The Procedure of Liver Transplantation: A Comprehensive Guide

From evaluation and organ matching to operative steps, perfusion technologies, and post-operative care.

Updated: October 21, 2025 Reading time: ~9–12 min Reviewed for clarity

Introduction

Liver transplantation is a complex, life-saving operation for severe hepatic failure. Advances in surgical technique, organ preservation, and immunosuppression have steadily improved outcomes.

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Pre-Operative Evaluation

Screening & Tests

  • Comprehensive labs, cardiopulmonary assessment, imaging (US/CT/MRI), and infection screening.
  • Nutrition, frailty/sarcopenia, and psychosocial assessment; substance-use evaluation and support.

Structured donor/recipient evaluation pathways are standard in modern programs.

Readiness & Education

  • Medication counseling (immunosuppression, prophylaxis) and vaccination review.
  • Advance directives, caregiver planning, and financial/transport logistics.

See Desai & Neuberger for evaluation principles. [D&N 2017]

Organ Matching & Allocation Logistics

  • Compatibility: ABO, size considerations (including split grafts/pediatrics).
  • Allocation context: Modern U.S. practice uses distance-based sharing (Acuity Circles) with MELD 3.0 urgency and ongoing transition toward continuous distribution weighting.
  • Donor type: Brain-death (DBD) and circulatory-death (DCD) donors; living donors in selected cases.

MELD 3.0 adds albumin and sex adjustments and has been active in allocation since July 13, 2023. [OPTN policy updates]

Surgical Procedure

Types of Transplants

  • Deceased donor whole-organ or split-liver grafts.
  • Living donor partial grafts (e.g., right/left lobe) using standardized techniques.

Key Operative Phases

  • Recipient hepatectomy: Removal of diseased liver, control of inflow/outflow.
  • Back-table preparation: Graft inspection, vascular/biliary preparation.
  • Implantation: Venous (caval) and portal anastomoses, reperfusion (manage IRI hemodynamics).
  • Arterial anastomosis & biliary reconstruction: Duct-to-duct or Roux-en-Y; leak/stricture prevention.
  • Hemostasis & closure: Drains as indicated; careful fluid/vasoactive management.

Living donor operative standardization described by Hwang et al. (modified right lobe). [Hwang 2016]

Organ Preservation & Machine Perfusion

Beyond static cold storage, machine perfusion is increasingly used: normothermic machine perfusion (NMP) to assess function pre-implant and hypothermic oxygenated perfusion (HOPE) to mitigate reperfusion injury—especially relevant for DCD grafts.

  • NMP allows physiologic assessment (e.g., lactate clearance, bile quality) and may reduce ischemic injury.
  • HOPE trials examine complication reduction versus cold storage; protocols vary by center.

See contemporary reviews/trials on NMP/HOPE for details. [NEJM 2023 review; Schlegel 2023 RCT]

Post-Operative Care

Monitoring & Medications

  • ICU monitoring of hemodynamics, coagulation, electrolytes; early ultrasound for flow.
  • Immunosuppression (e.g., tacrolimus ± mycophenolate ± steroids; center-specific induction).
  • Antimicrobial prophylaxis tailored to risk (CMV, PCP, fungal).

Enhanced Recovery

  • Pain control strategies, early mobilization, nutrition optimization.
  • Education on adherence, drug interactions, and clinic follow-up.

Immunosuppression frameworks summarized by Bonnel et al.; updated guideline resources available from AASLD/EASL.

Risks & Complications

  • Early allograft dysfunction (EAD) and primary non-function—linked with outcomes; standardized EAD definitions aid reporting.
  • Biliary complications (leaks/strictures; ischemic cholangiopathy risk higher with DCD—mitigated by modern perfusion strategies).
  • Vascular issues (hepatic artery thrombosis/stenosis), rejection, infection, renal dysfunction, metabolic complications.

EAD definition/validation (Olthoff 2010); contemporary biliary-complication analyses and consensus updates inform management.

Ethical Considerations

  • Living donor safety and independent advocacy.
  • Equitable allocation and transparency in offer acceptance; ongoing policy work to reduce disparities.

See classic legal/ethical texts (Price 2000) and current policy resources.

References

  1. Desai R, Neuberger J. Donor/recipient assessment principles. World J Surg. 2017:350-357.
  2. Sharma A, Ashworth A, Behnke M, et al. Living donor selection. Transplantation. 2013:501-506.
  3. Hwang S, Lee SG, Kim KH, et al. Standardized technique for LDLT (modified right lobe). Ann Surg. 2016:101-109.
  4. Bonnel AR, Bunchorntavakul C, Reddy KR. Immunosuppression overview. J Clin Exp Hepatol. 2012:258-269.
  5. Olthoff KM, Kulik L, Samstein B, et al. Validated EAD definition. Liver Transpl. 2010;16:943-949. :contentReference[oaicite:1]{index=1}
  6. NEJM Review. Liver Transplantation—organ preservation & NMP overview. N Engl J Med. 2023. :contentReference[oaicite:2]{index=2}
  7. Schlegel A, et al. RCT of HOPE in LT. Ann Surg. 2023. :contentReference[oaicite:3]{index=3}
  8. EASL Clinical Practice Guidelines on Liver Transplantation (updates on indications, perfusion, rejection). 2024. :contentReference[oaicite:4]{index=4}
  9. OPTN Policy Updates—MELD 3.0 implementation & monitoring (2023–2025). :contentReference[oaicite:5]{index=5}
  10. OPTN Allocation framework—Acuity Circles (2020) & ongoing continuous distribution work. :contentReference[oaicite:6]{index=6}
  11. Contemporary U.S. biliary complication data/consensus. Transplantation/SRTR analyses; consensus classification 2025. :contentReference[oaicite:7]{index=7}
  12. Price D. Legal & Ethical Aspects of Organ Transplantation. Cambridge Univ Press. 2000.

Mix of foundational and up-to-date sources; consult local protocols and current society guidelines for implementation.

Disclaimer

This article is for informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. Always consult your transplant team for recommendations tailored to your situation.

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