Br. J. Surg. Vol. 62 (1975) 438-440
Orthotopic liver transplantation utilizing a vascular stapling instrument P. T. B A R R O N , I. J. V O G E L F A N G E R A N D W. G. W A D D E L L * SUMMARY
A technique of orthotopic liver transplantation in the pig is described in which the main feature is the accomplish-
ment of four of the five anastomoses by the use of the Vogelfanger NRC vascular suturing instrument. The advantage of this instrument is the rapid accomplishment of safe leak-proof anastomoses.
DESCRIPTIONS of orthotopic liver transplantation in the pig have been reported by many authors (Garnier et al., 1965; Cordier et al., 1966; Mieny et al., 1967; Terblanche et al., 1967; Calne et al., 1968; Chalstrey et al., 1971). The surgical technique is of critical importance. The incidence of complications is frequent and often fatal. The most dangerous period is that interval during implantation of the donor liver when the recipient animal is totally bereft of liver function. It is vital, therefore, to restore hepatic blood supply promptly, and if this anhepatic period is prolonged beyond 45 minutes serious and often irreversible metabolic acidosis occurs. The usefulness and versatility of the Canadian Vogelfanger N R C vascular stapler (Vogelfanger et al., 1962, 1967) suggested an application to liver transplantation where rapidity in the performance of the vascular anastomoses is so desirable. The use of this instrument and modifications in the operative technique are described. Materials and methods Pigs of differing breeds, White Landrace and Black Poland China, of approximately 30 kg were used. Donor Through a subcostal incision the donor liver was freed from all its ligamentous attachments, and the portal vein, hepatic artery and common bile duct were dissected to the superior border of the pancreas. The subhepatic vena cava was isolated down to the renal vein, avoiding injury to the suprarenal vessels. The triangular ligaments above the liver were divided and phrenic veins draining into the suprahepatic inferior vena cava ligated. The liver was cooled in situ through the portal vein with Ringer’s lactate solution containing 10 ml of 8.4 per cent sodium bicarbonate, 200 mg of lidocaine, 1 ml of heparin and 100 mg of hydrocortisone per litre. Hepatectomy was then performed, preserving as much of the donor vessels as possible. Recipient The following parameters were monitored : arterial pressure, central venous pressure, temperature, ECG
438
and serial estimations of Pco, and standard bicarbonate. Hepatectomy was performed in the same manner as in the donor. On a number of occasions it was necessary to ligate the gastroduodenal artery but no damage to the duodenum was observed. Portosystemic shunt was performed by cannulation from the splenic to the jugular vein following splenectomy. Heparinization was performed with 0-5 mg of heparin per kg. The donor liver was implanted into the recipient and the anastomoses done in the following order: suprahepatic vena cava, portal vein, hepatic artery, infrahepatic vena cava and common bile duct. The suprahepatic inferior vena cava anastomosis was done as a single layer continuous suture utilizing 3/0 silk. End-to-end anastomoses between the donor and recipient portal vein, hepatic artery, subhepatic inferior vena cava and common bile duct were performed with the Vogelfanger NRC vascular stapling instruments (Vogelfanger et al., 1962, 1967), Mark IV (handling vessels 2-5 mm in diameter) and Mark XI1 (for vessels 6-12 mm in diameter). The key components of the vascular staples are the stapling bushing with the U-shaped tantalum staples and a corresponding anvil bushing with appropriately shaped moulding surfaces to bend the staples (Fig. 1). The vessel diameters were first measured. Vessel size ranged from 10 to 12 mm for the portal vein and subhepatic inferior vena cava, and from 2 to 3 mm for the hepatic artery. The diameter of the common bile duct was approximately 5-6 mm. Cuffs of donor and recipient vessels were then everted over the driving and anvil bushings respectively and held in position by plastic rings (Figs. 2, 3). In the larger vessels this was done by hand, and in the hepatic artery was readily achieved by an everting instrument. The two handles were locked together and the staple-driving mechanism operated to drive the staples through the vessel wall, towards the anvil bushing, moulding the driven staples in the shape of a letter B, thus forming an interrupted mattress suture. Removal of the instrument left a stapled vascular anastomosis. When the portal anastomosis was completed the vascular clamp was removed and the liver perfused with 300-400ml of portal venous blood which was allowed to egress into the abdominal cavity through the infrahepatic vena cava. In the preceding few
* Department of Surgery, University of Ottawa, and Ottawa Civic Hospital, Ottawa, Ontario, Canada. Requests for reprints to I. 5. Vogelfanger, Chief, Dlvision of Surgical Research, Ottawa Civic Hospital, 1053 Carling Avenue, Ottawa, Ontario, Canada KIY 4E9.
Orthotopic liver transplantation
Fig. 1. Instrument disassembled. Fig. 3. Both cuffs everted with nylon rings left by the evertor for fixation of the cuffs. Handles ready for assembly.
Fig. 2. Evertor being applied to produce a cuff over the bushing of the closed instrument.
minutes the animal had been transfused with a unit of blood to allow for this IOSS. The subhepatic inferior vena cava was then clamped and the vascular clamps on the suprahepatic inferior vena cava were removed t o restore portal to systemic circulation. The remaining anastomoses including the common duct were then completed rapidly, utilizing the same technique (Fig. 4). The time taken to complete the three critical anastomoses-suprahepatic vena cava, portal vein and hepatic artery-was approximately 15-20 minutes using this technique. Prior to closure of the abdomen and neck, vagotomy and pyloromyotomy were done (Calne et al., 1968). Discussion The complexities of liver transplantation relate to technical problems, the susceptibility of the liver to ischaemia and the tendency of the animal to develop serious metabolic problems during the anhepatic period. For this reason the ischaemic interval for the graft and the anhepatic period in the recipient should be as short as possible. A functioning portosystemic circulation is achieved quickly by first completing the suprahepatic vena cava anastomosis and then the portal vein, and immediately allowing a flow through the liver. The use of the Vogelfanger N R C vascular stapling instrument allows the rapid completion of these anastomoses, and in our hands shortens the
Fig. 4. Completed anastomosis of the portal vein (left), hepatic artery (right) and duct (above the hepatic artery).
anhepatic time t o under 15 minutes. The hepatic artery and infrahepatic vena cava anastomoses may then be equally rapidly completed, allowing the total time for the vascular anastomoses to be under 45 minutes. The instrument gives a very precise intima t o intima leak-proof anastomosis with a high degree of long term patency (Vogelfanger et al., 1962, 1967). A small vessel anastomosis with this technique also minimizes the trauma to the liver consequent upon dissection of the hepatic artery down to the coeliac artery and aorta which is necessary when a larger vascular reconstruction is done. A series of 31 liver transplants was done utilizing this method, with an operative mortality of 7 and with 12 animals surviving for 6-1 60 days. References CALNE R . Y., YOFFA D. E., WHITE H . J. O. and MAGINN R . R . (1968) A technique of orthotopic liver
transplantation in the pig. Br. J. Surg. 55,203-206. CHALSTREY L. J., PARBHOO S. P . , TAPPIN A., BAKER G. J., GRACEY L. R . H . , MULLEN P. A. and LESTER R. (1971)
Technique of orthotopic liver transplantation in the pig. BY.J. Surg. 58, 585-588.
439
P. T. Barron et al. CORDIER G., GARNIER H., CLOT J. P., CAMPLEZ R., GORIN J. P., CLOT P., RASSINIER J. P., NIZZA A. and LEVY R. (1966) La greffe de foie orthotopique
chez le porc. Premiers rbsultats. MPm. Acad. Chir. 92, 799. GARNIER H., CLOT J. P., BERTRAND M., CAMPLEZ P., KUNLIN A., GORIN J. P., LEGOAZIOU F., LEVY R. and CORDIER G . (1965) Greffe de foie chez le porc:
approche chirurgicale. C.R. Acad. Sci. ( D ) (Paris) 260, 5621-5623.
c. J., MOORE A. n., HOMATAS J. and EISEMAN B. (1967) Homotransplantation of the liver in pigs. S. Afr. J. Surg. 5 , 109-1 14.
MIENY
440
TERBLANCHE J., PEACOCK J. H., BOWES J., DAVIES R. P., TIERRIS E. J., PALMER D. B. and HUNT A. C. (1967)
The technique of orthotopic liver transplantation in the pig. Br. J. Surg. 54, 231. VOGELFANGER I. J., BEATTIE W. G. BROWN F. N., DEVITT J. E., SCOBIE T. K. and SCOBIE D. H. (1962)
The problem of small vessel anastomosis. Surgery 52, 354-362.
and COLLINS w. E. Experimental orthotopic kidney transplantation. Can. J. Surg. 10, 223-227.
VOGELFANGER I. J., IRVINE A. H.
( 1967)
Orthotopic liver transplantation utilizing a vascular stapling instrument P. T. B A R R O N , I. J. V O G E L F A N G E R A N D W. G. W A D D E L L * SUMMARY
A technique of orthotopic liver transplantation in the pig is described in which the main feature is the accomplish-
ment of four of the five anastomoses by the use of the Vogelfanger NRC vascular suturing instrument. The advantage of this instrument is the rapid accomplishment of safe leak-proof anastomoses.
DESCRIPTIONS of orthotopic liver transplantation in the pig have been reported by many authors (Garnier et al., 1965; Cordier et al., 1966; Mieny et al., 1967; Terblanche et al., 1967; Calne et al., 1968; Chalstrey et al., 1971). The surgical technique is of critical importance. The incidence of complications is frequent and often fatal. The most dangerous period is that interval during implantation of the donor liver when the recipient animal is totally bereft of liver function. It is vital, therefore, to restore hepatic blood supply promptly, and if this anhepatic period is prolonged beyond 45 minutes serious and often irreversible metabolic acidosis occurs. The usefulness and versatility of the Canadian Vogelfanger N R C vascular stapler (Vogelfanger et al., 1962, 1967) suggested an application to liver transplantation where rapidity in the performance of the vascular anastomoses is so desirable. The use of this instrument and modifications in the operative technique are described. Materials and methods Pigs of differing breeds, White Landrace and Black Poland China, of approximately 30 kg were used. Donor Through a subcostal incision the donor liver was freed from all its ligamentous attachments, and the portal vein, hepatic artery and common bile duct were dissected to the superior border of the pancreas. The subhepatic vena cava was isolated down to the renal vein, avoiding injury to the suprarenal vessels. The triangular ligaments above the liver were divided and phrenic veins draining into the suprahepatic inferior vena cava ligated. The liver was cooled in situ through the portal vein with Ringer’s lactate solution containing 10 ml of 8.4 per cent sodium bicarbonate, 200 mg of lidocaine, 1 ml of heparin and 100 mg of hydrocortisone per litre. Hepatectomy was then performed, preserving as much of the donor vessels as possible. Recipient The following parameters were monitored : arterial pressure, central venous pressure, temperature, ECG
438
and serial estimations of Pco, and standard bicarbonate. Hepatectomy was performed in the same manner as in the donor. On a number of occasions it was necessary to ligate the gastroduodenal artery but no damage to the duodenum was observed. Portosystemic shunt was performed by cannulation from the splenic to the jugular vein following splenectomy. Heparinization was performed with 0-5 mg of heparin per kg. The donor liver was implanted into the recipient and the anastomoses done in the following order: suprahepatic vena cava, portal vein, hepatic artery, infrahepatic vena cava and common bile duct. The suprahepatic inferior vena cava anastomosis was done as a single layer continuous suture utilizing 3/0 silk. End-to-end anastomoses between the donor and recipient portal vein, hepatic artery, subhepatic inferior vena cava and common bile duct were performed with the Vogelfanger NRC vascular stapling instruments (Vogelfanger et al., 1962, 1967), Mark IV (handling vessels 2-5 mm in diameter) and Mark XI1 (for vessels 6-12 mm in diameter). The key components of the vascular staples are the stapling bushing with the U-shaped tantalum staples and a corresponding anvil bushing with appropriately shaped moulding surfaces to bend the staples (Fig. 1). The vessel diameters were first measured. Vessel size ranged from 10 to 12 mm for the portal vein and subhepatic inferior vena cava, and from 2 to 3 mm for the hepatic artery. The diameter of the common bile duct was approximately 5-6 mm. Cuffs of donor and recipient vessels were then everted over the driving and anvil bushings respectively and held in position by plastic rings (Figs. 2, 3). In the larger vessels this was done by hand, and in the hepatic artery was readily achieved by an everting instrument. The two handles were locked together and the staple-driving mechanism operated to drive the staples through the vessel wall, towards the anvil bushing, moulding the driven staples in the shape of a letter B, thus forming an interrupted mattress suture. Removal of the instrument left a stapled vascular anastomosis. When the portal anastomosis was completed the vascular clamp was removed and the liver perfused with 300-400ml of portal venous blood which was allowed to egress into the abdominal cavity through the infrahepatic vena cava. In the preceding few
* Department of Surgery, University of Ottawa, and Ottawa Civic Hospital, Ottawa, Ontario, Canada. Requests for reprints to I. 5. Vogelfanger, Chief, Dlvision of Surgical Research, Ottawa Civic Hospital, 1053 Carling Avenue, Ottawa, Ontario, Canada KIY 4E9.
Orthotopic liver transplantation
Fig. 1. Instrument disassembled. Fig. 3. Both cuffs everted with nylon rings left by the evertor for fixation of the cuffs. Handles ready for assembly.
Fig. 2. Evertor being applied to produce a cuff over the bushing of the closed instrument.
minutes the animal had been transfused with a unit of blood to allow for this IOSS. The subhepatic inferior vena cava was then clamped and the vascular clamps on the suprahepatic inferior vena cava were removed t o restore portal to systemic circulation. The remaining anastomoses including the common duct were then completed rapidly, utilizing the same technique (Fig. 4). The time taken to complete the three critical anastomoses-suprahepatic vena cava, portal vein and hepatic artery-was approximately 15-20 minutes using this technique. Prior to closure of the abdomen and neck, vagotomy and pyloromyotomy were done (Calne et al., 1968). Discussion The complexities of liver transplantation relate to technical problems, the susceptibility of the liver to ischaemia and the tendency of the animal to develop serious metabolic problems during the anhepatic period. For this reason the ischaemic interval for the graft and the anhepatic period in the recipient should be as short as possible. A functioning portosystemic circulation is achieved quickly by first completing the suprahepatic vena cava anastomosis and then the portal vein, and immediately allowing a flow through the liver. The use of the Vogelfanger N R C vascular stapling instrument allows the rapid completion of these anastomoses, and in our hands shortens the
Fig. 4. Completed anastomosis of the portal vein (left), hepatic artery (right) and duct (above the hepatic artery).
anhepatic time t o under 15 minutes. The hepatic artery and infrahepatic vena cava anastomoses may then be equally rapidly completed, allowing the total time for the vascular anastomoses to be under 45 minutes. The instrument gives a very precise intima t o intima leak-proof anastomosis with a high degree of long term patency (Vogelfanger et al., 1962, 1967). A small vessel anastomosis with this technique also minimizes the trauma to the liver consequent upon dissection of the hepatic artery down to the coeliac artery and aorta which is necessary when a larger vascular reconstruction is done. A series of 31 liver transplants was done utilizing this method, with an operative mortality of 7 and with 12 animals surviving for 6-1 60 days. References CALNE R . Y., YOFFA D. E., WHITE H . J. O. and MAGINN R . R . (1968) A technique of orthotopic liver
transplantation in the pig. Br. J. Surg. 55,203-206. CHALSTREY L. J., PARBHOO S. P . , TAPPIN A., BAKER G. J., GRACEY L. R . H . , MULLEN P. A. and LESTER R. (1971)
Technique of orthotopic liver transplantation in the pig. BY.J. Surg. 58, 585-588.
439
P. T. Barron et al. CORDIER G., GARNIER H., CLOT J. P., CAMPLEZ R., GORIN J. P., CLOT P., RASSINIER J. P., NIZZA A. and LEVY R. (1966) La greffe de foie orthotopique
chez le porc. Premiers rbsultats. MPm. Acad. Chir. 92, 799. GARNIER H., CLOT J. P., BERTRAND M., CAMPLEZ P., KUNLIN A., GORIN J. P., LEGOAZIOU F., LEVY R. and CORDIER G . (1965) Greffe de foie chez le porc:
approche chirurgicale. C.R. Acad. Sci. ( D ) (Paris) 260, 5621-5623.
c. J., MOORE A. n., HOMATAS J. and EISEMAN B. (1967) Homotransplantation of the liver in pigs. S. Afr. J. Surg. 5 , 109-1 14.
MIENY
440
TERBLANCHE J., PEACOCK J. H., BOWES J., DAVIES R. P., TIERRIS E. J., PALMER D. B. and HUNT A. C. (1967)
The technique of orthotopic liver transplantation in the pig. Br. J. Surg. 54, 231. VOGELFANGER I. J., BEATTIE W. G. BROWN F. N., DEVITT J. E., SCOBIE T. K. and SCOBIE D. H. (1962)
The problem of small vessel anastomosis. Surgery 52, 354-362.
and COLLINS w. E. Experimental orthotopic kidney transplantation. Can. J. Surg. 10, 223-227.
VOGELFANGER I. J., IRVINE A. H.
( 1967)
