Modified liver hanging maneuver during orthotopic liver transplantation with inferior vena cava preservation

During orthotopic liver transplantation (OLT) with inferior vena cava (IVC) preservation, several technical modifications related to the outflow cavocaval anastomosis have been proposed. An end-to-side cavocaval outflow anastomosis created with the patch of the three native suprahepatic veins seems to be associated with a lower incidence of graft-related venous outflow complications. We describe a modification of Belghiti’s liver hanging maneuver applied to the last phase of hepatectomy during OLT with IVC preservation. The lifting of the liver provides a better exposure of the suprahepatic region and allows easier orthogonal clamping of the three suprahepatic veins that occlude only a minimal portion of IVC. In the proposed modification, the blind dissection of the anterior part of the IVC is limited to the region between the right and middle hepatic veins, minimizing the risk of this maneuver and exposing the suprahepatic veins for clamping. OLT with IVC preservation (1,2) has gained increasing acceptance because it offers several advantages (3) over the conventional method described by Starzl et al. in 1963 (11). Since then, some authors have reported several technical modifications, particularly related to the venovenous outflow anastomosis. Bismuth et al. (4) and Belghiti et al. (5) described the “face-à-face” and the “side to side” cavocaval anastomosis and later Parrilla et al. (6) and Belghiti et al. (7) described the advantages of an end-to-side outflow anastomosis centered on the three hepatic veins. Nevertheless, caval clamping that includes the three suprahepatic veins is sometimes technically difficult and requires transient IVC cross-clamping, especially in patients with a large liver. The application of a modified Belghiti hanging maneuver (8) during the last step of the hepatectomy allows a better exposition and an easier cross-clamping of the three suprahepatic veins to perform a large cavocaval anastomosis that preserves caval flow. The liver hanging maneuver was devised to reduce the risks of the right hepatectomy without complete mobilization of the liver and without retrohepatic IVC exposure. The procedure consists of a blind dissection of the region located in the midline of the anterior surface of the retrohepatic IVC between the right and middle hepatic veins. The liver is then lifted with a tape and safely transected. In the proposed modification, the blind dissection of the anterior part of the IVC is limited to the region between the right and middle hepatic veins, minimizing the risk of this maneuver and exposing the suprahepatic veins for clamping. During OLT with IVC preservation, the first step of recipient hepatectomy follows the principles described elsewhere by Belghiti et al. (7). When the anterior surface of the retrohepatic IVC is exposed, the space between the right and middle hepatic vein is identified, and a clamp is burrowed down towards the veins to the upper dissected suprahepatic region. A tape is then passed around the hepatic parenchyma. Stretching of this tape allows the elevation of the liver away from the IVC, providing a better exposure of the suprahepatic veins. A Satinsky clamp is then applied orthogonally to the three hepatic veins without occluding the IVC and preserving the caval flow (Fig. 1). The native liver is removed after dividing the veins 1 cm inside the liver parenchyma. To prepare a large anastomotic cloaca using the three suprahepatic veins, a single orifice is fashioned by dividing the intervening septa. The donor liver is placed orthotopically, and the anastomosis is then performed between the donor suprahepatic IVC and the created orifice. Portal, arterial, and biliary reconstructions are then performed as for conventional OLT. Figure 1: Modified liver hanging maneuver. Stretching of tape allows elevation of the liver away from the inferior vena cava (IVC) with better exposure of suprahepatic veins. A Satinsky clamp is applied orthogonally to the three suprahepatic veins, occluding a minimal portion of IVC and preserving caval flow.The main concept of the technique described in the present communication is a modification of the Belghiti hanging maneuver applied to OLT with IVC and IVC flow preservation that allows an easier application of caval clamp including the three suprahepatic veins for a large outflow anastomosis. Over the last years several series have been published on OLT with IVC preservation without the use of venovenous bypass. This procedure seems to ensure better hemodynamic stability, lower consumption of blood products, and avoids the complications related to venovenous bypass. The other advantage of this technique is that IVC preservation has allowed the implantation of different partial grafts (i.e., split liver, reduced graft, auxiliary graft, and living-donor graft). Nevertheless, some specific complications related to IVC preservation have been reported, particularly major venous tears in the recipient’s vena cava and congestion of the graft caused by liver mislocation after anastomosis to the middle and left hepatic veins (6). For this last reason, some authors (6,9,10) prefer to perform the anastomosis with a patch of the three suprahepatic veins. They report a lower incidence of complications related to the venous outflow of the graft. In this large anastomosis, two main factors avoid graft mislocation: (1) the length of the venous segment between the graft and the wall of the created common orifice is shorter, and (2) the anastomosis including the orifice of the native right hepatic vein is more located on the right side of the IVC. A good alternative technique that reduces graft mislocation and avoids IVC cross-clamping is the side-to-side cavocaval anastomosis (4,5), but because of insufficient exposure during implantation of large grafts and because of the impossibility of performing transjugular hepatic catheterization, an end-to-side anastomosis is preferable (5). One of the main advantages of OLT with IVC and IVC flow preservation (5) is to ensure hemodynamic stability during the anhepatic phase and during graft implantation. Nevertheless, in some particular anatomical conditions such as in large livers (i.e., polycystic liver, Budd-Chiari) or when the right hepatic vein is short or more laterally located, the clamping of the three suprahepatic veins may include an important portion of the IVC, thus reducing the caval flow (7). The application of the liver hanging maneuver at this step of the hepatectomy allows an easier orthogonal clamping of the three suprahepatic veins by lifting the liver and thus occluding a minimal portion of IVC. In conclusion, the proposed modified hanging maneuver provides a better exposure of the three suprahepatic veins during OLT with IVC preservation. This provides a large anastomotic cloaca that includes the right hepatic vein and preserves caval flow. Acknowledgments. The authors thank Alessandro Pedicelli, M.D. for help preparing the figure. Giuseppe Maria Ettorre Giovanni Vennarecci Roberto Santoro Mario Antonini Maria Teresa Lonardo Massimo Carlini Eugenio Santoro