Vol.18, No.

7 July 1996 V

Continuing Education Article

Surgical Techniques
FOCAL POINT
for Extravascular
★ Knowledge of anatomy of
the liver and its associated
Occlusion of
vasculature is critical for locating
and isolating intrahepatic
portosystemic shunts.
Intrahepatic Shunts
KEY FACTS Washington State University
Karen M. Swalec Tobias, DVM, MS
■ If not readily visible during surgery,
intrahepatic portosystemic shunts University of Georgia
may be located by palpation, Clarence A. Rawlings, DVM, PhD
ultrasonography, catheterization via
the portal vein, or measurement of
portal pressure changes during
digital vascular occlusion.

■ Intraoperative hepatic
I ntrahepatic portosystemic shunts are congenital vascular anomalies that are
found primarily in large-breed dogs.1 Surgical occlusion of portosystemic
shunts is the therapy of choice for improving the quality of life and increas-
ing the life span of affected animals. Location of intrahepatic portosystemic
shunts can be determined by exploratory laparotomy, ultrasonography, portog-
parenchymal hemorrhage is
decreased with blunt dissection
raphy, or nuclear scintigraphy.2 Because of the location of the intrahepatic por-
or use of an ultrasonic aspirator.
tosystemic shunt, direct ligation may be difficult. Other surgical options include
ligation of the portal vein branch supplying the shunt, ligation of the hepatic
■ Intrahepatic portosystemic
vein branch draining the shunt, or temporary inflow occlusion and intravascular
shunts of the left hepatic division
closure of the shunt or associated hepatic vein.3,4 This article reviews the perti-
are occluded by direct ligation of
nent anatomy and surgical approaches for extravascular occlusion of intrahepat-
the portosystemic shunt or by
ic portosystemic shunts and the veins supplying or draining intrahepatic shunts.
ligation of the left hepatic vein.
ANATOMY OF THE LIVER
■ Intrahepatic portosystemic
The canine liver consists of six lobes and three divisions (Figure 1). The left
shunts of the central and right
lateral and left medial lobes make up the left division; the right medial and
hepatic divisions are often
quadrate lobes, which lie on either side of the gallbladder, compose the central
occluded by ligation of the
division; and the right lateral and caudate lobes form the right division. The
associated portal vein branch.
caudate lobe is subdivided into the caudate and papillary processes, which re-
ceive portal blood supply from the vessels of the right and left divisions, respec-
tively.5–7 The right lateral and caudate lobes surround a portion of the caudal
vena cava as it courses cranially in the dorsal abdomen.6 The liver is attached to
the diaphragm, primarily by the left triangular ligament (Figure 2); the right
triangular ligament is smaller and provides less support.7
Caudal to the liver, the portal vein is ventral to the caudal vena cava, epiploic
Small Animal The Compendium July 1996

portal vein, although some branches may be

found dorsal to the portal vein.7
Dogs usually have six to eight hepatic
veins that form a partial spiral around
the caudal vena cava6 (Figure 2).
The left hepatic vein drains
the left division of the liver
and is the largest, most
cranially located hepatic
vein.5,7 The left hepatic
vein enters the left later-
al surface of the caudal
vena cava near the vis-
ceral surface of the di-
aphragm.6 One third to
one half of the vein’s cir-
cumference is in close con-
tact with hepatic parenchyma.
The left hepatic vein can be
seen more readily by incising
the left triangular ligament
(Figure 3). The central divi-
sion of the liver may be
drained by one or two hep-
atic veins. These veins enter
the ventral surface of the
caudal vena cava caudomedi-
al to the left hepatic vein and may be completely
Figure 1—Anatomy of the liver (visceral surface), hepatic surrounded by he-patic parenchyma at their insertions.7
artery, and portal vein in the dog. The six lobes of the liver Hepatic veins draining the right division of the liver
are the caudate lobe, which is subdivided into the caudate join the caudal vena cava on its right ventrolateral sur-
(CC ) and papillary (PC ) processes; left lateral lobe (LL); face and are completely surrounded by hepatic tissue.6,7
left medial lobe (LM ); quadrate lobe (Q ); right medial
lobe (RM ); and right lateral lobe (RL). The gallbladder GENERAL SURGICAL PRINCIPLES
(G ) lies between the quadrate and right medial lobes. a =
Identification of the Shunt
artery, v = vein.
Intrahepatic portosystemic shunts are approached via a
ventral midline celiotomy.
Median or paramedian ster- Key Facts About
foramen, and hepatic artery. Its tributaries, from caudal notomy and incision of the Intrahepatic Shunts
to cranial, include the cranial mesenteric, caudal diaphragm can also be per-
mesenteric, splenic, and gastroduodenal veins. The por- formed to increase exposure.
■ Large-breed dogs
tal vein branches are fairly consistent in number and lo- Intrahepatic portosystemic
cation (Figure 1). The right main branch of the portal shunts may be seen if they are primarily affected
vein supplies the right division of the liver, except for not completely surrounded ■ Left side of liver
the papillary process of the caudate lobe.6,7 The right by hepatic parenchyma (Fig- more often affected
main branch may be partially or completely surround- ure 2). Intrahepatic portosys- ■ Postligation
ed by hepatic tissue when it divides to form the right temic shunts and hepatic or complication rate =
lateral and caudate portal branches. The larger left portal vein branches that are
77%
main branch gives off a central branch to the right me- associated with the portosys-
dial lobe and a small papillary branch to the papillary temic shunts are usually dilat- ■ Postligation
lobe before dividing into left lateral, left medial, and quad- ed and have turbulent blood mortality rate =
rate branches.7 Branches of the hepatic artery and bile flow. If the portosystemic 11% to 25%
ducts are usually located on the ventral surface of the shunt is not visible, lobes

LIVER ANATOMY ■ SURGICAL APPROACHES

The Compendium July 1996 Small Animal

should be palpated to determine whether there is an easi-
ly compressible area (typical of an aneurysm) associated
with an intrahepatic shunt.8 The abdominal viscera
should be monitored during this palpation because ve-
nous distention and increased portal pressure can devel-
op if the portosystemic shunt is obstructed.
Intraoperative ultrasonography has been used during
exploratory surgery to locate portosystemic shunts that
are not readily visible. A sterilized ultrasound transduc-
er is gently rested on the liver surface and irrigated with
physiologic saline, as needed. A needle and suture may
then be passed around the portosystemic shunt with
ultrasonographic guidance to avoid perforating the
shunt.9
Another method of locating intrahepatic portosys-
temic shunts is to place a purse-string suture in the por-
tal vein and insert a large-bore catheter or tube through
the purse-string into the vein and advance it through
the shunt (Figure 4). The catheter can also be passed
through a splenic vein to avoid placement of the portal
vein purse-string suture. Proper placement of the
catheter is verified by palpating the tip in the caudal
vena cava cranial to the liver. Palpation of the intravas-
cular catheter will identify the intrahepatic location of
the portosystemic shunt and the hepatic and portal
veins draining and supplying the shunt, respectively.10
Identification of the shunt may be confirmed by
measuring changes in portal pressure. A mesenteric or
portal vein is catheterized, and baseline portal pressure
is measured with a water manometer zeroed to the level
of the portal vein or with a pressure transducer. Normal
portal pressure is approximately 8 to 13 cm H2O (6 to
10 mm Hg); portal pressure in dogs with portosystemic
shunts may be 0 to 12 cm H2O.2,11
The suspected shunt or its associated portal vein
branch is digitally occluded without inhibiting flow
through the portal vein or its remaining branches. Dig-
ital occlusion of the left hepatic vein may be similarly
attempted; the surgeon must be careful not to simulta-
neously obstruct the caudal vena cava. A rapid rise in
portal pressure occurs with occlusion of the portosys-
temic shunt or its associated portal vein branch or he-
patic vein; minimal changes are seen with compression
of other portal branches or hepatic veins. Occasionally,

Figure 2—Anatomy of the liver (diaphragmatic surface) and the hepatic veins. The hepatic veins form a partial spiral around
the ventral surface of the caudal vena cava near the diaphragm. After incising the left triangular ligament, the left medial
lobe is retracted to the right and the interlobar area is examined for a portosystemic shunt draining into the hepatic vein of
the left lateral or left medial liver lobe. RL = right lateral lobe, RM = right medial lobe, GB = gallbladder, LM = left medial
lobe, Q = quadrate lobe, LL = left lateral lobe, Lig = ligament.

SHUNT IDENTIFICATION ■ ULTRASONOGRAPHY ■ PURSE-STRING SUTURES

Small Animal The Compendium July 1996

with blunt dissection.13 Severe hemor-

rhage may be controlled temporarily
via occlusion of the portal
vein, hepatic artery, and
caudal vena cava. Blunt dis-
section of the parenchyma
will decrease hemorrhage
from larger vessels; however,
hemorrhage from smaller ves-
sels may obstruct visualization
and result in increased opera-
tive time and morbidity.
The ultrasonic aspirator
selectively removes hepatic
parenchyma without dam-
aging essential structures
(such as nerves or vessels).
Figure 3— Appearance of The aspirator emulsifies and
the caudal vena cava cra- aspirates soft tissue with high-
nial to the liver and caudal water content (such as tumors,
to the diaphragm. The left
hepatic parenchyma, or prostatic
triangular ligament has been in-
cised. The left hepatic vein is evi- tissue) and leaves elastic structures
dent entering the caudal vena cava. A (such as nerves and blood vessels) in-
portion of the central hepatic vein is also visible. The tact.14–17 In hepatic resections, ultra-
hepatic veins of the right division are completely encased sonic aspirators reduce perioperative hemorrhage, the
in hepatic parenchyma. The dashed line indicates the ap- number of transfusions, postoperative complications,
proximate location of the division between the left medial and duration of the opera-
and left lateral lobes. CVC = caudal vena cava, LHV = left tion.14–16 Ultrasonic surgical
hepatic vein, LM = left medial lobe, LL = left lateral lobe, aspirators are particularly
lig = ligament, v = vein. Indicators of
useful for dissecting around Intraoperative Portal
hepatic veins, which may be Hypertension During
easily disrupted by conven- Shunt Ligation
portal pressure changes minimally with shunt occlu- tional dissection tech-
sion; this variation may be caused by increased splanch- niques.18
■ Postligation portal
nic compliance and pooling of blood in the intestines
and spleen.12 Portosystemic pressure >17–24
Shunt Ligation cm H2O
Isolation of the Shunt In a recent study, 73% of ■ Increase in portal
Isolating hepatic veins and intrahepatic portosystemic intrahepatic portosystemic pressure >10 cm H2O
shunts for ligation may be difficult.6 Hepatic veins are shunts were partially ligated ■ Decrease in central
broad and short and, except for the left lateral hepatic to avoid development of fa-
venous pressure
vein, are usually completely surrounded by hepatic tal portal hypertension. 1
parenchyma.6 Intrahepatic shunts may be tortuous and Ligation limits for portosys- >1 cm H2O
thin-walled; ligation of the portal branch supplying the temic shunts are often deter- ■ Subjective signs,
shunt or the hepatic vein draining the shunt may be mined by measuring portal including blanching
necessary because of the difficulty in isolating the shunt pressures before and after of the intestines;
itself.1 ligation.2,10,12 Limits for maxi- pancreatic cyanosis;
Hemorrhage occurs frequently during isolation of in- mum postligation portal pres-
intestinal hypermotility;
trahepatic portosystemic shunts.10 Traditionally, hepatic sure range from 17 to 24 cm
hemorrhage has been decreased by providing adequate ex- H2O,1,8,12 with a maximum and distended,
posure, mobilizing the liver, isolating vascular structures, increase of 9 to 10 cm H2O pulsating jejunal
controlling hemorrhage from small vessels with electro- over baseline.11,12 Measure- vessels
cautery or ligation, and separating hepatic parenchyma ment of portal pressure

PORTAL PRESSURE CHANGES ■ HEPATIC HEMORRHAGE ■ ULTRASONIC ASPIRATORS

Small Animal The Compendium July 1996

changes is not always reliable for preventing postopera- needle.

tive mortality. In a recent report, all dogs that died after
shunt ligation had postligation portal pressure less than
19 cm H2O and increases in portal pressure of less than
10 cm H2O after ligation.1
Central venous pressure may be monitored during
shunt ligation; a decrease in central venous pressure of
greater than 1 cm H2O during shunt occlusion has
been associated with development of postoperative por-
tal hypertension.12 In addition, viscera may be observed
for subjective signs of intraoperative postligation portal
hypertension, including blanching of the intestines;
pancreatic cyanosis; distended, pulsating jejunal vessels;
and hypermotility of the small intestine.19 If objective
or subjective signs of intrahepatic portal hypertension
are apparent, the ligature should be loosened to a point
at which these signs are no longer present.
Care must be taken during partial ligation of porto-
systemic shunts to avoid overtightening the ligature
when the second throw is tied to set the first knot. Over-
tightening may be avoided by placing a catheter or sec-
tion of red rubber tubing alongside the portosystemic
shunt and including the tubing within the ligature. Once
the knot is tightened, the tubing is removed, thus pro-
viding a set diameter for the encircling ligature. Alterna-
tively, a bulldog clamp is placed across a portion of the
shunt, and pressures and vis-
cera are evaluated for portal
hypertension. Once the
d e s i r e d
degree of attenuation is
obtained, the clamped
portion of the shunt is
transfixed with fine su-
ture on a cardiovascular
PORTOSYSTEMIC SHUNTS
OF THE LEFT DIVISION
In the embryo, the ductus venosus connects the cra-
nial anastomosis of the right and left vitelline veins
with the left umbilical vein.5 Thus, intrahepatic por-
tosystemic shunts (patent ductus venosus) are more
likely to be found in the left division of the liver, drain-
ing into the left hepatic vein. Intrahepatic shunts of the
left division are often occluded at the level of the left
hepatic vein because this vein is readily accessible in
most dogs. Complete ligation of the left hepatic vein
results in transient hepatic congestion but no long-
standing effect on hepatic structure, circulation, or
function in healthy dogs.20
PORTOSYSTEMIC SHUNTS OF THE
CENTRAL AND RIGHT DIVISIONS
Because most hepatic veins of the central and right di-
visions are completely encircled with hepatic tissue, por-
tosystemic shunts of these divisions are often treated by
ligation of the supplying portal vein branch (Figure 5).
Ligation of a portal vein branch in healthy dogs results
in atrophy of the liver lobes supplied by the branch and
decreased bile flow and biliary excretion of these lobes.
Blood flow to the remaining
lobes increases, although
portal pressure remains
unchanged, and these
lobes hypertrophy

Figure 4—Location of a portosystemic shunt in the right medial liver lobe. A purse-string suture has been placed in the por-
tal vein and a catheter has been inserted through the purse-string into the vein and advanced through the shunt. The
catheter is palpated to determine the location of the shunt. In the illustrations, the right medial branch of the portal vein
becomes an aneurysmal dilatation at the site of the portosystemic shunt. CVC = caudal vena cava, GB = gallbladder, PV =
portal vein.

PORTAL HYPERTENSION ■ OVERTIGHTENING ■ SHUNT CHARACTERISTICS

The Compendium July 1996 Small Animal

so that overall hepatic function remains

normal.21,22
An alternative technique for ligation
of intrahepatic shunts is to “sandwich”
the shunt and surrounding liver tissue between
pieces of mesh placed on the diaphragmatic and
visceral surfaces of the affected lobe.a Suture is
passed through the mesh and liver parenchyma so
that the ligature surrounds the shunt and rests on the
mesh above and below the shunt. The ligature is tight-
ened until an appropriate rise in pressure is noted. Al-
though extensive dissection and hemorrhage are avoid-
ed, this technique is not effective for shunts that
Figure 5—Isolation of the right lateral branch of the portal
formed as windows between the portal vein and hepatic
vein (PV ). An ultrasonic aspirator was used to dissect he-
vein.
patic parenchyma from around the vessel. CVC = caudal
vena cava, v = vein.
PROGNOSIS FOR INTRAHEPATIC
SHUNT LIGATION
Postoperative complications may be seen in 77% of SUMMARY
dogs after portosystemic shunt ligation.23 The most Ligation of intrahepatic portosystemic shunts is tech-
common complication is abdominal distention, which nically demanding and can be associated with a high
may not require treatment if it is the only clinical ab- rate of intraoperative complications. Familiarity with
normality seen.23 Survival rates of dogs undergoing the anatomy of the liver and its vasculature is necessary
intrahepatic portosystemic shunt ligation range from to locate and isolate intrahepatic shunts. Shunt catheter-
75% to 89%.1,8,23 Causes of death include peritonitis, ization, dissection with ultrasonic aspirators, and other
thrombosis of the portal vein, and cardiovascular col- techniques that improve identification and isolation of
lapse secondary to fatal portal hypertension.1,3,8,23 Dogs intrahepatic portosystemic shunts may help to decrease
that have clinical signs of portal hypertension after surgical time and intraoperative and postoperative com-
surgery, such as severe abdominal pain, delayed recov- plications of intrahepatic portosystemic shunt ligation.
ery from anesthesia, or cardiovascular collapse, should With proper diagnostic, anesthetic, surgical, and critical
be treated with supportive therapy and immediately re- care expertise, surgery is an excellent option for treat-
turned to surgery for ligature removal. ment of intrahepatic portosystemic shunts.

aPersonalcommunication: Department of Companion Animal ACKNOWLEDGMENT

and Special Species Medicine, College of Veterinary Medicine, The authors thank Kip Carter of Educational Re-
North Carolina State University, Raleigh, NC, 1996. sources at the College of Veterinary Medicine, University

ABDOMINAL DISTENTION ■ SURVIVAL RATES ■ CAUSES OF DEATH

Small Animal
of Georgia, Athens, Georgia, for drawing the illustra-
tions for this article.
About the Authors
Dr. Tobias is affiliated with the Department of Veterinary
Clinical Sciences, College of Veterinary Medicine, Wash-
ington State University, Pullman, Washington. Dr. Rawl-
ings is affiliated with the Department of Small Animal
Medicine, College of Veterinary Medicine, University of
Georgia, Athens, Georgia. Drs. Tobias and Rawlings are
Diplomates of the American College of Veterinary Sur-
geons.
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