Tricks of the Senior Surgeon

■ For both the classical approach and the cava-sparing technique, the central venous pressure should be kept as low as possible. Otherwise the dissection of the liver from the retrohepatic IVC and the dissection of the Spigelian veins is rendered more difficult, which leads to increased blood loss.

■ A short period of hypotension is usually seen upon reperfusion of the graft. This can be due to bleeding or metabolic changes (i.e.,"post-reperfusion syndrome"). When venous bleeding occurs from the (retrohepatic) inferior vena cava or dorsal side of the liver, provide temporary packing for the retrohepatic space and wait for hemodynamic stabilization before attempting to place any sutures.

■ In case of preexisting portal vein thrombosis, adapt donor and recipient operations to reduce ischemic time. Be assured, before starting the allograft implantation, of the method of portal revascularization. First make the arterial anastomosis and revascularize the liver via the artery. This will provide more time to remove clots and perform the anastomosis of the portal vein, without extending the cold or warm ischemia time.

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