Pediatric liver transplantation programs currently achieve excellent results almost routinely. It is easy to forget that these are long and challenging operations with many potential complications, both technical and immunologic. Many of these children are quite ill and coagulopathic, making their preoperative assessment and preparation critically important aspects of their care. The task of “preopping” the patient often falls to a junior member of the surgical team, who might consider it a mundane chore; however, it is important to take this role seriously as poor preparation or a missed infection can cause significant harm to the patient. Fortunately, when the liver has been placed and is functional, the patient often becomes immediately more stable and the coagulopathy resolves within the first 8–12 h.
Hepatoblastoma is a primary hepatic malignancy that affects young children and is only considered curable if the entire tumor is excised with negative margins. Some children with “unresectable” tumors are candidates for hepatectomy and liver replacement by transplantation. These patients should be referred for evaluation early in the course of their disease because, although primary hepatectomy and transplantation, even after neoadjuvant chemotherapy, is associated with a relatively high chance of cure, the results of salvage transplantation after a failed hepatic resection are not nearly as good. Likewise, if a hepatoblastoma appears to be resectable only by performing a non-anatomic or unorthodox resection, one should, depending on the experience and confidence of the general surgeon at his or her institution, consider referring the patient to an experienced transplant surgeon: their experience with performing split-liver transplants and living-related transplants is useful when having to excise a large tumor with a margin when this requires a creative biliary or vascular reconstruction.
There are other techniques more frequently used by transplant surgeons that can occasionally be useful for the general surgeon during hepatic resection or trauma. Aggressive liver tumor resection or extraction of an adherent Wilms tumor thrombus will sometimes require removal of a portion of the inferior vena cava in order to obtain a negative margin. Reconstruction of the vena cava can be challenging but can be accomplished with the use of a polytetrafluoroethylene graft material, usually as a patch that is cut to the appropriate size and shape. During a prolonged resection or repair of a large liver resection, especially if the vena cava is involved, it is sometimes necessary to employ the Pringle maneuver. To prevent bowel congestion due to prolonged portal vein obstruction and lower body edema during caval occlusion, shunt tubing can be inserted into mesenteric veins and the inferior vena cava, with the blood returning to a large systemic vein above the diaphragm. Finally, the techniques that have been developed to create a secure biliary-enteric can be applied in other hepatobiliary operations: meticulous mucosa-to-mucosa approximation with fine absorbable suture, placement of a stent when the bile duct is small, liberal use of roux-en-Y hepatico-jejunostomy, consistent use of closed suction drains.