may require coagulation with the argon beam coagulator and a few hemo-static sutures. Depending on the degree of coagulopathy the new liver may need to be implanted while there is ongoing bleeding from the bare area. The donor liver is prepared for implantation on the back table by removing its diaphragmatic attachments including ligation of phrenic veins, removing the adrenal gland and ligation of the adrenal vein, and preparing the arterial and portal venous structures. The donor liver is then brought onto the operative field and end-to-end anastomoses are constructed using running non-absorbable monofilament su
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