Orthotopic liver transplantation describes the classic surgery in which a patient’s native diseased liver is replaced with a healthy donor organ at the same anatomic location. This surgery has evolved over the past 40 years and has seen advances in operative and anesthesia techniques. The classic operation described by Starzl et al.¹ in 1963 included total hepatectomy with the resection of the recipient retrohepatic inferior vena cava (IVC) and interposition of the donor IVC attached to the new graft. This technique was accompanied by complications that are seen with substantial decreases in venous return to the heart. For this reason, venovenous bypass was originally used to help ameliorate these changes in volume. In 1989, Tzakis et al.² popularized the so-called piggyback (PB) technique to help preserve blood flow to the heart during the anhepatic phase. In PB technique, the recipient IVC is not removed. Instead, the retrohepatic and caudate venous branches are ligated, preserving the entire IVC. Once the hepatic veins are clamped and the diseased liver removed, the donor IVC (just above the hepatic vein orifice) is sewn onto the recipient cava opening. In this manner, the recipient IVC is not completely cross-clamped and venovenous bypass obviated. There are some other proposed advantages to this PB technique as compared to IVC replacement:

Although no literature to date can adequately support or negate the use of either technique in liver transplant surgery (caval replacement or PB), using the PB technique is expeditious and safe.³ For those patients with advanced liver failure, decreased surgical times, fewer complications, and fewer blood transfusion is crucial to successful outcomes. Within this context, both techniques should be mastered.

A complete assessment of underlying cardiac or pulmonary disease is mandatory. Liver transplant candidates should not only be able to tolerate the operation but also to live many years following transplant. Careful attention should also be given to infections, hyponatremia, renal function, and frailty/functional status.

The patient is positioned supine, with the arms padded on arm boards. The incision is subcostal for most patients, using a superior midline extension reserved for those with narrow subcostal margins. For very large native livers, the right subcostal incision can also be extended laterally toward the subcostal area.

With advances in anesthetic management, partial cross-clamping of the IVC and temporary portal vein occlusion is well tolerated by most patients undergoing transplant. Although the hepatectomy is described in another section of this text (see Chapter 23), a few critical issues are detailed below:

During the anhepatic phase, control any bleeding near the vena cava, posterior portal vein, and retroperitoneum prior to bringing the donor liver onto the field.

Reinforce loose clips with sutures on the vena cava.

Anesthesiologist should correct any acidosis, electrolyte abnormalities, monitor cardiac status with a transesophageal echocardiogram, and prepare for reperfusion.