Liver Transplant (Deceased Donor)
End-stage liver disease: [alcoholic cirrhosis / NASH cirrhosis / HCC within Milan criteria / PSC / PBC / cryptogenic cirrhosis / acute liver failure]
Same
Orthotopic liver transplant, deceased donor, [piggyback / conventional caval replacement technique]
[***, MD/DO]
[Fellow/Resident name]
General endotracheal. Arterial line, CVP, and [PA catheter / TEE] used for hemodynamic monitoring.
Patient presents with end-stage liver disease secondary to [etiology], MELD score [X] at listing, [X] at time of transplant. [HCC within Milan criteria: AFP [X] ng/mL, within criteria at listing and transplant.] Donor: [DBD / DCD], [age], blood type [ABO compatible / identical]. CMV: D/R [+/-]. Cold ischemia time [X] hours. Risks including primary non-function, hepatic artery thrombosis, portal vein thrombosis, biliary leak/stricture, rejection, infection, and death discussed. Consent obtained.
Liver graft [appeared viable / moderate steatosis estimated [X]% on biopsy / excellent color and texture]. Back-table preparation included [accessory right hepatic artery from SMA ([incorporated / ligated and reconstructed])]. Explant: [cirrhotic / massively enlarged / acute necrosis]. Portal hypertension with [moderate / severe] varices encountered. On reperfusion: [immediate color change and bile production / initial congestion improved with flushing].
The patient was positioned supine. A bilateral subcostal incision with midline extension (Mercedes incision) was made. The hepatic ligaments were divided and the liver mobilized. The portal vein, hepatic artery, and infrahepatic/suprahepatic IVC were dissected and controlled.
[PIGGYBACK TECHNIQUE — CLASSICAL (Tzakis):] The recipient IVC was preserved. The hepatic veins were clamped and the liver removed. The three hepatic veins were confluenced into a common cuff. The donor suprahepatic IVC was anastomosed end-to-side to the recipient hepatic vein confluence cuff using running [3-0 Prolene]. The donor infrahepatic IVC was oversewn and ligated.
[MODIFIED PIGGYBACK / SIDE-TO-SIDE CAVOCAVOSTOMY (Belghiti):] The recipient IVC was preserved. A longitudinal cavotomy was made in the recipient IVC and matched to the donor retrohepatic IVC. A side-to-side anastomosis was constructed with running [3-0 Prolene]. The donor infrahepatic IVC was oversewn.
[CONVENTIONAL TECHNIQUE:] The suprahepatic and infrahepatic IVC were clamped and divided. The recipient liver was removed. IVC reconstruction was performed with running [3-0 Prolene] at the suprahepatic and infrahepatic positions.
Portal vein anastomosis was performed end-to-end with running [6-0 Prolene] with a growth factor to prevent purse-stringing on reperfusion. Portal reperfusion performed. Hepatic artery anastomosis was performed end-to-end [/ using donor iliac artery conduit] with running [6-0 / 7-0 Prolene]. Full reperfusion: [immediate color change and bile production confirmed].
[Duct-to-duct biliary anastomosis performed with running [5-0 PDS] / Roux-en-Y hepaticojejunostomy performed.] [T-tube / stent / no drainage placed.]
Hemostasis achieved. [Closed-suction drains placed near biliary anastomosis and hepatic hilum.] Fascia closed with running [looped PDS / #1 PDS]. Skin closed. Patient tolerated the procedure well.
None
[Native liver to pathology / Donor liver biopsy]
[X] mL
[Jackson-Pratt drains x2 / None]
Patient taken to liver transplant ICU in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: End-stage liver disease: [alcoholic cirrhosis / NASH / HCC within Milan / PSC / PBC / acute liver failure]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Orthotopic liver transplant, deceased donor, [piggyback / conventional caval replacement]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal; arterial line and CVP monitoring
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with ESRD secondary to *** MELD ***, listed for transplant. [HCC within Milan criteria; AFP ***.] ABO compatible. CMV D/R: ***. Cold ischemia time: *** hours. Risks including primary non-function, hepatic artery thrombosis, biliary leak, rejection, and death discussed. Informed consent obtained.
FINDINGS: Donor liver [viable, excellent appearance / moderate steatosis]. [Accessory right hepatic artery from SMA: incorporated / ligated.] Explant: cirrhotic. Portal hypertension with [moderate / severe] varices. Reperfusion: immediate color change and bile production.
DESCRIPTION OF PROCEDURE:
Patient supine; bilateral subcostal incision with midline extension. Hepatic ligaments divided; liver mobilized; portal vein, hepatic artery, and IVC controlled. [PIGGYBACK (Tzakis): IVC preserved; hepatic veins clamped; liver removed; donor SHIVC anastomosed end-to-side to recipient hepatic vein confluence cuff with 3-0 Prolene; donor IHVC oversewn.] [OR MODIFIED PIGGYBACK (Belghiti): side-to-side cavocavostomy between donor and recipient IVC with 3-0 Prolene; donor IHVC oversewn.] [CONVENTIONAL: Supra/infrahepatic IVC clamped and divided; liver removed; IVC reconstruction with 3-0 Prolene.] Portal vein anastomosis end-to-end with 6-0 Prolene (growth factor); portal reperfusion performed. Hepatic artery anastomosis end-to-end [/ via iliac conduit] with 6-0 Prolene; full reperfusion confirmed. [Duct-to-duct biliary anastomosis with 5-0 PDS / Roux-en-Y hepaticojejunostomy.] Hemostasis confirmed. [JP drains placed.] Fascia and skin closed. Patient tolerated the procedure well.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: Native liver to pathology
COMPLICATIONS: None
DRAINS: [JP drains x2 / None]
DISPOSITION: Patient to liver transplant ICU in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Living donor liver transplant (LDLT)
Right lobe (segments 5-8) most common for adult recipients. Document graft weight, GRWR (graft-to-recipient weight ratio, target >0.8%), and duct/vascular anatomy. Biliary reconstruction almost always Roux-en-Y.
Split liver transplant
Deceased donor liver divided for two recipients (left lobe for pediatric, right lobe for adult). Document split technique and anatomy allocation.
Simultaneous liver-kidney (SLK)
Document indication for SLK (AKI on CKD, ESRD, metabolic syndrome). Liver first, then kidney through separate Gibson incision.
Charting Tips
- Document cold ischemia time, anhepatic time, portal reperfusion time, and full (arterial) reperfusion time as discrete values. For DCD donors, document donor warm ischemia time separately. These are UNOS/OPTN Transplant Recipient Registration (TRR) required fields.
- State biliary anastomosis technique (duct-to-duct vs. Roux-en-Y and why)
- Note hepatic artery anatomy (accessory or replaced arteries and how managed)
- Document reperfusion quality (color change, bile production, hemodynamic stability)
- Record drain positions (biliary anastomosis and hepatic hilum)
- Note estimated graft steatosis (if biopsy performed intraoperatively)
Documentation & Reimbursement Considerations
- Primary service: Report Liver Transplant (Deceased Donor) as the primary service when it is the definitive operation performed.
- Venovenous bypass, when used, is not separately billable as a surgical procedure by the transplanting surgeon, as it is part of the transplant. If a perfusionist or vascular surgery team performs bypass, they may bill separately.
- Biliary anastomosis (duct-to-duct or Roux-en-Y hepaticojejunostomy) is included in the primary service. Do not separately bill biliary anastomosis codes. Document which technique was used.
- These are separately reportable procedures. Document both procedures, individual operative times, and CMS SLK eligibility criteria (eGFR <60 for at least 90 days, or eGFR <30, or AKI on dialysis at least 6 weeks).
- 90-day global includes all related postoperative visits, biliary stent removal, and anastomotic checks. ERCP for biliary leak within 90 days is a separate procedure but the surgical consultation component is bundled.