LIVER TRANSPLANTATION 17:88-92, 2011

IMAGES IN LIVER TRANSPLANTATION

Optimizing Outow in Piggyback Liver

Transplantation Without Caval Occlusion:
The Three-Vein Technique
Claude Tayar,1 Michael D. Kluger,1,2 Alexis Laurent,1 and Daniel Cherqui1,2
Department of Digestive and Hepatobiliary Surgery and Liver Transplantation, Hopital Henri Mondor,
Creteil, France; and 2The Section of Hepatobiliary Surgery and Liver Transplantation, New York Presbyterian
Hospital-Weill Cornell Medical Center, New York, NY, USA

Received September 20, 2010; accepted September 28, 2010.

Several methods of graft-to-inferior vena cava (IVC)
implantation during orthotopic liver transplantation
with preservation of the caval ow have been
described. Early studies used a side-to-side or end-toside anastomosis of the graft cava to the recipient
cava after the closure of both ends or the lower end of
the graft IVC, respectively.1,2 Others anastomosed the
graft IVC to the recipients common trunk of the left
and middle hepatic veins after they divided the intervening septum with or without an additional short
cavotomy (ie, the 2-vein technique).3,4 Anastomosis of
the graft IVC to the joined orice of the 3 main hepatic
veins with partial caval occlusion was rst mentioned
in 1997.5
Outow obstruction has been a concern with the
piggyback technique. Two European multicenter studies reported intraoperative graft congestion in 1% to
5% and acute or chronic Budd-Chiari syndrome in
0% to 1.6%.6,7 These 2 studies showed that the width
of the caval anastomosis was critical to the prevention
of such complications. A recent US single-center
report found that ascites and anastomotic strictures
were greater with a 2-vein piggyback anastomosis versus a 3-vein piggyback anastomosis.8
It is clear that optimal outow through the creation
of a wide and nonpositional anastomosis is critical to
the success of the piggyback anastomosis. The 3-vein
technique appears to be the most physiological way of
achieving this goal. Although it has often been mentioned, the approach to creating a large 3-vein stoma

without complete occlusion of the IVC has not been

clearly described in the existing literature. The purpose of this report is to present a safe, reliable, and
reproducible way of achieving this goal without occlusion of the cava.

THREE-VEIN TECHNIQUE
Hepatectomy with the early creation of a temporary
end-to-side portocaval shunt and preservation of the
recipients retrohepatic vena cava is performed.2 In
brief, the operation starts with dissection of the porta
hepatis. Hepatic arteries and the common bile duct
are divided close to the hilum. The portal trunk is dissected from its bifurcation down to the pancreas, and
an end-to-side portocaval shunt is created before any
liver mobilization.
Attention is then turned to complete mobilization of
the liver. The left triangular and coronary ligaments
and the pars accida (as well as a replaced left hepatic artery if it is present) are divided. The left part of
the caudate lobe is dissected free from the IVC by the
division of the left side of the hepatocaval ligament
and then by the ligation of the small hepatic veins
from segment 1. In this way, the anterior surface of
the retrohepatic IVC is dissected from left to right,
and two-thirds of its surface is exposed. The common
trunk of the middle and left hepatic veins is encircled
with umbilical tape.

Abbreviation: IVC, inferior vena cava.

Address reprint requests to Daniel Cherqui, M.D., Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, New York
Presbyterian HospitalWeill Cornell Medical Center, 525 East 68th Street, Room 734, New York, NY 10065. Telephone: 212-746-5386;
E-mail: dac7027@med.cornell.edu
DOI 10.1002/lt.22201
View this article online at wileyonlinelibrary.com
LIVER TRANSPLANTATION.DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases

C 2011 American Association for the Study of Liver Diseases.

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TAYER ETAL. 89

Figure 1. Dissection of the hepatic veins. (Left) The photograph demonstrates the thorough dissection of the right hepatic vein and
the common trunk of the middle and left hepatic veins (encircled by umbilical tape) as well as dissection of the connective tissue off
the anterior surface of the vena cava to its insertion through the diaphragm. (Right) The right hepatic vein is skeletonized to its
intraparenchymal egress from the liver to maximize the length. The posterior surface of the vena cava is not dissected in order to limit
its occlusion and resultant hemodynamic deficiencies.

The right liver is then mobilized by the division of

the triangular and coronary ligaments. The liver is
lifted off the vena cava, and any additional bridging
veins are clipped and transected; an inferior right hepatic vein is oversewn or stapled if it is present. The
right side of the hepatocaval ligament is transected,
and the extrahepatic portion of the right hepatic vein
is encircled with umbilical tape. Care is taken to not
detach the posterior surface of the IVC from the diaphragm (Fig. 1). The liver is now completely mobilized
with the exception of the 3 main hepatic veins.
The hepatic veins are now individually dissected at
their egress from the liver to clearly expose them for a
short distance intraparenchymally (Fig. 1). A small,
curved vascular clamp is placed on the right hepatic
vein at its caval insertion, and the vein is transected
intraparenchymally with the aim of length maximization. The liver is retracted caudally, and a medium
Satinsky clamp is applied to the IVC at the insertion
of the common trunk. The individual middle and left
hepatic veins are next severed from the liver intraparenchymally with the aim of length maximization, and
the hepatectomy is thereby completed. The vascular
clamp is moved proximally on the right hepatic vein,
and 2 new curved vascular clamps are placed on the
cut ends of the middle and left hepatic veins to create
working space at their insertion into the cava (Figs. 2
and 3, top). Each vein is circumferentially cleared of
connective tissue to its IVC insertion in order to provide length and exibility. The anterior surface of the
cava between the hepatic veins and the diaphragmatic
hiatus is also dissected free of connective tissue for
the same purpose.

The 3 vascular clamps are held in line and retracted

ventrally, and a single large Satinsky clamp is placed
transversally at the junction of the hepatic veins and
the cava (Fig. 3). The magnitude of the clamping is a
balance between exposure for the creation of an
appropriate anastomosis and preservation of the IVC
ow for the maintenance of the cardiac preload
throughout the implantation. If hemodynamic compromise is observed with anesthesia, this typically
can be remedied by minor repositioning of the Satinsky clamp. Leaving the IVC attached to the diaphragm
posteriorly splints the cava and minimizes the amount
of occlusion. This large clamp is not removed until
completion of the IVC and portal anastomoses.
The small vascular clamps are removed. A dissector
clamp is placed between the ostia of the middle and
left veins, and the bridge of tissue is transected to create a single neo-ostium (Fig. 3, bottom). Next, the dissector is inserted into the right hepatic vein and out
through the neo-ostium, and the intervening segment
of the cava wall is transected. Thus, a single neoostium is created from the 3 native hepatic vein ostia.
This neo-ostium spans at least the entire anterior aspect of the native vena cava, and the created cuff
extends 1 to 2 cm beyond the clamp (Figs. 2 and 4,
left). Uneven edges are not trimmed.
The graft cava is shortened to approximately 1 cm
distally to the hepatic veins; the infrahepatic cava is
closed with a thoracoabdominal stapler. A cannula is
inserted into the portal vein, and the graft is ushed
with a room-temperature 4% albumin solution during
the anastomosis procedure. We anastomose the back
cava wall with a running 4-0 permanent monolament

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LIVER TRANSPLANTATION, January 2011

Figure 2. Schematic view of the neo-ostium creation. (Left) After the 3 hepatic veins and anterior wall of the vena cava are
individually cleared of connective tissue, the 3 small vascular clamps are underclamped by a large Satinsky clamp along with a
hemodynamically insignificant diameter of the cava. Notably, the intraparenchymal dissection of the common trunk exposes the
middle and left hepatic veins proximally to their confluence. (Middle) The common channel distal to the ostia of the 3 hepatic veins is
visualized. (Right) After transection of the venous bridge between the left and middle hepatic veins and transection of the cava between
the common trunk and right hepatic vein, the common neo-ostium for the anastomosis is visualized.

Figure 3. In vivo preparation of the

neo-ostium. (Top left) The 3 vascular
clamps are held in line on the proximal
hepatic veins and are pulled ventrally
to maximize the length. (Top right) A
Satinsky clamp underclamps the
vascular clamps and a portion of the
cava. (Bottom left) A dissector clamp is
passed between the left and middle
hepatic vein ostia before transection of
the interceding venous bridge. (Bottom
right) A dissector clamp is next passed
between the common left/middle
hepatic vein neo-ostium and the right
hepatic vein ostium to help with the
even transection of the intervening
cava.

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TAYER ETAL. 91

Figure 4. Creation of the graft anastomosis. (Left) In vivo image of the final neo-ostium for graft implantation. The ostium spans the
entire anterior face of the cava and extends 1 to 2 cm perpendicularly from the anterior surface. The ostium walls are not trimmed in
order to preserve length for the anastomosis. (Right) The back wall of the anastomosis is completed. The excellent diameter match
between the recipient neo-ostium and graft cava is demonstrated. The Satinsky clamp placed after the dissection of the hepatic veins
is never again repositioned until its removal at the completion of the cava and portal anastomoses.

suture (Fig. 4, right) and then the front wall with

another 4-0 permanent monolament running suture.
When we are creating the anastomosis, we tend to fold
a rim of the neo-ostium and a rim of the donor cava to
fortify the endothelial juxtaposition. After the completion of the IVC anastomosis, the portocaval shunt is
taken down, and the transplant proceeds in a standard
manner.

DISCUSSION
Large studies have shown that optimal outow is
essential to a successful piggyback procedure.6-8
Although piggyback transplantation has been well
studied, few technical details about achieving a 3-vein
anastomosis with preservation of the caval ow can
be found in the literature. We have found that this
requires subtle technical maneuvers during native
hepatectomy and special attention during the preparation of the hepatic veins and the application of the
clamps.
Several factors result in complications related to the
piggyback technique.6,7 The success of the anastomosis that we present here is based on technical modications that overcome these factors. First, the common ostium created from the bridging of the 3 hepatic
veins provides a wide channel that matches any graft
vena cava and is unlikely to obstruct or develop a

high-pressure sink leading to outow block symptoms. Second, the anastomosis sits on the anterior
and right aspect of the cava, so large livers do not
compress a short channel, and small livers can settle
further into the hepatic fossa without twisting of the
anastomosis. In addition, we shorten the graft suprahepatic IVC to avoid redundancy and kinking of the
anastomosis. This anastomosis allows optimal venous
drainage of the graft and can be created with partial
clamping of the native cava.
In conclusion, we present a safe, reproducible, and
efcient technique for a 3-vein anastomosis without
caval occlusion that optimizes outow in IVC-preserving liver transplantation.

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LIVER TRANSPLANTATION, January 2011

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