Tayar et al. 1
recently published in Liver Transplantation. Although the so-called 3-vein technique has been reported previously, 2,3 as Tayar et al. mention, and is currently used by many transplant surgeons (the 3-vein technique outflow anastomosis is used in 39% of the liver transplant centers in Italy according to a recent national survey; personal communication with Massimo Rossi, MD, 2010), this article provides very useful technical information for those seeking a better understanding of the pathophysiology of graft outflow. The authors correctly emphasize the importance of avoiding as much as possible any obstructions of the recipient's inferior vena cava while the Satinsky clamp is being placed on the 3 hepatic veins; for example, the posterior surface of the inferior vena cava should not be detached from the diaphragm. However, the authors also write that the Satinsky clamp should be removed only after the completion of both the outflow and portal vein anastomoses and immediately before graft reperfusion; thus, the Satinsky clamp will be left in situ for the time needed not only for the completion of the outflow anastomosis but also for portal reconnection. On the basis of our personal experience, we perform the 3-vein technique in the same fashion, except that we move the Satinsky clamp proximally (toward the liver parenchyma) to the outflow anastomosis after its completion to test this anastomosis for possible bleeding and to avoid to the best of our ability any possible residual obstructions of the recipient's inferior vena cava; our goal is the maintenance of optimal hemodynamics during the creation of the portal vein anastomosis. We think that this simple modification of the 3-vein technique, which is so well described in Tayar et al.'s article, could be a simple way of avoiding any inferior vena cava obstructions during graft reimplantation and reducing the risk of bleeding during reperfusion.