The surgical procedure
The diseased liver is removed and a normal liver is transplanted into the space where the diseased liver was located, ie. on the right-hand side of the upper abdominal region. This requires a so-called “Mercedes Benz” incision on the upper abdomen.
The operation is very complicated and takes approximately six to eight hours. Removing the old liver can be extremely difficult, particularly if you have had previous abdominal operations.
Fig.1
During surgery your old diseased liver will be removed and a new healthy looking liver transplanted in its place. (A gallbladder will not be transplanted with the liver).This is the conventional operation where your own inferior vena cava (IVC) is left in place. The donor IVC is “piggy-backed” onto your IVC.
The liver is attached to a number of vital structures, all of which have to be severed and rejoined.
These are:
The inferior vena cava (IVC), the major vein that drains into the heart, both above (suprahepatic) and below (infrahepatic) the liver;
the portal vein, the vein that feeds blood from the intestines into the liver;
the hepatic artery; and the common bile duct, the major duct transporting bile from the liver to the intestine.
Once all these major structures have been joined from the donor liver to yours the abdominal cavity is washed with warm saline. Some of the saline will remain in the abdomen.
Three white drains called Jackson Pratt drains are inserted into your abdominal cavity. They will be attached to another suction container. The fluid (saline) which drains into them will be a little blood stained. This is quite normal. Your abdomen is closed in layers of muscle under the skin.
You will be transferred to ICU from theatre where the staff will observe the drainage and once it ceases the Jackson Pratt drains will be removed.
Dressings
We use clear dressings to cover the incision. The skin clips used to close the skin a re visible through them. The dressings are permeable to water vapour but impermeable to oganisms. Sometimes blood or fluid will be visible but it will not effect the skin healing. The dressings are left on for up to 7 days. You are able to shower with them on.
Split-Liver Transplantation
Because of the disparity between the increasing numbers of people waiting for transplant, and the numbers of donor livers available, ways are always being undertaken to increase the number of people able to undergo transplantation. A strategy that is used in many transplant centres around the world, including RPAH, is split-liver transplantation. In this procedure, a donor liver is divided in two parts, a larger right lobe, and a smaller left lobe (see figure 2). With this strategy, an adult and a child can be transplanted from the same donor organ. Not all people waiting for transplants are suitable to have a right lobe transplant and the transplant team will always select an appropriate recipient. The chance of developing complications from a split liver transplant is slightly higher than if a whole liver graft is used. Within the first few months after transplantation, the split liver increases in size until it is the size of a full-sized liver. Since the implementation of split liver transplantation, the number of children waiting for transplantation in Australia has significantly reduced.
Figure 2. Split liver transplantation. The left lobe is used for a child, and the right lobe is used for an adult.
Transplantation from living donors
Liver donation from living relatives to adult recipients is performed in many parts of the world, but is not currently offered in Australia. An adult recipient requires the right lobe of the liver, as the left lobe would be of insufficient size to sustain normal function. Severe complications and even death have been reported in living donors, and until the risks are reduced, it is unlikely that such a procedure will be offered routinely in Australia.
Gall bladder
Both your own gallbladder (if you still have one), and the gallbladder attached to the transplanted liver will be removed at the time of the operation. Do check with your surgeon if you have any questions.
Survival chances
Liver transplantation is a major operation. However, due to various recent advances the peri-operative mortality is now less than 10%. The 10-year post-transplant patient survival is about 70%. No doubt, these figures will continue to improve.