How long will my liver transplant operation take?

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Liver transplant surgery can take as little as 4 hours or as long as 12 to 15 hours. Many factors determine the length of the operation, including the experience of the surgical transplant team, the number of surgeries the recipient has undergone in the past, and the degree of the recipient’s illness.

In the preoperative holding area, you will meet the anesthesiologist who will care for you during your operation and sign a consent form to permit him or her to give you anesthesia for the operation. A lot of activity will occur in this area as the medical staff prepares you for the surgery. Intravenous (in the vein) and arterial (in the artery) lines are placed in your arm and neck. These lines will still be in place when you wake up after the surgery. Electrocardiogram leads are placed on your chest to monitor your heart as well. All these preparations are needed to perform the transplant operation safely. When these preparations are complete, you will be wheeled into the operating room on a stretcher for your transplant operation.

Your operation will be appropriately timed for the arrival of your organ. The anesthesiologist will give you intravenous medication to put you to sleep. The anesthesia team will monitor your blood pressure, heart rate, breathing, and blood chemistries very closely during the entire operation.

After you are asleep, a breathing tube (endotracheal, or ET, tube) is placed in your throat and connected to a machine (ventilator) that breathes for you while you are asleep. A soft, small tube, called a Foley catheter, is inserted into your urinary bladder to drain your urine.

A soft tube may also be inserted through your nose or mouth that goes into your stomach; this nasogastric (NG) tube is used to keep your stomach empty to prevent vomiting and choking.

Your surgeon makes an incision that is either shaped like an upside-down “Y” or a hockey stick. The longer portion will be about 12 inches long, extending from the lower right side of the rib cage to just below the breast bone. The shorter portion will be 3 to 4 inches long, extending along the left lower rib cage (Figure 9).

Depending on your liver disease and your physical condition at the time of your transplant, your surgeon will use one of two methods to keep blood away from the liver area (to decrease bleeding) during the operation.

In the piggyback technique, the blood vessels around the liver are clamped (held shut) while your new liver is sewn onto a part of your old blood vessel circulation. In a less frequently used procedure called venovenous bypass (Figure 10), a catheter (a small tube) is placed in a vein in your groin. Blood flows through this tube and through a machine that returns the blood to you through a catheter in a vein in your armpit. If the venovenous method is used, you will have two small punctures—in your armpit and in your groin—and a segment of your major blood vessels will be removed along with your old liver.

How your surgeon reconstructs your common bile duct depends on your liver disease. In most instances the ends of the original common bile duct and the donor

common bile duct are sewn together (Figure 11). In this case a temporary tube or stent is placed in the common bile duct to permit doctors to x-ray the bile ducts after the surgery is complete. This tube is brought outside of your body through a small incision in your abdomen. The part of the tube that remains outside of your body connects to a bag into which the bile—a green/goldcolored fluid produced by your new liver—drains.

Finally, your surgeon will place three drains in your abdomen around your new liver, called Jackson-Pratt drains. One part is inside of your body, and the other is outside. The purpose of these drains is to draw excess fluids away from your liver. Your incision will be closed with staples and covered with a gauze dressing. The drains will be attached to your skin to hold them securely

in place when you are moved. You will go directly to a postanesthesia care unit after the operation.

You will be given general anesthesia for the operation so you will have no recollection of the surgery or the time just before when you were in the preparation area. After the surgery is complete, you initially go to the postanesthesia care unit or to the intensive care unit (ICU) so that the doctors and nurses can monitor you very closely. When you wake up, you may hear unfamiliar sounds, such as the ventilator that may be helping you breathe and the machines that are monitoring your heartbeat, blood pressure, and breathing. You will not be able to talk if you have a breathing tube in place when you awaken. Some medications may make you very sensitive to the noises around you. You might feel nauseated from the anesthesia you were given to put you to sleep; you will be given medication for relief of this nausea. In addition, you may have some pain and discomfort from the surgery and will be given medication to help relieve it. Previous transplant recipients have described the incision pain as very manageable.

The dressing on your incision will be checked frequently and may be changed. It is not unusual for fluids to drain from your incision for some time after your operation.

Doctors and nurses in the postanesthesia care unit and ICU continuously monitor how well your new organ is functioning by taking blood tests, measuring and testing the fluids produced by your body, and using other testing methods, such as x-rays, when necessary and appropriate. When your condition is stable, you will move to the transplant unit for the remainder of your hospital stay.

Remember that many of the tubes, intravenous lines, and monitoring devices that were placed after you went to sleep will still be in place when you wake up. Any drains that were placed during the surgery will be in place as well.

Breathing Tube (Endotracheal Tube)

The tube that was placed in your throat and attached to the ventilator to help you breathe may still be in place when you wake up. While it is in place, fluid from your mouth and the tube will be removed frequently using a suction device. You will not be able to speak while the endotracheal (ET) tube is in place, but your nurse can help you communicate. You may want to establish a way to communicate with your loved ones, such as blinking your eyes once for “yes” and twice for “no.” Trying to relax and letting the respirator do the work for you will conserve your energy and make having the tube in place more comfortable. Remember that the ET tube is temporary and necessary for your recovery.

The breathing tube is removed when the anesthesia has worn off completely and your physicians know that your lungs can function on their own. After a liver transplant the ET tube usually is removed within 8 to 24 hours after your surgery. Your doctors and nurses determine when you are ready to breathe on your own by performing a chest x-ray and taking blood samples to measure the oxygen in your blood. After the tube is removed, you may have a mild sore throat; the soreness disappears in a few days.

After the ET tube is removed, you will be encouraged to cough and breathe deeply very frequently to keep your lungs clear of fluids and to help oxygen flow freely.

Having someone support (splint) your stomach and back with a hand or a pillow helps make coughing less painful. Respiratory therapists and your nurses will assist you in keeping your lungs clear with chest therapy (gentle tapping of the lung area) and a spirometer (a device that helps you breathe deeply). All these precautions are intended to prevent fluid and secretions from collecting in your lungs and causing a lung infection or pneumonia.

Nasogastric Tube

If a nasogastric (NG) tube was inserted through your nose and into your stomach to keep your stomach empty, it still will be in place when you wake up. This tube is removed when your bowel sounds return or when you pass gas on your own, which usually happens within 24 to 72 hours of your operation.

Intravenous Lines

The intravenous (IV) lines may remain in place for most of your hospital stay. They enable your caregivers to draw your blood for tests, administer any medications that may be needed during your recovery, and provide fluids that help your blood circulate. They also are helpful in monitoring your heart and lung function.

Foley Catheter

The tube that was placed in your bladder to drain your urine will still be in place when you wake up. It generally is removed a few days after surgery.

Electrocardiogram Leads

When you leave the postanesthesia care unit or ICU, the electrocardiogram (ECG) leads that have been monitoring your heart are removed.

Jackson-Pratt Drains

The three Jackson-Pratt drains that your surgeon placed around your new liver will still be in place when you wake up. These tubes enter your abdomen through small incisions. Outside of the body, they look like clear plastic tubes with suction bulbs attached at the end. The fluid in the bulbs may be clear, yellow, or tinged with blood. All these colors are normal. Generally, two of these drains are removed within 24 hours of your surgery. The remaining Jackson-Pratt drain is removed within 10 days of your surgery.

Bile Tube

The tube that was placed in your bile ducts will still be in place when you wake up. It permits the doctors to monitor how well your new liver is working and how well the new bile ducts are healing. The bile tube is clamped shut when a blood test indicates that your bilirubin is less than 3 micromoles per liter (µmol/L) as measured in your blood. It will be removed during an office visit about 8 to 12 weeks after your surgery.

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