Liver Transplant & Surgery

The Liver Transplant Operation

A liver transplant involves the removal of and preparation of the donor liver, removal of the diseased liver, and implantation of the new organ. The liver has several key connections that must be re-established for the new organ to receive blood flow and to drain bile from the liver. The structures that must be reconnected are the inferior vena cava, the portal vein, the hepatic artery, and the bile duct. The exact method of connecting these structures varies depending on specific donor and anatomy or recipient anatomic issues and, in some cases, the recipient disease.

For someone undergoing liver transplantation, the sequence of events in the operating room is as follows:

  1. Incision
  2. Evaluation of the abdomen for abnormalities that would preclude liver transplantation (for example: undiagnosed infection or malignancy)
  3. Mobilization of the native liver (dissection of the liver attachments to the abdominal cavity)
  4. Isolation of important structures (the inferior vena cava above, behind, and below the liver; the portal vein; the common bile duct; the hepatic artery)
  5. Transection of the above mentioned structures and removal of the native, diseased liver.
  6. Sewing in the new liver: First, venous blood flow is re-established by connecting the donor’s and the recipient’s inferior vena cava and portal veins. Next, arterial flow is re-established by sewing the donor’s and recipients hepatic arteries. Finally, biliary drainage is achieved by sewing the donor’s and recipient’s common bile ducts.
  7. Ensuring adequate control of bleeding
  8. Closure of the incision

Surgical Complications

As with any surgical procedure, complications related to the operation may occur, in addition to the many possible complications that may happen to any patient who is hospitalized. Some of the problems specific to liver transplantation that may be encountered include:

Primary non-function or poor function of the newly transplanted liver occurs in approximately 1-5% of new transplants. If the function of the liver does not improve sufficiently or quickly enough, the patient may urgently require a second transplant to survive.

  • Hepatic artery thrombosis or clotting of the hepatic artery (the blood vessel that brings oxygenated blood from the heart to the liver) occurs in 2-5% of all deceased donor transplants. The risk is doubled in patients who receive a living donor transplant. The liver cells themselves typically do not suffer from losing blood flow from the hepatic artery because they are primarily nourished by blood by the portal blood flow. In contrast, the bile ducts depend strongly on the hepatic artery for nutrition and loss of that blood flow may lead to bile duct scarring and infection. If this occurs, then another transplant may be necessary.
  • Portal vein thrombosis or clotting of the large vein that brings blood from the abdominal organs (the intestines, the pancreas, and the spleen – the organs that belong to the portal circulation) to the liver occurs infrequently. This complication may or may not require a second liver transplant.
  • Biliary complications: In general, there are two types of biliary problems: leak or stricture. Biliary complications affect approximately 15% of all deceased donor transplants and up to 40% of all living donor transplants.

Biliary leak means that bile is leaking out of the bile duct and into the abdominal cavity. Most frequently, this occurs where the donor and recipient bile ducts were sewn together. This is often treated by placing a stent, or plastic tube, across the connection through the stomach and small intestine and then allowing the connection to heal. In the case of living donor or split liver transplants, bile can also leak from the cut edge of the liver.  Typically, a drain is placed and left during the transplant operation along the cut edge to remove any bile that may leak. As long as the bile does not collect in the abdomen, the patient does not become ill. Leaks will often heal with time, but may require additional treatment procedures.

    • Biliary stricture means narrowing of the bile duct, resulting in relative or complete blockage of the bile flow and possible infection. Most frequently, the narrowing occurs at a single site, again where the donor and recipient ducts are sewn together. This narrowing can often be treated by dilating the narrowed area with a balloon and/or inserting a stent across the stricture. If these methods are unsuccessful, surgery is often done to create a new connection between the liver’s bile duct and a segment of intestine. Rarely, biliary strictures occur at multiple or innumerable sites throughout the biliary tree. This occurs most frequently because the biliary tree was poorly preserved during the period when the liver was not in either the donor or recipient circulation. Livers procured from cardiac death donors are at higher risk than those from brain dead donors. Alternatively, diffuse biliary strictures may occur if the biliary tree has inadequate blood supply because of an abnormality with the hepatic artery.
  • Bleeding is a risk of any surgical procedure but a particular risk after liver transplantation because of the extensive nature of the surgery and because clotting requires factors made by the liver. Most transplant patients bleed a minor amount and may get additional transfusions after the operation. If bleeding is substantial or brisk, return to the operating room for control of bleeding is often necessary. In general, approximately 10% of transplant recipients will require a second operation for bleeding.
  • Infection – Infections can occur during the healing of the wound created by any operation. Liver transplant recipients are also at risk for infections deep within the abdomen, particularly if there is a collection of blood or bile (from a bile leak). The immunosuppressive medications along with the history of liver failure increase the liver transplant recipient’s risk for developing an infection after transplantation.