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Surgical text for orthotopic liver transplantation model with small-for-size graft in the pig: key techniques and pitfalls.

Hori T, Yagi S, Iida T, Taniguchi K, Yamamoto C, Sakakura R, Nakamura K, Uryuhara K, Oike F, Uemto S - Ann Gastroenterol (2012)

Bottom Line: The recipient suprahepatic inferior vena cava is clamped at the intramediastinal level, including the margins of the diaphragm in the clamp.Although survival rate during first forty cases were under 0.2, a reasonable survival rate of 0.6 had been achieved after the experiences of forty cases.Hepatic venous reconstruction should be completed without any outflow block, by using venous plasty and adequate clamping.

View Article: PubMed Central - PubMed

Affiliation: Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan (Tomohide Hori, Shintaro Yagi, Taku Iida, Kenji Uryuhara, Fumitaka Oike, Shinji Uemto).

ABSTRACT

Background: Challenges with small-for-size grafts are a critical issue in the liver transplantation field, and a reliable and reproducible animal model is required.

Method: We performed 50 orthotopic liver transplantations in pigs with a 30% graft, and retrospectively investigated the learning curves. We modified our surgical procedures according to our experience. Here, we describe our current procedures in detail with retrospective evaluation of our experience. The artery to the right lateral lobe crosses the portal vein trunk. A 30% graft is taken using the right lateral lobe attached to a sufficient length of aorta. Hepatic venous plasty is undertaken on the back table to attach a venous patch to the anterior wall of the suprahepatic inferior vena cava, which has no extrahepatic margin. To minimize hypoperfusion to the digestive tract, an aorta-to-aorta anastomosis is performed in a side-to-end fashion in a minimal surgical field before suprahepatic inferior vena cava and portal vein reconstruction. A temporary transjugular portosystemic shunt is also inserted before suprahepatic inferior vena cava reconstruction. The recipient suprahepatic inferior vena cava is clamped at the intramediastinal level, including the margins of the diaphragm in the clamp.

Results: Although survival rate during first forty cases were under 0.2, a reasonable survival rate of 0.6 had been achieved after the experiences of forty cases.

Conclusion: Precedent arterial reconstruction using an aorta-to-aorta anastomosis minimizes congestive damage and shortens operative time. Hepatic venous reconstruction should be completed without any outflow block, by using venous plasty and adequate clamping.

No MeSH data available.


Related in: MedlinePlus

(A) Hepatic resection is started at the hepatic margin near the SHIVC. (B) Vessels and ducts crossing the line of transection are ligated. (C) Hemostasis of the cut surface is carefully confirmed. (D) The retroperitoneum is incised to the left of the aorta and to the right of the IHIVCIHIVC, infrahepatic inferior vena cava; RLL, right lateral lobe
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Figure 8: (A) Hepatic resection is started at the hepatic margin near the SHIVC. (B) Vessels and ducts crossing the line of transection are ligated. (C) Hemostasis of the cut surface is carefully confirmed. (D) The retroperitoneum is incised to the left of the aorta and to the right of the IHIVCIHIVC, infrahepatic inferior vena cava; RLL, right lateral lobe

Mentions: The appearance of the hepatic hilus is shown in Fig. 5C. The hepatoduodenal and hepatogastric ligaments are sharply cut by a pinch-and-burn cutting technique (Fig. 5D), and the right gastric artery arising from the artery to the LLL is ligated. The CBD is skeletonized and cut, and a stent tube is inserted. The stent tube is fixed in place with a suture, and bile discharge is observed (Fig. 6A). The periportal lymph nodes are removed (Fig. 6B), and the PV and CHA are skeletonized (Fig. 6C). The PV and CHA should be adequately separated from one another. The PV trunk includes the splenic vein and three or four branches of the superior mesenteric vein at the pancreas. The hepatic artery is dissected away from surrounding tissues from the hepatic hilus to the root of celiac artery, including the dense connective tissue around the celiac and superior mesenteric arteries. The artery to the RLL is carefully identified, and the proper hepatic artery is ligated distal to the artery to the RLL. This immediately changes the color of the liver except for the RLL (Fig. 6D). The left PV is completely skeletonized (Fig. 7A), and is clamped with a Pott’s clamp (Fig. 7B). This increases the change in liver color. The left PV of the graft is closed with a continuous bilateral retention suture using 6-0 monofilament polypropylene suture (MPS) (Fig. 7C). Glisson’s capsules for the RML, LML and LLL are dissected and ligated en bloc (Fig. 7D). Hepatic resection is started at the hepatic margin near the SHIVC (Fig. 8A), and vessels and ducts crossing the line of transection are carefully ligated (Fig. 8B). Because bleeding or oozing from the cut surface after graft recirculation is a potentially fatal problem, hemostasis is carefully confirmed (Fig. 8C). An electrocautery scalpel and bipolar forceps with saline irrigation are very useful for ensuring hemostasis. The transparent membranes around the liver, which fix each lobe to the surrounding organs, are cut, and the retroperitoneum is incised to the left of the aorta and to the right of the IHIVC (Fig. 8D). The abdominal aorta is dissected from above the celiac artery to the common iliac artery (Fig. 9A). The renal arteries and superior and inferior mesenteric arteries are ligated. The IHIVC is dissected to below the right renal vein, and both renal veins are ligated (Fig. 9B). The right adrenal gland is removed from the IHIVC later on the back table. Identification of the vessels to the right adrenal gland at this time is often risky. With adequate retraction, the dorsally located lumbar branches of the aorta and IHIVC are identified (Fig. 9C). Immediately before the graft is harvested, it remains attached only by vessels and the diaphragm (Fig. 9D).


Surgical text for orthotopic liver transplantation model with small-for-size graft in the pig: key techniques and pitfalls.

Hori T, Yagi S, Iida T, Taniguchi K, Yamamoto C, Sakakura R, Nakamura K, Uryuhara K, Oike F, Uemto S - Ann Gastroenterol (2012)

(A) Hepatic resection is started at the hepatic margin near the SHIVC. (B) Vessels and ducts crossing the line of transection are ligated. (C) Hemostasis of the cut surface is carefully confirmed. (D) The retroperitoneum is incised to the left of the aorta and to the right of the IHIVCIHIVC, infrahepatic inferior vena cava; RLL, right lateral lobe
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3959390&req=5

Figure 8: (A) Hepatic resection is started at the hepatic margin near the SHIVC. (B) Vessels and ducts crossing the line of transection are ligated. (C) Hemostasis of the cut surface is carefully confirmed. (D) The retroperitoneum is incised to the left of the aorta and to the right of the IHIVCIHIVC, infrahepatic inferior vena cava; RLL, right lateral lobe
Mentions: The appearance of the hepatic hilus is shown in Fig. 5C. The hepatoduodenal and hepatogastric ligaments are sharply cut by a pinch-and-burn cutting technique (Fig. 5D), and the right gastric artery arising from the artery to the LLL is ligated. The CBD is skeletonized and cut, and a stent tube is inserted. The stent tube is fixed in place with a suture, and bile discharge is observed (Fig. 6A). The periportal lymph nodes are removed (Fig. 6B), and the PV and CHA are skeletonized (Fig. 6C). The PV and CHA should be adequately separated from one another. The PV trunk includes the splenic vein and three or four branches of the superior mesenteric vein at the pancreas. The hepatic artery is dissected away from surrounding tissues from the hepatic hilus to the root of celiac artery, including the dense connective tissue around the celiac and superior mesenteric arteries. The artery to the RLL is carefully identified, and the proper hepatic artery is ligated distal to the artery to the RLL. This immediately changes the color of the liver except for the RLL (Fig. 6D). The left PV is completely skeletonized (Fig. 7A), and is clamped with a Pott’s clamp (Fig. 7B). This increases the change in liver color. The left PV of the graft is closed with a continuous bilateral retention suture using 6-0 monofilament polypropylene suture (MPS) (Fig. 7C). Glisson’s capsules for the RML, LML and LLL are dissected and ligated en bloc (Fig. 7D). Hepatic resection is started at the hepatic margin near the SHIVC (Fig. 8A), and vessels and ducts crossing the line of transection are carefully ligated (Fig. 8B). Because bleeding or oozing from the cut surface after graft recirculation is a potentially fatal problem, hemostasis is carefully confirmed (Fig. 8C). An electrocautery scalpel and bipolar forceps with saline irrigation are very useful for ensuring hemostasis. The transparent membranes around the liver, which fix each lobe to the surrounding organs, are cut, and the retroperitoneum is incised to the left of the aorta and to the right of the IHIVC (Fig. 8D). The abdominal aorta is dissected from above the celiac artery to the common iliac artery (Fig. 9A). The renal arteries and superior and inferior mesenteric arteries are ligated. The IHIVC is dissected to below the right renal vein, and both renal veins are ligated (Fig. 9B). The right adrenal gland is removed from the IHIVC later on the back table. Identification of the vessels to the right adrenal gland at this time is often risky. With adequate retraction, the dorsally located lumbar branches of the aorta and IHIVC are identified (Fig. 9C). Immediately before the graft is harvested, it remains attached only by vessels and the diaphragm (Fig. 9D).

Bottom Line: The recipient suprahepatic inferior vena cava is clamped at the intramediastinal level, including the margins of the diaphragm in the clamp.Although survival rate during first forty cases were under 0.2, a reasonable survival rate of 0.6 had been achieved after the experiences of forty cases.Hepatic venous reconstruction should be completed without any outflow block, by using venous plasty and adequate clamping.

View Article: PubMed Central - PubMed

Affiliation: Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan (Tomohide Hori, Shintaro Yagi, Taku Iida, Kenji Uryuhara, Fumitaka Oike, Shinji Uemto).

ABSTRACT

Background: Challenges with small-for-size grafts are a critical issue in the liver transplantation field, and a reliable and reproducible animal model is required.

Method: We performed 50 orthotopic liver transplantations in pigs with a 30% graft, and retrospectively investigated the learning curves. We modified our surgical procedures according to our experience. Here, we describe our current procedures in detail with retrospective evaluation of our experience. The artery to the right lateral lobe crosses the portal vein trunk. A 30% graft is taken using the right lateral lobe attached to a sufficient length of aorta. Hepatic venous plasty is undertaken on the back table to attach a venous patch to the anterior wall of the suprahepatic inferior vena cava, which has no extrahepatic margin. To minimize hypoperfusion to the digestive tract, an aorta-to-aorta anastomosis is performed in a side-to-end fashion in a minimal surgical field before suprahepatic inferior vena cava and portal vein reconstruction. A temporary transjugular portosystemic shunt is also inserted before suprahepatic inferior vena cava reconstruction. The recipient suprahepatic inferior vena cava is clamped at the intramediastinal level, including the margins of the diaphragm in the clamp.

Results: Although survival rate during first forty cases were under 0.2, a reasonable survival rate of 0.6 had been achieved after the experiences of forty cases.

Conclusion: Precedent arterial reconstruction using an aorta-to-aorta anastomosis minimizes congestive damage and shortens operative time. Hepatic venous reconstruction should be completed without any outflow block, by using venous plasty and adequate clamping.

No MeSH data available.


Related in: MedlinePlus