At this stage of the operation, the planes of dissection are different for the classical (with resection of the IVC) and the cava-sparing (or piggyback) technique. The latter technique is more demanding but has the advantage of avoiding interruption of the caval venous return and of a shorter warm ischemia time during implantation, because only one instead of two IVC anastomoses have to be performed. The two techniques will be described separately.
The liver is turned to the left and the infrahepatic inferior vena cava is exposed. The right adrenal vein is identified and ligated between ties. The inferior vena cava is mobilized circumferentially by opening the peritoneal reflection along the right side of the cava with cautery. Care must be taken not to injure the right hepatic vein. The same technique is applied on the left side of the cava.
Mobilization of the infrahepatic inferior vena cava
The Cava-Sparing (or Piggyback) Technique
For this technique the right liver is rotated to the left upper quadrant in order to expose adequately the right and anterior sides of the retrohepatic IVC. The tissue between the retrohepatic IVC and the posterior surface of the liver is divided. All smaller Spigelian veins draining the caudate lobe and the right accessory veins when present are selectively ligated and divided from below upwards. In this way, the hepatic veins are approached. The right hepatic vein is encircled and transected using a vascular endosta-pler. Precise stapler application close to the liver parenchyma permits safe and tight transsection of the right hepatic vein without narrowing the retrohepatic IVC. The transsection of the right hepatic vein allows the retrohepatic-IVC to be turned away from to a further extent and makes the safe isolation of the middle and left hepatic veins much easier.
In the case of a retransplant following a previous classical liver transplant with IVC replacement, the previous allograft's IVC is preserved. The plane between the parenchyma and the previous donor IVC will have remained intact. In case of a retrans-plant after previous cava-sparing transplant, the graft can be removed without interfering with IVC flow.
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