Liver transplant surgery

After you have been put to sleep under anaesthetic, the surgery will begin.

Your damaged liver will be removed and the donor liver will be transplanted into its place.

The incision (cut) used will be in the upper half of your abdomen either shaped like a hockey stick or like an upside-down Y, depending on surgeon choice. 

The removal of your own liver can be done in two ways. This depends on what's best option for you and the personal choice of the surgeon.

• Either by removing the main vein going up to the heart and replacing it with the main vein from the donated liver. The vein is called the inferior vena cava, and this method is known as caval replacement or the classical procedure.

Or,

• By leaving your main vein place and attaching the new liver to it. This is known as a side-to-side cava-cavostomy or the ’piggy-back’ method.

During the removal of your liver the blood vessels into and out of the liver are cut and the bile duct (tube) draining bile from the liver into the small bowel is also cut.

The donated liver is connected in the following way:

• The blood vessels going into and out of the new liver will be connected to your own blood vessels. 

• The gallbladder of the transplanted liver will be removed and the bile duct (the tube carrying bile into the bowel) will be connected to your own bile duct. Usually, this is a direct join between the donor bile duct and your bile duct.

An adult patient may be able to receive a ‘split liver’. This is made up of the right half of the liver and half of the left side (called an ‘extended right lobe’ liver transplant). The smaller left part of the liver is then used for a child patient. This is a more complex operation and the transplant centre will discuss this option with you during the assessment period and at the time it is offered.  

For most operations one or two drains are inserted into your abdomen at the end of the operation to drain any fluid or blood that collects around the transplanted liver following the operation. Your skin wound is then closed.

When you get to theatre, the anaesthetist will give you a general anaesthetic and help prepare you for the transplant operation.

When you have a general anaesthetic, you become unconscious, which means you will go to sleep and not feel the operation. The anaesthetists will talk to you before the operation about the risks of the anaesthetic.

You will have plastic tubes (lines or catheters) inserted into your neck, arms, bladder, stomach and windpipe. Before the operation, the surgical and anaesthetic teams will explain where the tubes will be placed. 

What are the tubes for?

A tube is passed down your mouth into your windpipe and attached to a ventilator to assist your breathing.

Another tube is passed down your nose into your stomach – this is to prevent your stomach becoming bloated during the operation. It remains in place until you are ready to eat and drink.

Small tubes (lines or drips) are inserted into your arms to enable fluid and medications to be given to you during and after the surgery.

Additional drips will be placed in the veins of your neck. These are used to give you fluid and drugs, and to monitor your condition. They remain in place until your condition is stable and you are able to drink fluid on your own.

A catheter (tube) is inserted into your bladder, which drains urine until you are awake and able to go to the toilet.

Risks

Inserting tubes into you can lead to bleeding, infection, or damage to other structures such as blood vessels or nerves. These complications are rare.

Removing your diseased liver can be difficult and may result in a lot of blood loss. It is very common for patients to receive a blood transfusion during the operation. Your own blood that is lost can often be collected and re-circulated back into your bloodstream.

Frequent blood tests will be taken throughout the surgery to help determine how well your blood is clotting. Sometimes it is necessary to give you additional blood products (e.g. plasma or platelets) to help with clotting.

Some units will use a bypass machine to circulate blood back to the heart while the donated liver is being stitched in.

This is called veno-venous bypass. 

Once the donated liver has been transplanted, the bypass machine can be removed.

If a bypass machine is not used, your surgeon may need to temporarily attach the vein that carries blood to your liver to a different vein within your body. This allows blood to flow back to your heart while the diseased liver is being removed. The procedure then proceeds in the same way.

Many surgeons will take a small piece of tissue (biopsy) of the donated liver. This can happen just after the liver is removed from the donor, when the liver arrives in your transplant centre, or after the liver has been transplanted.

With your consent, a liver biopsy might be taken for research. It would be used to find better treatments for liver disease or to help the transplant team understand the quality of the donated liver. This may help if there are concerns in the future about your liver function.

Risks

Taking a liver biopsy is usually straightforward, but can (rarely) lead to bleeding from the liver.

Sometimes a clot (thrombosis) can form in the vein carrying blood to your liver (portal vein). This clot may need to be removed or a new vein may need to be created using veins from the donor.

Risks

This procedure increases the risk of complications of the surgery and can double the mortality risk.

Your hepatic artery supplies oxygenated blood to your liver. The structure of this artery can be different in over 40 in 100 people.

Approximately 25 in 100 of these people will require some form of reconstruction of the artery before transplantation. This means the artery will need to be adapted for the transplant. 

Risks

Reconstruction of hepatic arteries increases the risk of blood clot blockages within these arteries (hepatic artery thrombosis).

On occasion the hepatic artery is of poor quality or diseased. In these cases, a new artery has to be made using an artery from the donor. This will be attached to the main artery of your body (aorta) or a major branch of the aorta (e.g. the common iliac artery). This is called an aortic conduit or a jump graft and is needed in about 2 in 100 transplants. It is more common in re-transplants.

Your bile duct carries bile from your liver to your bowel. Usually during a liver transplant, your bile duct is joined to the bile duct of the donated liver.

Sometimes, it is not possible to use your own bile duct because it might be diseased. In this situation, a loop of small bowel is joined to the donor bile duct to allow bile to drain into your small bowel (roux-en-Y hepaticojejunostomy). This is commonly performed for patients with Primary sclerosing cholangitis (PSC), re-transplants, or if there is a significant different in size between your bile duct and the donated bile ducts.

Learn more about bile complications