Novel End-to-end Supra-And Infra-hepatic Caval Anstomosis for Orthotopic Liver Transplantation With a 21 Mm Circular Stapler.

Muhammad S Ikram, MD, John Ham, MD, Shawn Tsuda, MD. University of Nevada Las Vegas, University Medical Center,Las Vegas, Nevada

Background: The potential advantages of using veno-veno bypass during recipient hepatectomy in orthotopic liver transplantation (OLT) are to reduced the amount of hemorrhage, improve cardiac stability, preserved renal perfusion, and avoid bowel edema during the bicaval anastomosis. Most centers use veno-veno bypass on a selective basis for patients who are intolerant of suprahepatic cross-clamping. In those patients time is essential and bicaval anastomosis needs to be performed efficiently. The average time for liver perfusion after supra, infra, and portal anastomosis is 35-45 min. The operative course of bicaval anastomosis may be shortened by using a 21-mm circular stapler in order to reduce bypass time and improve warm ischemia time during the transplantation.
Objective: The objective of this study is to demonstrate a supra- and infra-hepatic caval anastomosis for OLT using a 21 mm circular stapler device in an animal model.
Methods: This procedure was performed in a live pig model. A midline incision was made, fixed retractors placed, and the duodenum was mobilized medially. The infra-hepatic cava was isolated and the hepatic artery and portal vein were divided. The supra-hepatic cava was isolated at the diaphragm by taking down the falciform ligament. Two clamps 1cm apart were applied to the supra- and infra-hepatic cava and divided with a linear stapler. A 21 mm circular stapler (Ethicon, Cincinatti) was then introduced via a venotomy in the suprahepatic caval stump to the infra-hepatic staple line. The stapler anvil was placed in the proximal portion of the divided infra hepatic cava and secured with a purse sting suture and the anastomosis created. The supra-hepatic venotomy was then. closed with a linear stapler. The circular stapler was then introduced through a venotomy in the infrahepatic cava until it reached the supra hepatic staple line. The anvil was placed in the distal portion of the divided supra-hepatic cava and mated with the stapler to create the anastomosis. Then venotomy site was closed with a running prolene suture.
Results: Bi-Caval anastomoses with a 21mm circular stapler was performed in 2 live pigs. Total procedure time was under 30 min. No staple-line bleeding was identified post anastomosis.
Conclusion: Bicaval anastomosis can be performed in a veno-veno bypass patient with a circular stapling device with a 21 mm outer diameter. This is the first demonstration of an end-to-end circular anastomsis for Bi-Caval anatomosis. This technique may help to improve perfusion time by decreasing warm ischemia during an hepatic phase of the procedure.

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