The patient will be placed prone and when all lines are placed the arms will both be placed on arm boards. A urinary catheter, TED stockings, a diathermy pad, and Bair huggers will be placed prior to scrubbing.

Clean towels will be laid across the patient’s face, along the sides and across the knees of the patient. The anterior aspect of the chest (to the sternal notch), the abdomen and the lower extremities down to the knees will be scrubbed with betadine for 10 minutes. In the event of a patient being allergic to iodine, hibiscrub will be used as an alternative. On completion of the scrub, two sterile towels will be used to pat the area dry. The area will then be painted with iodine in alcohol (alternative will be alcohol alone) and draping will proceed with side drapes, arm board drapes, top and bottom drapes and a large steridrape. Three suction devices (two to cell saver and one for discard ["junk sucker"]) and one diathermy pencil and one monopolar diathermy forceps will be placed conveniently around the field.

A bilateral subcostal incision will be made, incorporating where possible old incisional scars, and a midline extension to the xiphisternum will be used in most cases. The incision will be carried down through the muscle layers and the peritoneum entered and drained of any ascitic content using the "junk" sucker. Once the wound is fully opened, adhesions taken down and haemostasis secured, a general inspection and palpation of the abdomen is to be undertaken. This will be a convenient time to ensure that the NG or NJ tube is in a satisfactory position.

The liver will be mobilised by taking down the diaphragmatic attachments, the Gray liver retractor used to gain good exposure and the iron intern retractors placed to displace the viscera caudally. During the mobilisation of the liver, care will be taken to expose and divide the peritoneum lateral to the caudate lobe so that the retrocaval area is accessible from the left in case urgent clamping of the cava becomes necessary. Attention will then be turned to the hepaticoduodenal ligament which will be dissected from right to left by taking the cystic duct, the CBD, right and left hepatic arteries, and then completed by skeletonising the portal vein. If convenient, the right and left branches of the portal vein could be tagged with 1 silk ligatures at this time. Attention will then be turned to the left aspect of the retrohepatic cava.

The peritoneum over the infrahepatic cava is to be divided and the dissection carried cephalad along and on top of the left side of the retrohepatic cava, serially ligating and dividing venous tributaries from the caudate lobe. This dissection is to be carried up to either the left phrenic vein or the left hepatic vein, whichever is identified first.

It will not usually be possible to dissect the entire liver off the cava from the left side, so the process will be repeated on the right side, serially dividing venous tributaries from the right lobe of the liver until the main right hepatic vein is identified (there will frequently be a lower right hepatic vein present which will be sizeable and require careful division). The right hepatic vein will be divided using the vascular stapling device, fired twice. If bleeding from raw surfaces of the right lobe should become problematic at this stage, it will be best to ligate and divide the portal vein unless the removal of the liver is imminent. Division of the portal vein frequently allows better exposure of the retrohepatic cava for the final stages of the hepatectomy.

The liver at this stage will be almost completely mobilised from the cava, leaving only the middle and left hepatic veins intact. These will be clamped as far to the caval end as practical without significantly impeding caval blood flow with a medium sized Klintmalm clamp (the largest being reserved for emergency use or clamping above the medium-sized clamp). The middle and left hepatic veins will be divided sharply at this stage within the substance of the liver to allow as long a remnant of each vein as possible. The liver can then be removed.

The left and middle hepatic vein orifices will be combined to form a single orifice and residual liver tissue trimmed. A double-armed 3-0 prolene suture will then be placed through the right and left sides of this orifice, and a third suture placed centrally in the posterior wall. The donor liver will be positioned on the retracted viscera and the three previously placed sutures will be carried through the suprahepatic cava. The liver will be eased into the subdiaphragmatic space and the two venous orifices approximated. The anastamosis will be carefully completed in continuous fashion taking care to evert the posterior walls. At this point the donor liver will be flushed with Lactated Ringers solution, first via the artery (200ml), then via the portal vein (300ml). Attention will then turn to the portal vein of the donor and recipient which will be sewn end-to-end using 6-0 prolene sutures (continuous). A convenient routine for this (and the artery) is to place anterior and posterior central stay sutures, bringing the anterior stay suture to the right and the posterior stay suture to the left of the patient. In this way the left side is sewn first and then the remaining posterior stay is passed underneath the vessel and brought out to the right, whilst the three other prolene ends are taken from the right across to the left, to facilitate the sewing of the right side of the vessel. The clamp on the portal vein can be rotated in such a manner as to reduce tension and improve exposure. Growth factors will be left of at least 1cm on tying each suture of this anastamosis. After the portal vein anastamosis has been completed the liver will be reperfused.

During reperfusion the liver will be vented via the infrahepatic vena cava (using a tube placed at the time of procurement). When approximately 50-300ml (depending on the degree of congestion of the liver) has run through this tube it will be removed and the purse string surrounding it tied. A close inspection will be made for surgical bleeding sites which will be controlled with interrupted sutures. Attention will then be turned to the hepatic artery anastamosis. The preferred joining site will be recipient common hepatic artery to donor common hepatic artery will little or no redundancy.

This anastamosis is technically critical and is best done under magnification using 6-0 or 7-0 prolene using the same technique as for the portal vein (or alternatively by using 6-0 prolene interrupted sutures). It is usually necessary to clamp the donor artery in addition to the recipient artery because of backflow from the portally reperfused liver. Great care must be taken to avoid narrowing the lumen of the artery and one means of doing this is to leave the tying of the last sutures until after letting off the arterial clamps. If there is any doubt about narrowing or kinking of this anastamosis it should be redone, if necessary with interrupted sutures. If inflow via the recipient artery is unsatisfactory an interposition graft of donor iliac artery from the infrarenal aorta will be used instead. Attention will then be turned to the donor gallbladder which will be excised. At the time of gallbladder excision the cystic artery will be left to bleed prior to ligation to ensure that arterial inflow is satisfactory. The donor cystic duct will then be cannulated with a ureteric stent (5-7 french) which will be positioned so that the tip is well within the recipient common bile duct. This tube will be secured with a haemorrhoidal band and a vicryl suture applied to the cystic duct. The bile duct anastamosis (CBD to CBD) will then be carried out using interrupted 5-0 PDS sutures, over the ureteric stent. If the recipient CBD is unsatisfactory (PSC or biliary atresia patients) a Roux-en-Y limb will be constructed (using a hand-sewn jejunojejunostomy to avoid anastamotic bleeding) and the CBD of the donor sewn end-to-side to the Roux limb using interrupted 6-0 PDS. When this arrangement is used, the bile tube will be a fine-bore silastic one (infant feeding tube or Jackson Pratt) introduced via the Roux limb using a large bore angiocatheter, and secured with a vicryl suture and invaginated using a Witzel technique and interrupted silk sutures. The tip of this tube will be placed well up in the liver. Upon completion of the biliary anastamosis the implantation is complete.

When difficulty is predicted in disconnecting the liver from the anterior vena cava, or varices are formidable, or the recipient liver is very large, or when significant cardiac co-morbidity is present venovenous bypass will be used. In all cases a return cannula will be placed in an upper extremity to facilitate this eventuality. Portal and femoral (via the saphenous vein) catheters (Gott shunts) will be placed by the surgeon and tubing connected to the venovenous bypass pump with the help of the pump technician. A flow of approximately 2L/min is the goal but should not result in "stuttering" of either cannula which would indicate excessive suction force. Inordinately low flows (<1L/min) may result in clot formation, in which case venovenous bypass should be abandoned.

When the portal vein is thrombosed, it is usually possible to perform a thrombectomy and obtain sufficient inflow to safely proceed with the usual end-to-end portal vein anastamosis. If this is unsuccessful or deemed dangerous, an interposition graft of donor iliac vein will be used to extend the donor portal vein and thereby allow attachment to the superior mesenteric vein. Care should be taken to ensure that the donor iliac vein is directed properly or contains no valves. The clamp on the SMV should not be removed until the liver is ready for reperfusion as the anastamosis to this vein tolerates high pressures poorly.

If bleeding is minimal 1 or 2 large bore redivac drains will be placed. If bleeding is substantial (because of coagulopathy) 4 drains should be placed, 2 above and 2 below the liver to help identify the "active" quadrant should re-exploration become necessary.

A posterior layer of continuous 0 vicryl and an anterior layer of continuous 1 prolene will be used to close the abdominal musculature. The skin will be closed with skin staples except in paediatric patients and selected adult patients for who a subcuticular suture will be used (vicryl). All drains, including the bile, tube will be secured with silk drain stitches (3-0).