What Happens During an Orthotopic Liver Transplant?

An orthotopic liver transplant is a surgical procedure to replace a diseased or failing liver with a healthy one from a donor. The term “orthotopic” means the new organ is placed in the same location as the original one. This procedure is a treatment for individuals with irreversible liver failure when other medical treatments are no longer effective. The process involves a detailed evaluation, a potential wait for a suitable organ, and a lifetime of follow-up care, with the goal of restoring function and improving quality of life.

When a Liver Transplant is Necessary

A liver transplant becomes an option when the liver is damaged beyond repair, a condition known as end-stage liver disease (ESLD) or chronic liver failure. The liver performs many functions, including filtering toxins from the blood, producing bile to aid digestion, and making proteins for blood clotting. When these functions cease, it can be life-threatening. The most common pathway to ESLD is cirrhosis, where healthy liver tissue is progressively replaced by scar tissue, impeding blood flow and function.

Numerous conditions can lead to cirrhosis and the need for a transplant.

• Chronic viral infections like hepatitis B and C
• Alcohol-related liver disease, which results from long-term excessive alcohol consumption
• Metabolic dysfunction-associated steatotic liver disease (MASLD), formerly known as non-alcoholic fatty liver disease, which is linked to obesity and metabolic syndrome
• Autoimmune diseases, where the body’s immune system attacks the liver
• Genetic conditions such as Wilson’s disease

In some cases, a transplant is needed for acute liver failure, a rapid loss of liver function that can occur in days or weeks, often due to a viral infection or a reaction to medication. Symptoms can include jaundice, where the skin and eyes turn yellow; ascites, a buildup of fluid in the abdomen; and hepatic encephalopathy, which causes confusion and memory problems due to the buildup of toxins in the blood.

Navigating the Transplant Evaluation and Waiting List

Before a patient can be considered for a transplant, they must undergo a comprehensive evaluation by a multidisciplinary team of specialists, including surgeons, hepatologists, pharmacists, and social workers. The evaluation includes extensive medical testing, such as blood work, imaging scans, and assessments of heart and lung function. A critical part of the evaluation is a psychosocial assessment, which examines a patient’s mental health, social support system, and ability to adhere to complex medical instructions after the transplant. Absolute contraindications, such as active substance abuse or cancer that has spread beyond the liver, would prevent a patient from being listed.

Once approved, a patient is placed on a national waiting list managed by organizations like the United Network for Organ Sharing (UNOS). Priority on the list for adults is determined by the Model for End-Stage Liver Disease (MELD) score, which ranges from 6 to 40. This score is calculated using lab results for bilirubin, creatinine, and the international normalized ratio (INR), which measures blood clotting. A higher MELD score indicates a greater risk of mortality within 90 days, giving that person higher priority for an available organ.

Donor livers come from two sources: deceased donors and living donors. Deceased donors are individuals who have been declared brain dead and whose families have consented to organ donation. Living donation involves a healthy person, often a family member or friend, donating a portion of their liver. The donor’s remaining liver and the transplanted segment both have the remarkable ability to regenerate to a normal size.

The Orthotopic Liver Transplant Operation

The transplant surgery is a complex procedure that lasts between five and eight hours under general anesthesia. The operation begins with the surgical team making an incision in the upper abdomen, often in the shape of an upside-down “Y” or a hockey stick, to access the liver. The first stage is the hepatectomy, the removal of the patient’s diseased liver. The surgeon detaches the liver from its ligamentous attachments and disconnects the main blood vessels and the common bile duct.

Following the removal of the native liver, the implantation of the donor organ begins. This stage involves precise vascular connections (anastomoses). The team connects the donor liver’s major blood vessels—the inferior vena cava, the portal vein, and the hepatic artery—to the recipient’s corresponding vessels to re-establish blood flow. Finally, the bile duct from the donor liver is connected to the recipient’s bile duct to allow bile to drain into the intestine.

After checking all connections for bleeding or other issues, the surgeon closes the incision. Drainage tubes are often left in the abdomen to remove any excess fluid that might accumulate around the new organ. After the operation, the patient is transferred to the Intensive Care Unit (ICU) for close monitoring.

The initial hospital stay after a liver transplant averages between one and two weeks, though this can vary depending on the patient’s recovery. During this time, pain is managed, and the first doses of immunosuppressant medications are administered to prevent the body from rejecting the new organ.

Living with a Transplanted Liver

Life after a liver transplant requires a lifelong commitment to taking immunosuppressive medications. These anti-rejection drugs dampen the body’s immune system to prevent it from attacking the new liver. Patients are started on a combination of two or three different immunosuppressants, and while the dosages may decrease over time, the need for these medications is permanent.

By suppressing the immune system, these medications increase a person’s susceptibility to infections. Long-term use can also increase the risk for other health issues, including kidney problems, high blood pressure, and certain types of cancer, particularly skin cancer.

Ongoing care involves frequent clinic visits and blood tests, especially in the first few months after surgery. These appointments, which become less frequent over time, allow the transplant team to monitor liver function, check drug levels in the blood, and watch for any signs of organ rejection or other complications. Symptoms of rejection can include fatigue, fever, or pain in the abdomen, and prompt treatment is needed to manage it.

Lifestyle adjustments are also important for protecting the new liver and overall health. This includes maintaining a balanced diet low in salt and fat, engaging in regular physical activity as approved by the medical team, and completely avoiding alcohol. With careful management, many people who receive a liver transplant go on to live active, productive lives for many years.