Living donor transplants are planned in advance, patients and donors are admitted to the hospital a day prior to surgery. Both donors and recipients must not eat or drink anything after midnight before the operation. Deceased donor transplants are performed on emergency basis when a cadaveric liver is available. Patients are called to the hospital urgently; they undergo a rapid review and tests before surgery to ensure that they are healthy and ready for surgery. Patients should not eat or drink anything once they receive intimation for the transplant. After the patients are admitted, the transplant team has a discussion about the quality of organ and transplantation process and ask the patient to sign the consent form after complete understanding of the process. Patients should inform the transplant team about pre existing health problems, current medicines and known drug allergies, to prevent any accidental use and interaction with transplant medicines. If patients develop new unexpected problems such as fever, if review tests show significant change compared to previous reports or if any new concerns or active problems are discovered, they might need treatment first and the transplant might have to be postponed.
The timings of donor and recipient surgeries are synchronised to ensure minimal ischemia (storage damage) to the liver. In deceased donor transplant, patients’ surgery is started only after donor liver has been examined and found satisfactory. The operation does not start immediately after the patient is taken to the operation theatre as it takes about 2 hours to prepare for the operation. Both donors and recipients undergo the operation under general anaesthesia, where they are put to sleep, with no consciousness, pain, awareness or recollection of the operation. While under anaesthesia, they are put on a ventilator and various lines / catheters (arterial line, central line, endotracheal tube, urinary catheter, naso-gastric tube, etc.) are used to accurately monitor various parameters and allow rapid administration of blood products, IV fluids and drugs. During the surgery, various blood and other tests are continuously performed for monitoring.
The living donor operation involves removal of a portion of the liver and may be done using different types of incisions or even with laparoscopy (keyhole) or robotic surgery. The choice of incision depends on donor’s body habitus and findings during surgery. This decision is best made during surgery. The transplant surgeons always keep in mind the cosmetic results and safety while choosing an incision. The liver is split in two parts as planned pre operatively. One of these parts is removed along with the blood vessels and bile ducts going in and out of the lobe, leaving the other half in the donor with its blood vessels and bile ducts intact. The surgery lasts about 6-8 hours. In addition to the planned portion of the liver, the gall bladder is always removed because it is stuck to the under surface of the liver. A drain tube is kept in the abdomen to monitor any bleeding and the incision line is closed using very fine absorbable sutures or staples.
The first step is to remove the entire cirrhotic liver (including gall bladder) to make space for the new liver. The cirrhotic liver is shrunken, stiff, with multiple thin-walled blood vessels around it under high pressure and may be stuck to surrounding organs because of previous infection or surgery. This part of the operation is done slowly to minimise chances of bleeding. This is followed by transplantation of the new liver by joining (anastomoses) all blood vessels and allowing blood circulation through the liver. The liver starts working immediately. Bile ducts of the new liver may be joined with the patient’s own bile duct or directly with the intestine. A drain tube is kept in the abdomen to monitor for any bleeding and the incision line is closed using staples. The recipient surgery generally takes 8-12 hours and about 5-10 units of blood and blood products are used, however, in difficult cases, it may be much longer with significantly more blood product requirement. At the end of surgery, the donor is taken off the ventilator and shifted to the ICU for overnight observation; the recipient is generally shifted to the ICU on a ventilator. While the operation is going on, family members should stay in the waiting lounge. The transplant team will talk to them at the end of the surgery.