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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_775_Библиотеки_им_академика_М_И_Перельмана.pdf
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- •Foreword
- •Preface
- •Introduction
- •Contents
- •Contributors
- •1.5 Venous Anatomy
- •1.6 Conclusion
- •References
- •2.1 Introduction
- •2.1.1.1 IPDA
- •1.1 Introduction
- •1.2 Arterial Anatomy
- •1.3 Portal Venous Anatomy
- •1.4 Biliary Anatomy
- •2.1.1.4 Dorsal Pancreatic Artery (DPA)
- •2.3 Surgical Techniques
- •2.4 Discussion
- •2.5 Conclusion
- •References
- •3.1 Introduction
- •3.2 Intrahepatic Biliary Tract
- •3.2.4 Accessory Biliary Ducts
- •3.3 Extrahepatic Biliary Tract
- •3.3.2 Retroduodenopancreatic Portion
- •3.3.3 Intramural Portion
- •3.5 Accessory Biliary Tract
- •3.5.2 Vascularization
- •References
- •4.1 Introduction
- •4.2 Posthepatectomy Liver Failure (PHLF)
- •4.3.1 Portal Hypertension
- •4.3.3 Blood Chemistry Tests
- •4.3.4 Indocyanine Green (ICG) Clearance Test
- •4.4 M2BPGi
- •4.5 Scintigraphy
- •4.7 Measuring FLR Function
- •4.8 Conclusions
- •References
- •5.1.1 Hemangioma
- •5.1.2 Focal Nodular Hyperplasia
- •5.1.3 Simple Hepatic Cyst
- •5.1.4 Hepatic Adenoma
- •5.2.1 Hepatocellular Carcinoma
- •5.2.2 Metastatic Disease
- •5.2.3 Intrahepatic Cholangiocarcinoma
- •5.2.4 Hepatic Angiosarcoma
- •5.3.1 Acute Calculous Cholecystitis
- •5.3.2 Chronic Cholecystitis
- •5.3.3 Acalculous Cholecystitis
- •5.3.4 Biliary Dyskinesia
- •5.3.5 Choledocolithiasis
- •5.3.7 Choledochal Cysts
- •5.3.8 Primary Sclerosing Cholangitis
- •5.3.9 Benign Biliary Stricture
- •5.4.1 Extrahepatic Cholangiocarcinoma
- •5.4.2 Gall Bladder Cancer
- •5.5.1 Acute Pancreatitis
- •5.5.2 Chronic Pancreatitis
- •5.5.3 Pancreas Neuroendocrine Tumors
- •5.5.4 Pancreas Cystic Neoplasms
- •5.5.4.1 Intraductal Papillary Mucinous Neoplasm
- •5.5.4.2 Mucinous Cystic Neoplasm
- •5.5.4.3 Solid Pseudopapillary Neoplasm
- •5.6.1 Pancreas Adenocarcinoma
- •References
- •6.2.1 Gallbladder
- •6.3.1 Gallbladder Dysfunction
- •6.3.3 Pancreaticobiliary Maljunction
- •6.4.2 Enterohepatic Circulation
- •6.4.3 Bile Acids
- •References
- •7.1 Introduction
- •BilINs
- •IPNBs
- •7.1.1.2 Imaging Findings
- •BilINs
- •IPNB
- •7.1.2.1 Gross
- •BilIN
- •IPNB
- •Controversial Cases: BilIN or IPNB
- •7.1.2.2 Histologies
- •BilINs
- •IPNB.
- •8.4 Gallbladder Carcinoma
- •8.4.1 Gross Features
- •8.4.2 Microscopic Features
- •8.4.3 Molecular Features
- •References
- •BilIN
- •IPNB
- •7.1.4.1 BilIN
- •7.1.4.2 IPNB
- •7.2 Conclusion
- •References
- •8.1 Introduction
- •8.2 Intrahepatic Cholangiocarcinoma
- •8.2.1 Gross Features
- •8.2.2 Microscopic Features
- •8.2.3 Molecular Features
- •8.3 Extrahepatic Cholangiocarcinoma
- •8.3.1 Gross Features
- •8.3.2 Microscopic Features
- •8.3.3 Molecular Features
- •References
- •10.1.2 Epidemiology
- •10.1.3 Etiology
- •10.1.4 Clinical Features
- •10.1.5 Radiology
- •10.1.6 Pathology
- •10.1.6.1 Macroscopic Appearance
- •10.1.6.3 Immunohistochemistry
- •10.1.6.4 Grading
- •10.1.6.6 Molecular Pathology
- •10.2.2 Epidemiology
- •10.2.3 Etiology
- •10.2.4 Clinical Features
- •10.2.5 Radiology
- •10.2.6 Pathology
- •10.2.6.1 Macroscopic Appearance
- •10.2.6.2 Microscopic Appearance
- •10.2.6.3 Immunohistochemistry
- •10.2.6.5 Molecular Pathology
- •10.3.2 Epidemiology
- •10.3.3 Etiology
- •10.3.4 Clinical Features
- •10.3.5 Radiology
- •10.3.6 Pathology
- •10.3.6.1 Macroscopic Appearance
- •10.3.6.3 Immunohistochemistry
- •10.3.6.5 Molecular Pathology
- •References
- •11: Mucinous Cystic Neoplasms
- •11.1 Introduction
- •11.2 Clinical Aspects
- •11.3 Pathological Findings
- •11.3.1 Macroscopical Features
- •11.3.2 Histological Features
- •11.4 Molecular Abnormalities
- •References
- •12.1 Introduction
- •12.1.1 General Features
- •12.1.2 Diagnostic Features
- •12.1.3 Clinical Implications
- •12.1.4 Desmoplastic Stroma
- •12.1.5 Venous Invasion
- •12.1.6 Variants
- •12.2 Conclusions
- •References
- •13.2.1 Benign Liver Tumors
- •13.2.2 Malignant Liver Tumors
- •13.2.3.1 Liver Abscess
- •13.4.1 Biliary Tree Tumors
- •13.5.1 Pancreatic Tumors
- •References
- •14.1 MRE Technique
- •14.2 MRE Performance
- •14.4 Technical Limitations
- •14.5 Summary
- •References
- •15.1 Introduction
- •15.6 Conclusion
- •References
- •17.1 Intraoperative Cholangiography
- •17.2 Intraoperative Ultrasound
- •17.2.1 Anatomy
- •17.2.2 Diagnosis
- •17.2.3 Resection Guidance
- •17.2.3.2 Resection Guidance
- •17.3 Intraoperative Fluorescence Imaging
- •17.4 Navigation Assisted Liver Resection
- •References
- •18.1 Introduction
- •18.2 Photon Therapy
- •18.3 Charged Particles Therapy
- •18.4 MRI Guided Therapy
- •18.5 Combination Strategies Using Cytotoxics
- •18.6 Radioimmunotherapy
- •18.8 Summary
- •References
- •19.1 Introduction
- •19.2 Systemic Chemotherapy
- •19.2.1 Adjuvant Therapy
- •19.2.2 First-Line Therapy
- •19.2.3 Second-Line Therapy
- •19.3 Targeted Therapy
- •19.4 Immunotherapy
- •19.5 Precision Medicine
- •References
- •20.1 Introduction
- •20.2.1 Neoadjuvant Chemotherapy
- •20.2.2 Adjuvant Chemotherapy
- •20.2.3 Palliative Chemotherapy
- •20.3 Immunotherapy
- •20.4 Tumor Microenvironment
- •20.5 Summary
- •References
- •21.1 Background
- •21.5 Combination Strategies
- •21.7 Future Perspectives
- •References
- •22.1 FGFR Alterations
- •22.2 IDH Mutations
- •22.3 BRAF Alterations
- •22.7 Conclusions
- •References
- •23.1 Introduction
- •23.2 Adjuvant Systemic Therapy
- •23.3 Neoadjuvant Systemic Therapy
- •23.4.3 Second-Line Therapy
- •23.4.4 Targeted Therapy
- •References
- •24.1 Introduction
- •24.4 The Various Stents Available
- •24.8 Hilar Strictures (Resectable Cases)
- •24.9 Hilar Stricture: Palliative Cases
- •24.11 Endoscopic Ultrasound-Guided Biliary Drainage
- •24.12 Conclusions
- •References
- •25.1 Introduction
- •25.3 EUS-TD Technique
- •25.4 EN Technique
- •25.6 Conclusion
- •References
- •26.1 Background
- •26.2 Short History
- •26.4.6 Personalized Cancer Treatment
- •References
- •27.1 Introduction
- •27.3.1 Pre-Admission Optimization
- •27.3.3 Carbohydrate Loading
- •27.3.6 Early Feeding
- •27.6 Conclusion
- •References
- •28.1 Introduction
- •28.5 Conclusion
- •References
- •29.6 Conclusion
- •References
- •30.1 Introduction
- •30.3 Surgical Indication
- •30.4 Surgical Technique
- •30.4.1 Exposure
- •30.4.4 Parenchymal Transection
- •30.5 Clinical Advantages
- •30.5.1 Technical Advantages
- •30.5.2 Prognostic Advantages
- •30.6 Conclusions
- •References
- •31.1 Introduction
- •31.2 Multiple Bilobar CLM
- •31.2.1 Intraoperative Ultrasound
- •31.2.2 Tumor-vessel Detachment
- •31.2.3 Communicating Veins
- •31.3 New Procedures
- •31.3.1.1 Eligibility Criteria
- •31.3.2 Upper Trasversal Hepatectomy (UTH))
- •31.3.2.1 Mini-Upper Transversal Hepatectomy
- •31.3.2.2 Right Upper Transversal Hepatectomy [33]
- •31.3.2.3 Left Upper Transversal Hepatectomy [24]
- •31.3.2.4 Total Upper Transversal Hepatectomy [24, 34]
- •Eligibility Criteria
- •31.3.3 Mini-mesohepatectomy (MMH) [35, 36]
- •31.3.3.1 Eligibility Criteria
- •31.3.4 Liver Tunnel [37, 38]
- •Eligibility Criteria
- •31.4 Discussion
- •31.5 Concerns & Future Directions
- •31.6 Conclusions
- •References
- •32.1 Introduction
- •References
- •33.1 Introduction
- •33.6 Segmentectomy, Cone Unit Resection
- •33.7 Surgical Outcomes
- •References
- •34.1 Introduction
- •34.6 Laparoscopic Parenchymal Sparing Anatomical Hepatectomy (Lap-PSAH)
- •34.7 Surgical Procedures at Ageo Central General Hospital (ACGH)
- •34.8 Conclusion
- •References
- •35.5 Laparoscopic Segmentectomy V (S5)
- •35.6 Laparoscopic Segmentectomy VI (S6)
- •35.7 Laparoscopic Segmentectomy VII (S7)
- •References
- •36: Modified ALPPS Procedure
- •36.1 Introduction
- •36.2 Discussion
- •36.2.1 Parenchymal Transection
- •36.2.2 Hepatoduodenal Ligament Dissection
- •36.2.4.1 Partial ALPPS
- •36.2.4.2 Hybrid ALPPS
- •36.2.4.3 Mini-ALPPS/ALPTIPS
- •36.2.4.5 Tourniquet ALPPS
- •36.3 Conclusion
- •References
- •37.1 Introduction
- •37.3 Right-Posterior Approach
- •37.4 Right-Uncinate Approach
- •37.5 Mesenteric Approach
- •37.6 Left-Posterior Approach
- •37.7 Anterior Approach
- •37.8 Mesopancreatic Resection
- •37.10 Summary
- •References
- •38: Organ- and Parenchyma-sparing Pancreatic Surgery
- •38.1 Introduction
- •38.2 Organ-Sparing Techniques
- •38.2.1 Spleen-Preserving Distal Pancreatectomy
- •38.3 Parenchyma-Sparing Techniques
- •38.3.2 Dorsal Pancreatectomy
- •38.3.4 Middle-Preserving Pancreatectomy
- •38.4 Conclusion
- •References
- •39.1 Introduction
- •39.2.1 Laparotomy
- •39.2.2 Supramesocolic Approach
- •39.2.3 Inframesocolic Approach
- •39.3 Mesenteric Incision
- •39.9 Antithrombogenic PV Catheter Bypass
- •39.13 Discussion
- •References
- •40.1 Introduction
- •40.4 HA Reconstruction
- •40.4.1 Simple Reconstruction Case
- •40.4.2 Complicated Reconstruction Case
- •40.4.3 Concomitant Vein Resection
- •40.4.4 Management after HA Reconstruction
- •40.5 Conclusions
- •References
- •41.1 Introduction
- •41.3.1 Patients
- •41.3.2 Preoperative Treatments
- •41.3.5 Statistical Analyses
- •41.4 Results
- •41.5 Discussion
- •References
- •42.1 Introduction
- •42.1.1 Preoperative Planning
- •42.2 Surgical Technique
- •42.2.1 Basic Preliminary Maneuvers
- •42.3 Postoperative Management
- •42.4 Conclusions
- •References
- •43: Robotic Pancreaticoduodenectomy
- •43.1 Background
- •43.2 Robotic PD
- •43.3 Conclusion
- •References
- •44: Duodenum-Preserving Pancreatic Head Resection
- •References
- •45.1 Introduction
- •45.2 Surgical Technique
- •45.3 Discussion
- •References
- •46: Spleen-Preserving Distal Pancreatectomy
- •46.1 Introduction
- •46.2 Indications
- •46.4 Technique
- •46.4.1 Warshaw’s Technique
- •46.5 Postoperative Follow-Up
- •References
- •References
- •48.1 Introduction
- •48.10 Surgical Technique Preserving Left Gastric Artery
- •48.12 Conclusions
- •References
- •49: Robotic Distal Pancreatectomy
- •49.1 Surgical Technique
- •49.1.3 Distal Splenopancreatectomy
- •49.1.4 Spleen-Preserving Distal Pancreatectomy
- •49.2 Results
- •49.3 Discussion
- •References
- •50: Total Pancreatectomy
- •50.1 Introduction
- •50.2 Indications
- •50.3 Surgical Procedure
- •50.4 Vascular Resection
- •50.5 Comment
- •References
- •References
- •52.1 Introduction
- •52.2.1 Non-Functional PNEN (NF-PNEN)
- •52.2.2 Functional PNEN
- •52.2.4 High-grade PNEN
- •52.4 Conclusions
- •References
- •53.1 Introduction
- •53.1.1 Fukuoka Guidelines 2012 (Revised 2017)
- •53.1.2 European Guidelines 2018 (EG18)
- •53.2 Discussion
- •References
- •54.1 Introduction
- •54.1.1 Developmental Mechanism
- •54.1.2 Designations
- •54.1.3 Incidence
- •54.1.4 Predictive Factors
- •54.1.5 Treatment
- •54.2 Conclusion
- •References
- •55: Benign Biliary Diseases
- •55.1 Introduction
- •55.2 Congenital Anomalies
- •55.2.1 Biliary Atresia
- •55.2.2 Choledochal Cyst
- •55.3 Diagnosis
- •55.4 Complications
- •55.5 Management
- •55.5.1 Gallstones
- •55.6 Pathogenesis
- •55.8 Complications
- •55.9 Bile Duct Stones
- •55.10 Management
- •55.11 Intrahepatic Stones
- •55.13.1 Benign Biliary Strictures (BBS)
- •55.14 Iatrogenic Biliary Injury
- •55.15 Mirizzi Syndrome (MS)
- •55.16 Liver Transplantation Related BBS
- •55.17 Primary Sclerosing Cholangitis (PSC)
- •55.17.1 Biliary Dyskinesia
- •References
- •56.1 Introduction
- •56.2 Preoperative Evaluation
- •56.2.1 Preoperative Biliary Drainage
- •56.2.2 Portal Vein Embolization
- •56.3.2 Hilar No Touch “En-bloc” Technique
- •56.3.3 Vascular Resection
- •56.3.4 Margin Status
- •56.3.5 Lymph Node Dissection
- •56.3.6 Minimally Invasive Surgery
- •56.4 Short-term Results
- •56.5 Long-term Results
- •56.6 Conclusions
- •Bibliography
- •57.1 Introduction
- •57.2 Clinical Presentation
- •57.3 Serum Tumor Markers
- •57.4 Imaging
- •57.5 Treatment
- •57.6 Surgical Management
- •57.6.1 Liver Resection
- •57.11 Surgical Resection Procedure
- •57.13.2 Long-Term Outcomes
- •57.14 Recurrence
- •57.14.1 Liver Transplantation
- •References
- •58.1 Introduction
- •58.1.2 Surgical Techniques
- •58.1.4 Outcomes After HPD
- •58.1.5 Practical Management During Surgery
- •References
- •59: Hepato-biliary Injuries
- •59.1 Etiology
- •59.4 Diagnosis
- •59.4.1 Clinical Presentation
- •59.4.2 Imaging
- •References
- •60.1 Background
- •60.2 Diagnostics
- •60.3 Treatment
- •60.3.1 Nonoperative Management
- •60.3.2 Interventional Treatment
- •60.3.3 Surgery
- •References
- •61.1 Historical Overview
- •61.2.1.1 Acute Liver Failure (ALF)
- •61.2.1.2 Chronic Liver Failure
- •61.2.3 MELD Exceptions
- •61.2.4 Other Standardized MELD Exceptions
- •61.2.4.1 Non-Standardized MELD Exceptions
- •References
- •62.3 Patient Assessment
- •62.4 Prognostic Factors
- •62.6 Extracorporeal Liver Support Systems
- •62.8 Conclusion
- •References
- •63.1 Introduction
- •63.2 Donation After Brain Death
- •63.3 Donors after Circulatory Death
- •63.4.1 Surgical Technique
- •63.4.1.1 Cross-clamping
- •63.4.2 Technical Variants
- •63.4.2.1 Split Liver Retrieval
- •63.4.2.2 En-bloc Liver-pancreas Retrieval
- •63.4.2.3 En-bloc Liver-bowel Retrieval
- •63.4.3 Back-table
- •63.4.3.1 Incidents: Accidents
- •References
- •64.1 Introduction
- •64.11 Conclusions
- •References
- •65: Living Donor Liver Transplantation
- •65.1 Introduction
- •65.2.1 Graft Size
- •65.2.2 Left Liver Graft
- •65.2.3 Right Liver Graft
- •65.2.4 Right Lateral Sector Graft
- •65.2.5 Dual Graft
- •65.2.6 ABO Blood Type Incompatible Graft
- •References

478
Fig. 63.6 Liver steatosis macroscopic aspect (left), normal (right) (from the photo collection of Genadyi Vatachki Roumenov)
F. Botea et al.
• focal liver lesions (a biopsy with freeze section examination is required).
Fatty liver grafts carry an increased risk of primary non-
function (PNF). Steatosis between 10% and 30% is acceptable as a marginal graft; some centers may even accept
steatosis up to 60% [13].
Next, the colon, rectum, kidneys, and pelvic organs (in
female donors) are inspected for malignancies. Any abnormal nding should be documented and reported to the transplant center, including biopsies.
Once the inspection is complete, the surgeon may proceed
with the sternotomy. Then, the pericardium is opened for an
appropriate exposure of the pericardial IVC; even if the heart
is not procured, this step is also essential for keeping track of
the heart movements and taking adequate measures in case
cardiac arrest should occur.
The left lobe is mobilized, and the lesser sac is inspected
for an aberrant left hepatic artery (ALHA) (Fig.63.7a), then
incised, preserving the artery if present. The right aspect of
the porta hepatis is palpated for detecting an aberrant right
hepatic artery (ARHA).
Possible arterial variations at this level are best classied
by Varotti etal. [14]:
• Type 1—a single hepatic artery (HA) emerging from the
celiac trunk;
• Type 2A—HA from the celiac trunk, giving both right
and left HAs; left accessory HA emerging from the left
gastric artery (LGA);
• Type 2B—HA from the celiac trunk, giving only a right
HA; left HA from the LGA (replaced left HA);
• Type 3A—HA from the celiac trunk, giving both right
and left HAs; right accessory HA from the superior mesenteric artery (SMA);
• Type 3B—right HA from SMA, and left HA from LGA;
• Type 4A—HA from the celiac trunk, and two accessory
HAs: right accessory HA from SMA, and left accessory
HA from LGA;
• Type 4B—HA from SMA, giving both right and left HAs;
left accessory HA from LGA;
• Type 5—a single HA from SMA (Fig.63.7b) [15].
According to a meta-analysis, classic branching of the common HA from the celiac trunk is seen in 55–60% of cases,
while variations in hepatic arterial anatomy are observed in
40–45% of cases.
The liver hilum can be palpated from the left through the
lesser sac. The presence of a posterior pulsation suggests a
right HA originating from the SMA.Placed posterior to the
duodenum, the right HAs stemming from the SMA come in
several trajectory variations, in relation to the head of the
pancreas: in the sagittal plane—posterior to the pancreatic
head or through it, and in frontal plane—more lateral or
medial in relation to the portal vein and splenomesenteric
conuent, respectively. In this area, a HA originating from
the celiac trunk or even from the aorta should be considered.
(Fig.63.7c and d).
Early proper identication of liver arterial anatomy is the
key to a safe retrieval procedure. For example, a right HA
coming from a low bifurcation of the proper HA may be confused with an aberrant right HA originating from the
SMA.An aberrant right HA has a cranio-caudal trajectory,
whereas in case of a low bifurcation, the right HA presents

63 Liver Graft Retrieval inDeceased Donors
a b
cd
479
Fig. 63.7 (a) Aberrant left hepatic artery originating from left gastric artery. (b) Common hepatic artery originating from the superior mesenteric
artery. (c) ARHA originating from celiac trunk. (d) Common hepatic artery originating directly from the aorta (from the photo collection of
Genadyi Vatachki Roumenov)
an angulation from medial to lateral, followed by an ascending trajectory. The angulation spot is predisposed to accidental injury if the two variations are not identied correctly. A
low bifurcation of the HA, below the emergence of the gastroduodenal artery, may be present in 6% of cases (Fig.63.8).
By placing a ne bulldog clamp on a suspected aberrant
artery, the surgeon can distinguish between an aberrant right
HA and an artery of the common bile duct (CBD): clamping
the aberrant artery may cause a visible ischemic delimitation
on the liver parenchyma. The same method may identify an
accessory left HA emerging from the LGA: the presence of a
pulse distal to the bulldog placed on the aberrant HA indicates anastomotic arterial collaterals in the hilum.
The line of Told is incised to mobilize the colon and
small bowel completely from the retroperitoneum (CattellBraasch maneuver), exposing the IVC, towards the left renal
vein, and the aorta, up to the origin of the SMA (Fig.63.9)
[16]. Dissection continues cephalad from the right iliac

480
Fig. 63.8 Low bifurcation of common hepatic artery exposed after
mobilization of the pancreatic head (from the photo collection of
Genadyi Vatachki Roumenov)
artery towards the portal vein, and medially, to completely
mobilize the head of the pancreas. Last, the surgeon places
the index nger through the foramen of Winslow, posterior
to the liver hilum, to expose and incise the connective tissue
medially to the origin of the SMA, completing the mobilization maneuver [1].
If the donor is hemodynamically unstable, the surgeon
may proceed with aortic cannulation at this point and complete dissection in the cold phase.
After cholecystostomy, the CBD is identied, ligated
above the head of the pancreas, as distally as possible, sectioned, and ushed through the gallbladder followed by cholecystectomy. The pyloric and gastroduodenal arteries are
identied and ligated; it is recommended to keep the gastroduodenal artery stump if possible, to facilitate blood ow
assessment of the HA in the recipient, or even thrombectomy. Next the common HA is dissected along its axis, the
LGA and splenic artery are identied and ligated preserving
5–10mm stumps, followed by a good exposure of the celiac
trunk. The extensive dissection of the celiac trunk must be
done with utmost attention to avoid injuring the diaphragmatic arteries, which stem from its base. Exposure of the
infra-diaphragmatic aorta is achieved by transversely sectioning the right diaphragmatic crus, and a vascular tie is
passed around the aorta at this level (Fig.63.10).
Alternatively, a tie may be passed around the aorta above
the diaphragm by sectioning the inferior portion of the left
pulmonary ligament, called the transpericardic transpleural
approach. Circumferential dissection of the aorta at this level
F. Botea et al.
Fig. 63.9 Cattell-Braasch maneuver exposing the major vessels in the
retroperitoneum (from the photo collection of Genadyi Vatachki
Roumenov)
is preferably done under digital control, to prevent injuring
any vertebral arteries.
The inferior mesenteric vein is then dissected at the
Treitz’s ligament and cannulated; after insertion, the portal
cannula is placed in the PV.Alternatively, the cannula may
be placed directly into the PV (Fig.63.11). This maneuver
should be followed by cross-clamping, to minimize the lack
of portal blood ow. Alternatively, the cannula may be
inserted directly into the PV (in the portion located posteriorly to the duodenum, or via the superior mesenteric vein.
The patency of the portal cannula is conrmed by aspiration,
followed by heparinized saline solution bolus infusion.
The dissection of the aorta is carried out above the iliac
bifurcation by ligating and sectioning the inferior mesenteric
artery. At this level, the aorta is ligated distally and cannulated
(Fig.63.11). The patency of the aortic cannula is checked by
aspiration, followed by heparinized saline solution bolus infu-

63 Liver Graft Retrieval inDeceased Donors
Fig. 63.10 Celiac trunk dissected circumferentially (left). Aortic ties positioned for cross-clamping (right) (from the photo collection of Genadyi
Vatachki Roumenov)
481
sion. Bleeding from the aortic cannulation level may originate
from a lumbar artery, which must be identied and sutured.
The IVC must also be identied and dissected at this
level. A systemic heparin bolus is administered (300 UI/kg),
followed by a 3-minute waiting time, allowing a full systemic circuit.
63.4.1.1 Cross-clamping
This maneuver consists of several steps that isolate the arterial and portal pathways of the abdominal organs in a closed
circuit that is ushed with preservation solution and emptied
through the IVC:
• clamping the infra-diaphragmatic aorta (by ligation);
• ushing the abdominal organs with cold preservation
solution through the cannulas placed in the PV (1ml/g of
liver tissue, or 2 liters) and aorta (3ml/g of liver tissue, or
5 liters);
• the IVC is sectioned inferior to the right atrium and above
the iliac veins;
• topic cooling for the abdominal organs is applied by ll-
ing the abdomen with sterile ice;
• a clamp may also be placed on the mesentery root to
exclude the intestines from the circuit.
After cross-clamping, the liver graft is detached en-bloc with
a diaphragm patch. The retrohepatic IVC is dissected cau-
dally and sectioned above the renal vein ostium. The PV is
sectioned above the pancreas head, leaving a 1-cm stump
distally if the pancreas is also retrieved. The aorta is sectioned above and below the celiac trunk, and completely dissected from its posterior attachments. The liver graft is now
removed from the donor.
63.4.2 Technical Variants
63.4.2.1 Split Liver Retrieval
This type of retrieval is used to split the graft between 2
recipients. The split may be done between segments II-III
and the rest of the liver (pediatric and adult split), or between
segments II-III-IV and the rest of the liver (adult and adult
split). Splitting may be difcult due to varying vascular and
biliary anatomy. It is worth mentioning that certain arterial
anatomical variants favor the splitting, such as types 2B and
3B according to Varotti’s classication.
In-situ splitting requires separation of the liver before
cross-clamping. The donor must meet the following criteria:
optimal liver quality, medium-large size graft, and stable
donor. The advantages of in-situ over ex-situ splitting are:
• optimal hemostasis of the liver cut surface, especially
when transection is carried out with an ultrasound
dissector,

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Fig. 63.11 Cannulation of the portal vein (left) and aorta (right) (from the photo collection of Genadyi Vatachki Roumenov)
• allows the assessment of the viability of both hepatic
grafts.
• allows a meticulous transection facilitating the identication of veins with caliber larger than 5mm (requiring reconstruction), and of aberrant vascular and biliary anatomy.
retrieved and separated on the back-table. For pancreas
retrieval, the GDA and splenic artery are not ligated. The
organs may be transplanted together, as a ‘cluster’ transplant,
which has very few indications. During this type of retrieval,
the ‘no touch technique’ is used for the pancreas, which is
indirectly mobilized by using the spleen as “handle” (which
In ex-situ split liver retrieval, the liver graft is split after
is later removed on the back-table).
retrieval, on the “back-table”. The advantages of ex-situ
splitting are the reduced operating time and the diminished
63.4.2.3 En-bloc Liver-bowel Retrieval
demand for resources.
This type of retrieval involves bowel preparation and lavage
63.4.2.2 En-bloc Liver-pancreas Retrieval
En-bloc retrieval of the two organs requires an aortic patch
that includes the celiac trunk and SMA (Fig.63.12). After
mobilization of the organs and cross-clamping, the grafts are
through a nasojejunal tube with saline solution and antibiot-
ics. The jejunum is sealed with stapler close to the angle of
Treitz, marking the area with a suture thread for later orienta-
tion. The transvers mesocolon is sectioned and the right

63 Liver Graft Retrieval inDeceased Donors
483
colon vascularization is ligated. The pancreas is separated
from the portal and superior mesenteric vein and then transection at level of the pancreatic isthmus. In the event of an
unstable donor, separation from the pancreas may also be
done on the back-table. Stapling the ileum is performed as
late as possible, to allow the complete evacuation of the
intestinal content into the colon. The hepatic and intestinal
grafts are lifted together with celiac trunk, SMA and aortic
patch (Carell patch), which can be extended on the back-
table using an iliac graft [17]. An “in-vivo” dissection of the
liver hilum is recommended by some authors, to reduce the
back-table organ separation time by early identication of
anatomical variants [18].
63.4.3 Back-table
The graft is then moved to the back-table and positioned. The
liver graft is perfused on the back-table with preservation
solution through the PV and HA (Fig.63.13). Flushing the
CBD is also done in order to avoid autolysis of the biliary tree
epithelium under the effect of the remnant bile during cold
Fig. 63.12 En-bloc liver and kidney retrieval in pediatric donor (from
the photo collection of Genadyi Vatachki Roumenov)
Fig. 63.13 Back-table dissection and perfusion (from the photo col-
lection of Genadyi Vatachki Roumenov)
Fig. 63.14 Varotti 4A reconstruction on the back table and in recipient (from the photo collection of Genadyi Vatachki Roumenov)

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ischemia time. Uniform discoloration of the liver and outow
of clear preservation uid through the hepatic veins are proof
of a proper ushing of the liver graft [17, 19]. The excess of
connective tissue and the portion of diaphragm attached to the
liver graft are also removed on the back-table.
The IVC is prepared for anastomosis depending on the
technique used in the recipient: a termino-terminal (T-T)
anastomosis between the recipient’s and donor’s and IVCs, a
termino-lateral (T-L) anastomosis between the cranial extremity of the donor’s IVC and the recipient’s IVC anastomosis,
after sealing both ends of the latter (the piggy back technique), a latero-lateral (L-L) anastomosis (the Belghiti technique), or a L-L anastomosis using the triangulation technique
(the triangle is fashioned by an transversal incision on the
anterior wall of the recipient’s IVC, uniting the ostiums of the
hepatic veins, combined with a longitudinal incision).
The hepatic pedicle elements are prepared for anastomosis. The portal vein and hepatic artery are checked again to
assure all branches are properly sealed, by infusing sterile
saline solution with a relative pressure.
If arterial variations are present, they are reconstructed
and prepared for implantation (Fig. 63.14). The common
practice in arterial anatomical variations is to reduce the
anastomotic partner to a single arterial trajectory of convenient caliber. When a right HA originates from SMA, the
celiac trunk and SMA aortic patches are sutured together.
The distal portion of the SMA is connected to the recipient’s
HA.The right HA can also be T-T anastomosed to the GDA
or splenic artery stumps; in this case, the anastomotic partner
of the recipient’s HA is the aortic patch corresponding to the
celiac trunk. There is no need for arterial reconstruction in
case of a left HA stemming from the LGA.
If the recipient’s HA does not achieve an acceptable blood
ow, the liver can be vascularized by an arterial graft interposition (donor’s iliac artery) or implant the celiac trunk patch of the
graft directly into the aorta distal to the origin of the renal veins.
After the preparation of the graft is completed, the liver is
packed in three separate sterile bags with saline solution
between each one for extra protection during transportation.
The recommended period of cold ischemia (the interval
between cross-clamping and nishing the cavo-caval and
porto-portal anastomoses with subsequent declamping) is
less than 12hours, since the liver graft quality declines after
this period [19].
Fig. 63.15 Abnormal trajectory of the IVC (left). Horse-shoe kidney (with 4 arteries, 3 veins and 2 urethers), positioned anterior to the aorta and
IVC; a surprising obstacle during Cattell-Braasch maneuver (right) (from the photo collection of Genadyi Vatachki Roumenov)

63 Liver Graft Retrieval inDeceased Donors
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63.4.3.1 Incidents: Accidents
In a multiorgan retrieval, a wide array of unforeseen situations
may arise due to donor instability, challenges generated by sharing the vascular capacity of the donor between retrieval teams,
failure to recognize the anatomical vascular variants with consequent vascular injuries, or issues related to logistics (Fig.63.15).
In case of an unstable donor or even cardiac arrest during
retrieval, the next steps should be followed:
• systemic heparin administration—a bolus of 300U/kg;
• aorta cannulation only (portal vein cannulation and perfusion are done on the “back-table”)
• cross-clamping as fast as possible in order to avoid prolonged organ ischemia;
• cold phase dissection of the vessels followed by hepatic
graft extraction [18, 20].
If cardiac arrest occurs, the donor status changes to a type IV
cardiac arrest donor (according to the Maastricht classication). Cardiac arrest in a DBD donor is followed by sectioning of the IVC (venting), aortic cannulation and infusion
with cold preservation solution, followed by clamping of the
aorta, sterile ice cooling, portal vein cannulation, and liver
graft extraction.
In case of a damaged or short IVC, the liver graft can be
salvaged by reconstructive augmentation with venous grafts
from the iliac veins.
During retrieval, if an accessory branch of right HA origi-
nating from SMA is injured, the management depends on
when the injury was produced—before or after
cross-clamping:
• before cross-clamping: proceeds with cross-clamping and
separate infusion of the injured vessel through a thin catheter, to obtain a uniform ushing of the liver graft. After
graft extraction, the injured branch will be re-attached to
the GDA or splenic artery stump, on the back-table;
• after cross-clamping: the above-mentioned vascular
reconstruction will be carried out on the back-table.
Sometimes, due to logistic or transportation reasons, the
retrieval time must be cut short. For a shorter retrieval time,
the surgeon may also exclude back-table time completely
and carry it out at the transplantation center [12, 21].
The procedure must always be adapted to all contributing
factors linked to the donor.
In conclusion, the key points of a successful retrieval are
optimal retrieval technique, thorough ushing of the graft,
and minimal warm and cold ischemia time.
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Deceased Donor Liver Transplantation:
ThePendulum ofVisions andIdeas
JanLerut andQuirinoLai
64
Abstract
During the second half of the twentieth-century, liver
transplantation (LT) became a clinical reality. Many technical, medical, physiologic, and immunological hurdles
needed to be taken to make this endeavour successful.
Starzl stated already in 1989 that “the conceptual appeal
of liver transplantation would become so great that the
procedure should come to mind as a last resort for virtually every patient with lethal hepatic disease.” Technical
perfection and the introduction in the 80s of the selective
immunosuppressive drugs cyclosporine A and tacrolimus
transformed LT into a routine procedure. Since then, signs
of progress have been spectacular. The number of procedures applied to more than 50 different benign and malignant liver diseases has grown exponentially, reaching the
400,000 marks nowadays.
This chapter deals with different aspects of this medical adventure, such as developed in the context of
deceased donor LT experiences. The concept of this chapter is based on the “pendulum” of visions and ideas.
Indeed, nearly all historical observations and descriptions
made and written down by Starzl in his 1969 classical
textbook, “Experience in Hepatic Transplantation,” have
been conrmed many decades later. This “closing circle
concept” will be highlighted at the beginning of each section by recalling a visionary quote of Starzl followed by
the current status of LT (Starzl, Experience in liver transplantation. WB Saunders Company, Philadelphia, 1969).
J. Lerut (*)
Institute for Experimental and Clinical Research [IREC],
Université catholique Louvain (UCL), Brussels, Belgium
e-mail: Jan.lerut@uclouvain.be
Q. Lai
General Surgery and Organ Transplantation Unit, Sapienza
University of Rome, Rome, Italy
64.1 Introduction
There are clear signs that homotransplantation of the liver
will be a valuable means in the future of treating patients
who have otherwise hopeless prognosis from hepatic disease
(Th. E. Starzl foreword book Experience in Hepatic
Transplantation)
Liver transplantation (LT) has turned from a dream into a
reality. The rst attempts of canine LT covered a one-page
short letter by St.Welch in 1955 in the ‘Transplantation
Bulletin,’ a supplement of the Journal of Plastic and
Reconstructive Surgery. At that time, a transplantation journal did even not exist! Later on, it was discovered that the
Milanese surgeon V.Staudacher had realized the rst experiments in 1952. Starzl’s large animal experience resulted in
the “rst LT experiment in human” on March 26, 1963 [1].
Twenty years later, the National Institute of Health Consensus
Development Conference based on only 540 LTs performed
in Denver-Pittsburgh, Hannover, Cambridge, and Groningen,
concluded that LT was “a promising alternative to current
therapy in the management of late phase of several forms of
severe liver diseases.” Moreover, the Committee declared
that LT had the potential to become a “clinical service”
instead of an experimental procedure. This consensus conference’s results represented the starting point for the highspeed implementation of LT as a curative treatment of many
livers and liver-based diseases [1–4]. From 1960 to 1990,
knowledge was almost exclusively based on deceased donor
LT experiences. From 1990 onwards, living donor LT
(LDLT) expanded further knowledge about surgical technique, physiology, and peri-operative care [5]. The LDLT
experience will undoubtedly lead to the full development of
all other technical LT variants, badly needed to overcome
allograft shortage and optimize liver recipients’ surgical and
medical care [5].
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Makuuchi et al. (eds.), The IASGO Textbook of Multi-Disciplinary Management of Hepato-Pancreato-Biliary Diseases,
https://doi.org/10.1007/978-981-19-0063-1_64
487
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