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2 Back-Table Procedure ofaWhole Liver Graft forthePiggyback Technique
Fig. 2.2 Dissection of the posterior aspect of the suprahepatic inferior
vena cava
Fig. 2.3 Dissection of the posterior aspect of the infrahepatic inferior
vena cava
Fig. 2.5 Dissection of the posterior aspect of the suprahepatic inferior
vena cava with ligation of a small phrenic vein
Fig. 2.6 Dissection of the right part of posterior aspect of the retrohepatic inferior vena cava
Fig. 2.4 Dissection of the anterior aspect of the infrahepatic inferior
vena cava
Fig. 2.7 Dissection of the right aspect of the retrohepatic inferior vena
cava with control of the right adrenal vein
2 Back-Table Procedure ofaWhole Liver Graft forthePiggyback Technique
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Fig. 2.8 Dissection of the anterior aspect of the suprahepatic inferior
vena cava
Fig. 2.9 Dissection of the anterior aspect of the suprahepatic inferior
vena cava with control of a phrenic vein
Fig. 2.11 Division of the ligament of the inferior vena cava and mobilization of the caudate lobe to expose the retrohepatic inferior vena cava
Fig. 2.12 Clamping of the supra- and infrahepatic inferior vena cava
to identify any iatrogenic injury to the inferior vena cava
Fig. 2.10 Dissection of the anterior aspect of the suprahepatic inferior
vena cava with control of another phrenic vein
Fig. 2.13 Dissection of the anterior aspect of the portal vein from the
posterior part of the pancreas
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2 Back-Table Procedure ofaWhole Liver Graft forthePiggyback Technique
Fig. 2.14 Transection of the pancreas
Fig. 2.15 Control of the splenic vein
Fig. 2.17 The portal vein is cannulated for portal cold perfusion of the
graft
Fig. 2.18 Surgical view of the mesentericoportal axis after removing
the pancreas
Fig. 2.16 Transection of the pancreas showing the portal vein
Fig. 2.19 Looking for the portal bifurcation. (Note: In that case, the
hepatic artery has been dissected rst)
2 Back-Table Procedure ofaWhole Liver Graft forthePiggyback Technique
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Fig. 2.20 Dissection of the posterior aspect of the superior mesenteric
artery
Fig. 2.21 Dissection of the posterior aspect of the superior mesenteric
artery
Fig. 2.23 Dissection of the anterior aspect of the superior mesenteric
artery showing some jejunal and pancreatic arteries
Fig. 2.24 Dissection of the arterial inow from the aortic patch, cleaning off the celiac plexus and fatty tissue enveloping the arteries
Fig. 2.22 Dissection of the superior mesenteric artery to detect an
accessory right hepatic artery
Fig. 2.25 Dissection of the splenic artery at the superior part of the
pancreas to the level of the gastroduodenal artery (mosquito forceps is
applied to the corner of the gastroduodenal artery)
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2 Back-Table Procedure ofaWhole Liver Graft forthePiggyback Technique
Fig. 2.26 Dissection of the left gastric artery including an accessory
left hepatic artery
Fig. 2.27 Liver graft with a common hepatic artery (mosquito forceps
is applied to the corner of the gastroduodenal artery)
Fig. 2.29 Dissection of the bile duct at the level of the pancreas
Fig. 2.30 Dissection of the bile duct above the pancreas
Fig. 2.28 Liver graft with two arteries: a common hepatic artery and a
replaced right hepatic artery arising from the superior mesenteric artery
Fig. 2.31 Closure of the infrahepatic inferior vena cava
2 Back-Table Procedure ofaWhole Liver Graft forthePiggyback Technique
Fig. 2.32 Closure of the suprahepatic inferior vena cava
Fig. 2.33 Incision of the posterior wall of the inferior vena cava for
piggyback technique
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Piggyback Total Hepatectomy
3
The standard technical procedure of a piggyback total hepatectomy includes preservation of the native inferior vena
cava [1–7] and a temporary end-to-side portocaval shunt,
according to the surgeon’s preference and the liver transplantation scenario. During the recipient total hepatectomy, each
element of the hepatic pedicle (hepatic artery, bile duct, and
portal vein) is dissected, ligated, and transected. The retrohe-
patic inferior vena cava is then dissected, and the native liver
is progressively separated from the native inferior vena cava
(Figs. 3.1, 3.2, 3.3, 3.4, 3.5, 3.6, 3.7, 3.8, 3.9, 3.10, 3.11,
3.12, 3.13, 3.14, 3.15, 3.16, 3.17, 3.18, 3.19, 3.20, 3.21, 3.22,
3.23, 3.24, 3.25, 3.26, 3.27, 3.28, 3.29, 3.30, 3.31, 3.32, 3.33,
3.34, 3.35, 3.36, 3.37, 3.38, 3.39, 3.40, and 3.41).
Fig. 3.1 Exposing the hepatic pedicle
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
C. Lim et al., Atlas of Liver Transplantation, https://doi.org/10.1007/978-3-031-85264-0_3
Fig. 3.2 Control of the left branch of the hepatic artery and the arterial
branch of segment IV
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20
3 Piggyback Total Hepatectomy
a
Fig. 3.3 Dissecting the proper hepatic artery. (a) Isolating the right branch of the hepatic artery. (b) Isolating the left branch of the hepatic artery
after ligation and division of the right branch of the hepatic artery
b
Fig. 3.4 The right and left branches of the hepatic artery have been
ligated and divided
Fig. 3.5 The common hepatic artery and gastroduodenal artery have
been isolated and taped
Fig. 3.6 The right (RBHA) and left (LBHA) branches of the hepatic
artery, the arterial branch of segment IV (A4), and the proper hepatic
artery (PHA) have been isolated and taped
Fig. 3.7 After division of the left (LBHA) and right (RBHA) branches
of the hepatic artery, the common bile duct has been isolated and taped
3 Piggyback Total Hepatectomy
Fig. 3.8 Ligation of the common bile duct above the level of the cystic
duct (CD)
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Fig. 3.10 After division of the hepatic artery and common bile duct,
the portal vein is exposed (RBHA, right branch of the hepatic artery;
LBHA, left branch of the hepatic artery; CBD, common bile duct)
Fig. 3.9 Division of the common bile duct (CD, cystic duct)
Fig. 3.11 The portal vein is divided using a vascular stapler
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3 Piggyback Total Hepatectomy
a
c
b
d
Fig. 3.12 Performing a temporary portocaval anastomosis. (a) The inferior vena cava is clamped laterally. (b) The inferior vena cava is opened.
(c) The portal vein is anastomosed to the inferior vena cava. (d) Portocaval anastomosis after unclamping
a
b
c
Fig. 3.13 Mobilization of the left liver. (a) Section of the falciform ligament. (b) Section of the left triangular ligament. (c) Section of the pars
accida