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Re-Arterialized Rat Partial Liver Transplantation with an in vivo Vessel-Oriented 70% Hepatectomy
Summary April 8th, 2018
Here, a protocol involving re-arterialized rat partial liver transplantation is presented. Specifically, 70% liver was resected in vivo by using an updated technique of vessel-oriented hepatectomy. The hepatic artery was reconstructed in an end-to-side manner. The cuff technique was modified to shorten the anastomosis time of the infrahepatic vena cava.
Transcript
A protocol involving re-arterialized rat partial liver transplantation is presented in this article. Specifically, 70%of liver was resected in vivo by using the updated technique of vessel-oriented hepatectomy. The hepatic artery was reconstructed in an end-to-side manner.
The cuff technique was modified to shorten the anastomosis time of the inferior patic vena cava. Isoflurane mixed with zero point five liter per minute oxygen was used to induce and maintain inhalation anesthesia. Cut a small transverse incision on the upper abdomen.
Then, extend the transverse incision close to the costal margin on the upper abdomen. Reverse and affix upper abdomen wall to the cranial side. Next, reverse the xiphoid process to cranial side, too.
Cut off the falciform ligament, coronary ligament, and a triangular ligament, in sequence. Free the left diaphragmatic vein from the diaphragm using microforceps. Then, double ligate it using six-zero silk sutures.
Free the hepatoesophageal ligament and artery. Then, double-ligate it and divide it. Expose the first hepatic hilum of the liver.
First, carefully dissect the posterior wall of the common trunk of the portal vein. Then, double ligate it and divide it with the corresponding bile duct and the hepatic artery together. Second, gently dissect, double-ligate and divide the portal vein of the right medium lobe.
Third, double ligate and divide the hepatic artery and the bile duct of the right medium lobe using six-zero silk sutures. Ligate the hepatic of the left lateral lobe using circumstantial three-zero silk suture. Remove the liver mass using micro scissors above the ligation.
Clamp the left median hepatic vein by mosquito hemostatic forceps placed along the median fissure. Remove all of the liver parenchyma above the forceps using micro scissors. Place the piercing suture under the forceps surrounding the left median hepatic vein.
Then, tie a square knot to ligate it. Besides, place another two piercing sutures to close the rest of the incision. After this, place a mosquito hemostatic forceps at a distance of point two-five centimeters to occlude the right median hepatic vein.
Remove all liver parenchyma above the forceps. Place the first piercing suture penetrating the liver parenchyma under the forceps to surround the middle median hepatic vein. Then, tie a square knot to ligate it.
Place a second piercing suture under the forceps to surround the middle median hepatic vein. Then, ligate it using the same method. Place another two piercing sutures under the mosquito hemostatic forceps to close the rest of the incision of the medium lobe by using these piercing sutures.
The remnant stump of the medium lobe was able to spread over the vena cava. Cut open the retroperitoneum to expose the inferior hepatic vena cava. Dissect and ligate the right adrenal vein, which drains into the inferior hepatic vena cava from the rear.
Free the right renal artery and the right renal vein. Perform a right nephrectomy after ligating the right renal vein and the right renal artery. Mobilize the common bile duct from the first hepatic hilum using micro forceps.
Then, ligate the common bile duct at the crest point of the polaric vein and the common bile duct. Cut a transverse incision on the interior wall of the common bile duct. Insert a 22-gauge biliary stent immediately into lumen of the common bile duct.
Secure the biliary stent with circumferential six-zero silk suture. Transect the common bile duct between the two six-zero silk sutures. Free the pyloric vein using micro forceps then double ligate and divide it.
Next, double ligate and divide the splenic vein the same way. Carefully free the common hepatic artery and it's two bifurcations. Double ligate the gastroduodenal artery using six-zero silk sutures at the bifurcation of the common hepatic artery to gastroduodenal artery.
Inject 50 IU of heparin in one milliliter of saline via the penile vein. Cross-clamp the inferior hepatic vena cava portal vein and the common hepatic artery using three curved micro Perform a small incision on the interior wall of the portal vein to insert a 22-gauge catheter. Profuse the partial liver graft with saline at four degrees celsius via the catheter under pressure of 20 centimeters water.
Rapidly cut open the thoracic cavity and intrathoracic vena cava using surgical scissors to drain out the blood and profuse it Use micro scissors to transect the left diaphragmatic vein between the two ligations which were placed previously. Next, transect the suprahepatic vena cava close to the diaphragm to keep the vascular lanes as long as possible. Cut off the portal vein at the level of the splenic vein and transect the common hepatic artery close to the select trunk.
Cut off the adrenal vessels on the distill side of the ligation. Then, divide the infrahepatic vena cava at the level of the left renal vein. Pull the portal vein through the lumen of the cuff made with a 12-gauge intravenous catheter.
Temporarily fix puff handle and portal vein together. Avert the portal vessel wall to cover the outside surface of the cuff. Secure the vessel wall and the cuff in position with circumferential six-zero silk suture.
Install the infrahepatic vena cava cuff using the same method. Penetrate the vessel wall of the suprahepatic vena cava from outside to inside using two seven-zero polypropylene sutures along the three o'clock and nine o'clock directions, respectively. Repeat the procedures in 6.1, 6.2, and 6.7 in the recipient, except for the right nephrectomy.
Mobilize, double ligate, and divide the common bile duct at the first bifurcation in the hepatic hilum. Transect and prepare the hepatic artery using micro scissors, subsequent to double ligation using six-zero silk suture. Retract the recipient liver to the left side using two cotton sticks.
Cut off the ligament in the rear of the liver from the suprahepatic vena cava to the right adrenal vein. Introduce a rubber band through the back space of the suprahepatic vena cava. Cross-clamp the infrahepatic vena cava above the renal vein using a vessel clamp and the portal vein above the pyloric vein.
the suprahepatic vena cava and diaphragm and clamp the parts of the diaphragm together with the intrathoracic vena cava. Cut the vessel wall of the suprahepatic vena cava carefully along the upper edge of the liver parenchyma to keep the vascular wall as long as possible. Transect the portal vein at the first bifurcation in the hepatic hilum using micro scissors.
Transect the inferior vena cava and parenchyma of the right inferior lobe rather than in the vessel wall to leave a section of circumferential liver parenchyma around the vena cava. Keep the cutting edge in the right inferior lobe at a distance of four millimeters to the inferior hepatic vena cava. Place the partial liver graft in the abdominal cavity, isotopically.
Pierce the vessel wall of the suprahepatic vena cava from inside to outside along three o'clock and nine o'clock directions Using two prestat stay sutures. Pull the stay sutures to the right and left after tying into a knot with their own ends. Pierce the suprahepatic vena cava vessel wall from outside to inside, close to the knot in the three o'clock direction.
Anastomose the posterior wall of the suprahepatic vena cava by running suture inside the vascular lumen from the three o'clock direction to the nine o'clock direction. At the corner of the nine o'clock direction, pierce the vessel wall from inside to outside, close to the knot, to introduce the needle out of the vascular lumen. Use this suture to anastomose interior wall using running suture outside the vascular lumen from the nine o'clock direction to the three direction.
Finally, tie the suture with its own end three times. Place two seven-zero polypropylene stay sutures at the end of the portal vein of the recipient, following the description in seven point two. Pull two stay sutures in the opposite direction to extend the vessel wall.
Inject approximately one milliliter of saline into the vascular lumen of the portal vein to force out air bubbles. Quickly insert the portal vein cuff into the vascular lumen of the portal vein in the recipient when it is opened using microforceps. Secure the cuff anastomosis using circumferential six-zero silk suture.
Then, release the clamps on the suprahepatic vena cava and the portal vein, in sequence. Inject one milliliter of saline into the vascular lumen to force out air bubbles. Insert the cuff into cylindrical vascular lumen of the inferior hepatic vena cava.
Quickly secure the cuff anastomosis using a six-zero silk suture. Release the two vessel clamps in the inferior hepatic vena cava to restart the profusion. Then, trim off the surrounding liver parenchyma carefully, above the circumferential silk suture using micro scissors.
Penetrate the vessel wall of the common hepatic artery in the liver graft from outside to inside using two eleven-zero polypropylene sutures in the three o'clock and nine o'clock directions, respectively. Occlude the blood flow of the common hepatic artery and the gastroduodenal artery in the recipient using two curved micro Transect the proper hepatic artery of the recipient at its root to expose the vascular lumen. Enlarge the vascular lumen of the proper hepatic artery in the recipient by cutting part of the vessel wall, longitudinally, to accommodate the diameter of the common hepatic artery in the liver graft.
Flush the vascular lumen using saline. Anastomose the common hepatic artery of the liver graft to enlarge the proper hepatic artery in an end-to-side manner using the running suture technique. Perform a transverse incision on the anterior wall of the bile duct in the recipient.
Pull the biliary stent in the partial liver graft down to insert it into the lumen of the bile duct in the recipient. Divide the transverse incision. Secure the stent using six-zero circumferential silk suture.
Tie the two six-zero circumferential silk sutures in the bile duct to each other to reduce the tension of the anastomosis. After surgery, treat all recipients with 0.1 milligram per kilogram Buprenorphine and Cefuroxime 16 milligram per kilogram, subcutaneously. In total, 31 cases have seen generic arterialized rat partial liver transplantation were completed using this protocol.
All of the recipients survived until the end of the observation time. The body weight of the recipient began to recover after postoperative day four. The slope of the body weight was close to that of the Lewis rat after postoperative day six, which indirectly implied recovery of the recipient.
Histologically, a slight proliferation of the bile duct was observed in the recipients and the liver lobular architecture of the recipient was intact. No necrosis or obvious sign of pseudo dilation was observed. The serum level of alanine aminotransferase was in the normal range at postoperative day 30.
No cases of yellow urine caused by jaundice were observed in these recipients, which was indicated by checking the cage bedding daily, indicating the patency of the biliary stent. The normal serum level of bilirubin on postoperative day 30 further confirmed the success for reconstruction of the bile duct. The average duration of the anhepatic phase was 22.03 plus or minus 2.3 minutes.
The cuff anastomosis of the portal vein took 4.68 plus or minus 0.77 minutes, while the cuff anastomosis of the inferior hepatic vena cava only took 2.05 plus or minus 0.71 mminutes. Comparatively, the cuff anastomosis of the portal vein, the cuff anastomosis of the inferior hepatic vena cava saved the staff of placing stay sutures, and thereby, further shortens the anastomosis time. Two cases of bleeding in the remnant stump of the medium lobe during the 70%hepatectomy were observed, among 31 cases of vessel-oriented hepatectomy.
In the previous experiment, bleeding in the remnant stump of the medium lobe was observed in eight out of 18 cases of parenchyma, preserving vessel-oriented hepatectomy. This result indicated a lower rate of bleeding in the remnant liver stump of the medium lobe, after using vessel-oriented 70%hepatectomy. By using this protocol of rat partial liver transplantation, a low liver enzyme level and intact liver lobular architecture and a high survival rate were achieved after microsurgery.
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