Left-to-right approach facilitates total hepatectomy with caval flow preservation.

Liver transplantation (LT) techniques have changed continually over the last 4 decades. Caval preservation, first reported by Calne and Williams in 19681 and popularized by Tzakis et al. in 19892 as the piggyback (PB) technique, has been adopted by many transplant teams.3-6 In 1992, we described a procedure preserving the caval flow during the whole procedure.7 Hemodynamic stability was sought by the adjunction of a temporary portocaval shunt.3,7 Preservation of the vena cava has gained many indications because it allows the implantation of a partial graft (split and living donor). Although preservation of both caval and portal flow avoids the need of venous bypass,3 its hemodynamic superiority is contrabalanced by the risk of outflow obstruction.8,9 It was shown in 2001 that a very large side caval anastomosis, if necessary with temporary caval clamping during the anastomosis procedure, is necessary for good graft liver function.3 All these technical modifications focus on graft implantation and vascular reconstruction. Technical procedures used during total hepatectomy with caval preservation and its effects on hemodynamic variations have not been exhaustively described. One particular point linked to this technique is that hemodynamic changes related to torsion of the vena cava can occur during explantation of the native liver. The aim of this article is to describe a “left-to-right approach total hepatectomy,” which allows removal of the recipient liver with minimal mobilization of the vena cava, limiting hemodynamic disturbances related to variation of the caval flow.