A novel technique of cavo-caval anastomosis in orthotopic liver transplantation with graft mismatch size

Abstract

Introduction: Preservation of retrohepatic vena cava during orthotopic liver transplantation (OLT) has the main advantage to maintain the venous return preventing hemodynamic alterations and avoiding venous-venous by-pass. Tzakis popularized in 1989 the piggyback technique that underwent thereafter several technical modifications in the effort to minimize its specific limit such as venous outflow obstruction. In case of graft mismatch in size due to a larger right lobe, cavo-caval anastomosis results under tension or even not practicable. Method and results: A 39-year old man was referred for OLT. Donor and recipient were matching for physical parameters. After completion of recipient hepatectomy preserving cava vein, liver graft was inserted in the hepatic fossa to perform cavo-cavostomy; for the larger size of right lobe, recipient and donor cava did not fit on the same plane. The posterior cavo-caval suture was carried out but the anterior line of suture was not perfomed due to the excessive distance between caval walls. Therefore a 3 × 8 cm venous patch from donor iliac vein was inserted and anastomosed to repair the defect between recipient and donor cava. Caval anastomosis was completed without any tension in 49 minutes (operative time 300 minutes, cold ischemia 262 minutes, warm ischemia 62 minutes, blood loss 2600cc). On postoperative day 15th the patients was discharged. At one-year follow up the patient is getting very well. Conclusion: This novel technique is feasible, allows to preserve retrohepatic cava, and presents a valid option in case of discrepancy between graft size and recipient right hypochondrium.