NewYork-Presbyterian. The University Hospital of Columbia and Cornell.

Liver Transplant Surgery

The liver is the largest solid organ in the body and is located in the upper right quadrant of the abdomen. An average adult liver weighs between two and three pounds.

Because of its many functions, the liver is considered one of the most important organs in the body. It controls the storage and concentration of nutrients such as proteins, fats, carbohydrates, vitamins, and minerals. It regulates the disposal of waste products in the bile. Finally, it processes and filters poisons, toxins, medications, and bacteria.

Injury to the liver can be caused by many factors. The liver is unique in its ability to regenerate in response to injury. However, when injury occurs over time progressive scarring develops and the liver becomes unable to function properly. This is known as cirrhosis of the liver. As cirrhosis worsens, almost all liver function is lost and the organ becomes harder and smaller. In the absence of a healthy liver, fluid accumulates in the abdomen and legs. Bile salts can build up in the skin causing itching and jaundice. Bleeding from large veins in the esophagus and GI tract may occur. Toxins can accumulate in the blood resulting in mental slowing and confusion.

Every patient's liver disease develops differently. This means that there is no one pattern of symptoms to anticipate as one's health deteriorates. As the disease progresses, the liver is unable to perform its many functions adequately. Patients may develop any of the following symptoms:

• Fatigue
• Forgetfulness or mental confusion
• Lost of consciousness (coma)
• Sleep reversal (inability to sleep at night but wanting to sleep all day)
• Ascites (Fluid in the abdomen)
• Spontaneous bacterial peritonitis (infection of the ascites)
• Edema (swelling of the legs)
• Bleeding gums
• Vomiting of blood
• Bleeding from rectum or passing black stools (from internal bleeding)
• Itching of the skin
• Enlarged breasts in male patients
• Jaundice or "liver spots" (spider angiomata, and petechiae)

It is important to discuss any and all symptoms with the transplant team. Although there are no medicines to cure cirrhosis, there are many drugs that can be used to manage these various manifestations of liver disease. They can make waiting for a transplant more manageable.

Biliary atresia in infants is a congenital absence or closure of the major bile ducts, the ducts that drain bile from the liver. It causes a progressive inflammatory process, which may lead to cirrhosis of the liver. There are no medications that can be given to unblock the bile ducts or to encourage new bile ducts to grow where there were none before. However, there are two different treatments. One is an operation that connects the bile drainage from the liver directly to the intestinal tract. If bile flow is not significant enough following this procedure, the only option is a liver transplant. However, most children who successfully undergo the first procedure eventually need to have a transplant.

Treatment

When all other treatment options for a damaged liver are exhausted, a transplantation may be recommended. This surgical procedure replaces your damaged liver with a healthy one. Ideally, after transplant, you are free from disease and able to lead a fairly normal life with your new liver. There are three options for liver transplantation.

Cadaveric-Donor Transplantation

When an individual is declared brain dead and his or her family chooses to donate the organs - called cadaveric organs - for transplantation, the liver is made available for transplantation. An adult cadaveric liver transplant was first performed in 1964 and remains the most common liver transplant procedure performed.

During this liver transplant surgery, the recipient is administered general anesthesia. The surgical team carefully inspects the cadaveric liver, which has been on ice since it was harvested from the donor, and marks those anatomical structures that will be connected during the transplant surgery. Next, the liver transplant surgeon will make the standard incision for a liver transplant, which is called a "chevron incision." It starts at the right side of the midsection?just under the ribs - and extends to the left edge of the abdomen. There is also a short incision starting under the sternum (breastbone), which extends to meet the horizontal incision.

Special retractors help hold open the abdominal cavity. The surgeon uses clamps to block blood flow from the major veins and arteries supplying the liver and then detaches the diseased liver from the arteries and veins. After the liver is removed, it is replaced by the donor liver. Then the veins, hepatic artery and bile duct are connected with sutures. Blood flow to the liver is resumed and, once the surgical team determines that the new liver is functioning well, the clamps expanding the chest cavity are removed and the surgeon closes the incision using surgical staples. The staples stay in place for about 2-3 weeks and are covered by a dressing, which will remain in place for a few days following surgery.

The surgery itself lasts approximately 5-6 hours. Following surgery, the patient goes to the surgical intensive care unit.

Living-Donor Transplantation

A healthy family member - usually a parent, sibling or adult child - or someone emotionally close, such as a spouse, may volunteer to donate a portion of their healthy liver to the patient. The donor is carefully evaluated by the transplant team to ensure the donation would harm neither donor nor the recipient. The Center is a recognized leader in this important procedure that can provide an organ immediately to those in need of a liver transplantation.

Split-Liver Transplantation

Split-liver transplantation is a technique in which a whole cadaveric donor liver is "split" into two approximately equal halves, each of which is transplanted into a different adult, or into an adult and a child. Therefore, one adult cadaver can donate to two recipients. This technique is possible because of the liver's unique ability to regenerate after transplantation. Following transplantation, each liver half will grow and remodel to form a complete liver. Split-liver transplantation has been performed for more than ten years with excellent results. Presently, split-liver transplantation is reserved for optimum cadaveric livers because of their regenerative potential.