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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) The graft SHIVC is placed in position with correct axial alignment, using the hepatic margin as a guide. Stay sutures are placed bilaterally. The posterior wall lies straight and the anterior wall is curved. (B) Stay sutures are placed bilaterally. The posterior wall is sutured from the left side using a continuous suture. The suture bites of the graft SHIVC usually include liver parenchyma. (C) The anterior wall is sutured from both sides using a continuous suture (solid arrow). (D) Before completion of the anterior wall suture, the SHIVC is filled with heparinized saline to expel the air (dotted arrow)SHIVC, suprahepatic inferior vena cava
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Figure 15: (A) The graft SHIVC is placed in position with correct axial alignment, using the hepatic margin as a guide. Stay sutures are placed bilaterally. The posterior wall lies straight and the anterior wall is curved. (B) Stay sutures are placed bilaterally. The posterior wall is sutured from the left side using a continuous suture. The suture bites of the graft SHIVC usually include liver parenchyma. (C) The anterior wall is sutured from both sides using a continuous suture (solid arrow). (D) Before completion of the anterior wall suture, the SHIVC is filled with heparinized saline to expel the air (dotted arrow)SHIVC, suprahepatic inferior vena cava

Mentions: During liver removal, the IHIVC and SHIVC clamps should be carefully placed, especially the SHIVC clamp. In the recipient operation, the Satinsky clamp should be placed on the intramediastinal IVC making sure to grasp sufficient margins of the diaphragm in the clamp, because the SHIVC does not have a sufficient extrahepatic margin for anastomosis (Fig. 14AD). Ventrally- and caudally-directed retraction of the Satinsky clamp exposes a good surgical field for anastomosis. The graft SHIVC is placed in position with correct axial alignment using the hepatic margin as a marker (Fig. 14B, 14D, 15A). Each lobe has its own drainage vein near the level of the SHIVC, and the vein from the RLL lies in a common channel with the vein from the RML (Fig. 14C). Stay sutures are placed bilaterally (Fig. 15A, 15B). The posterior wall of the graft SHIVC lies straight and the anterior wall is curved (Fig. 15A). The first suture is placed from the outside of the graft SHIVC to the inside, and the posterior wall is sutured from the left side with a continuous suture (Fig. 15B). The graft SHIVC suture bites may include liver parenchyma. Secure posterior suturing is important, because hemostasis of any bleeding points in this area is impossible after graft reperfusion. The last suture is tied on the outside of the recipient SHIVC, and this thread is tied to a stay suture from the right side, avoiding over-tightening. The anterior wall is then sutured from both sides using a continuous suture (Fig. 15C). Before completion of the anterior wall suture, the SHIVC is filled with heparinized saline to expel the air (Fig. 15D). The anterior suture is completed, and this thread is used to form a stay suture, avoiding over-tightening (Fig. 16A). A growth factor is not required. The retractors are released.


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) The graft SHIVC is placed in position with correct axial alignment, using the hepatic margin as a guide. Stay sutures are placed bilaterally. The posterior wall lies straight and the anterior wall is curved. (B) Stay sutures are placed bilaterally. The posterior wall is sutured from the left side using a continuous suture. The suture bites of the graft SHIVC usually include liver parenchyma. (C) The anterior wall is sutured from both sides using a continuous suture (solid arrow). (D) Before completion of the anterior wall suture, the SHIVC is filled with heparinized saline to expel the air (dotted arrow)SHIVC, suprahepatic inferior vena cava
© Copyright Policy - open-access
Related In: Results  -  Collection

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

Figure 15: (A) The graft SHIVC is placed in position with correct axial alignment, using the hepatic margin as a guide. Stay sutures are placed bilaterally. The posterior wall lies straight and the anterior wall is curved. (B) Stay sutures are placed bilaterally. The posterior wall is sutured from the left side using a continuous suture. The suture bites of the graft SHIVC usually include liver parenchyma. (C) The anterior wall is sutured from both sides using a continuous suture (solid arrow). (D) Before completion of the anterior wall suture, the SHIVC is filled with heparinized saline to expel the air (dotted arrow)SHIVC, suprahepatic inferior vena cava
Mentions: During liver removal, the IHIVC and SHIVC clamps should be carefully placed, especially the SHIVC clamp. In the recipient operation, the Satinsky clamp should be placed on the intramediastinal IVC making sure to grasp sufficient margins of the diaphragm in the clamp, because the SHIVC does not have a sufficient extrahepatic margin for anastomosis (Fig. 14AD). Ventrally- and caudally-directed retraction of the Satinsky clamp exposes a good surgical field for anastomosis. The graft SHIVC is placed in position with correct axial alignment using the hepatic margin as a marker (Fig. 14B, 14D, 15A). Each lobe has its own drainage vein near the level of the SHIVC, and the vein from the RLL lies in a common channel with the vein from the RML (Fig. 14C). Stay sutures are placed bilaterally (Fig. 15A, 15B). The posterior wall of the graft SHIVC lies straight and the anterior wall is curved (Fig. 15A). The first suture is placed from the outside of the graft SHIVC to the inside, and the posterior wall is sutured from the left side with a continuous suture (Fig. 15B). The graft SHIVC suture bites may include liver parenchyma. Secure posterior suturing is important, because hemostasis of any bleeding points in this area is impossible after graft reperfusion. The last suture is tied on the outside of the recipient SHIVC, and this thread is tied to a stay suture from the right side, avoiding over-tightening. The anterior wall is then sutured from both sides using a continuous suture (Fig. 15C). Before completion of the anterior wall suture, the SHIVC is filled with heparinized saline to expel the air (Fig. 15D). The anterior suture is completed, and this thread is used to form a stay suture, avoiding over-tightening (Fig. 16A). A growth factor is not required. The retractors are released.

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