Transplant Procedure

Indications for liver transplantation are listed in Table86:2. The harvested liver can tolerate ischemia up to 24 h, but it functions best if ischemia time is less than 8 h. The risk of preservation injury increases after this time. Most patients undergo bilateral subcostal incision with upper midline extension to the xiphoid process. After recipient hepatectomy, the donor liver is placed in the recipient typically in the same (orthotopic) location as the liver it is replacing ( Fig 86:1). Venovenous bypass, used in most centers, may predispose the patient to thrombosis and pulmonary embolism. Normal color and consistency return to the organ in approximately 15 min. Early bile production after vascular reanastomosis is most indicative of graft function. 3 The preferred method for biliary tract reconstruction is an end-to-end choledochocholedochostomy. The use of a percutaneous biliary drain varies by center and when used typically stays in place 3 to 6 months. In children and in those whose anatomy will not allow choledochocholedochostomy, Roux-en-Y hepaticojejunostomy is performed. Newer techniques being used increasingly in pediatric patients include reduced-size liver transplant, split liver transplant, and living-related transplantation. 4

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TABLE BS-2 Indications for Liver Transplantation

Choledochocholedochostomy

FIG. 86-1. End-to-end choledochocholedochostomy. If the recipient's system permits, this is the preferred method for reconstruction of the biliary system, the last part of the operative phase in liver transplantation.

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