How the liver is procured from the donor
Removing the liver from a donor is as delicate and complicated as any major abdominal procedure. This surgery is performed by certified surgeons who are credentialed by many medical organizations and local agencies. In Michigan, only certified transplant surgeons can do a liver procurement operation. In the first step, an anesthesiologist will assist in assuring a stable blood pressure from the donor. The surgeon starts the operation with the plan to remove the liver with attached vessels.
The liver has several attachments:
Two vessels feed it - the hepatic artery-HA and portal vein-PV
A large vessel (emptying blood from the kidneys and legs) also goes through the liver and has to be included with the resection (vena cava-VC)
Because the liver makes bile that is stored in the gallbladder and then empties into the intestine through a bile duct, the gallbladder and bile duct must be included. The liver is removed with all the attachments and the celiac trunk. The celiac trunk is the larger vessel feeding the hepatic artery. Once the surgeons have completed the dissection, clamps are placed around the liver and it's then flushed with a preservative solution and soaked in ice while still in the abdomen. If other organs are to be removed, they are usually flushed at the same time.
Time is important here. Every wasted minute can result in organ damage while the organ is in preservation. Preservation limit varies by organ. Under normal circumstances, the time from clamping to transplantation of the liver should not exceed 16 hours. The longer the preservation period the higher the chance the organ may not work at all.
Once the flush is complete, the liver is cut out, flushed again with the same solution and packaged in a sterile fashion in multiple bags and placed on ice in a special container to allow handling without damage to the organ. This whole process is standardized among institutions. The time it takes to travel to the donor hospital and return with the liver averages four to eight hours, barring any complications.
What happens during the liver transplant surgery?
Once the liver arrives at Henry Ford, the transplant surgeon prepares the liver for implantation and trims its vessels so they are suitable for suturing. This prep work usually takes about an hour. The patient is then escorted to the operating room where he or she will be placed under general anesthesia. Multiple IV lines are placed so the patient can receive medications, blood or plasma. Monitors for the blood pressure and heart function also are attached to the patient. The abdomen and chest are then cleaned with alcohol and betadine solution and covered with sterile drapes.
Now is time for the incision. The "rooftop" incision extends along the patient's right side (under the rib cage) to the left side at the level of the left nipple. Depending on their body shape, a midline extension is made to improve the exposure to the area. That incision is called a "Mercedes" because the cut resembles a Mercedes-Benz logo. The dissection of the diseased liver can begin. The bile ducts and other vessels feeding it are divided. Some patients then are placed on liver bypass, which is not at all like heart bypass. In liver bypass, the heart is pumping just fine; blood is diverted from the intestine and lower body around the liver and fed back to the heart using either the left armpit or the neck. Only one out of 10 patients in our program needs the bypass.
Once the diseased liver is removed, the new liver is taken out of preservation and placed in the abdomen to be sutured in place. Only the blood vessels are connected at this time. This is a critical phase requiring skill and good coordination so no time is wasted. Once all vessel hookups are completed, the clamps are removed and fresh blood is allowed to flow into the liver. This is the most important moment of the operation. If the liver is doing well, it will show normal color and will start making bile and blood clot.
There are many reasons the liver function may not be perfect. This is usually indicated by poor or no bile production and continued bleeding. If the liver has no function at all, the patient may become very ill and need to be urgently relisted for a second liver.
If the liver is doing well, it is being perfused with blood. Now the surgeon makes sure there is no evidence of any bleeding before moving on.
The anesthesiologist helps tremendously in this part of the operation as plasma and platelets help cut down the bleeding until the liver starts working. This work may take up to a few hours. The donor gallbladder is removed. The gall bladder doesn't serve any purpose with the new liver. If the recipient has a normal bile duct, the new bile duct is connected to the patient bile duct using fine absorbable suture material. A small stent is left inside to prevent blockage. This usually passes into the intestine by itself but may need to be removed a month later by endoscopy.
In some patients, especially those with primary sclerosing cholangitis, their bile duct is not of good quality to be used. Therefore, we connect the new liver bile duct to the intestine directly. This is called a Roux-en-Y connection - named after the French surgeon who first described it. This does not have any impact on the patient but takes an additional 30-60 minutes to complete.
Once these hookups are completed and inspected for obvious bleeding, the abdomen is closed with sutures and the skin with staples. The transplant operation, from skin incision to closure, usually takes five to six hours. Previous surgery, being overweight or technical problems can extend this up to 11 or 12 hours. The family is always given updates as to the progress of the operation.
The patient is then taken to the surgical intensive care unit and is usually on the breathing machine. Once fully awake with no evidence of other problems such as bleeding or slow liver function, the breathing tube is removed and the patient allowed to breathe on his own. This usually happens six to 24 hours after the operation is complete. Completion of the operation and arrival to ICU ushers in the second and bigger phase of the patient's care.
Because the liver makes bile that is stored in the gallbladder and then empties into the intestine through a bile duct, the gallbladder and bile duct must be included. The liver is removed with all the attachments and the celiac trunk. The celiac trunk is the larger vessel feeding the hepatic artery. Once the surgeons have completed the dissection, clamps are placed around the liver and it's then flushed with a preservative solution and soaked in ice while still in the abdomen. If other organs are to be removed, they are usually flushed at the same time.
