1 Multiorgan Procurement from the Deceased Donor Standard Multiorgan Procurement Mark L.Sturdevant and AbhinavHumar Introduction Operative Technique Non–Heart-Beating Donor Organ Procurement David J.Reich Background a) Definitions b) History c) Impact of Non–Heart-Beating Donors Results Following Transplantation of Non–Heart-Beating Donor Organs a) Kidneys b) Livers c) Author’s Experience Preoperative Maneuvers and Operative Strategy for Non–Heart-Beating Donor Organ Procurement a) Uncontrolled Non–Heart-Beating Donors b) Controlled Non–Heart-Beating Donors c) Surgical Technique d) Premortem Cannulation Technique Ethical Issues and Professionalism Standard Multiorgan Procurement Mark L.Sturdevant and Abhinav Humar Introduction Organ procurement for transplantation was first accomplished by the Soviet surgeon Yu Yu Voronoy, who performed the first human kidney transplant on April 3, 1933. The donor was a 60-year-old man who died on admission to the hospital from a traumatic brain injury; the kidney was removed 6 hours postmortem and transplanted into the thigh ofa 26-year-old woman with acute renal failure from mercury poisoning.The allo- graft did produce several milliliters of urine before the patient died 2 days after trans- plantation.The first attempt at liver transplantation,on March 1,1963,by Thomas Starzl, was possible only after successful liver procurement from a child who had died after cardiac surgery,but was left on the heart-lung machine to allow for procurement. 1 2 Atlas of OrganTransplantation Kidney transplantation in the 1950s and 1960s was primarily from live donors. However, in 1966 the concept of brain death was established in France by Guy Alexandre,who described the removal of kidneys from “heart-beating”cadavers with subsequent transplantation. In the United States, public support for this concept was overwhelming and led to the Harvard Ad Hoc Committee report in 1968 that outlined the criteria for brain death determination. The donor pool increased markedly after these policies entered clinical practice. Advancement to the modern-day status of deceased-donor organ procurement was aided in large part by work done in organ preservation.The combined efforts ofDr.John Najarian and Dr.Folkert Belzer at the University of California–San Francisco (UCSF), starting in 1966,aimed at decreasing ischemia times and adding organ preservatives to increase organ viability.Prior to the acceptance ofbrain death,Belzer procured kidneys from non–heart-beating donors in the greater San Francisco area and emergently trans- ported the organs to Najarian at Moffitt Hospital,who would have simultaneously started the recipient operation.Advances in organ preservation along with the acceptance of donation after brain death resulted in a more systematic,semielective kidney procure- ment,which resulted in organ delivery to recipients almost anywhere.Within 5 years a portable perfusion machine had been developed,and on December 24,1971,a deceased- donor kidney procured in San Francisco was hand delivered by Belzer to transplant surgeon Hans Dicke in the Netherlands with a cold ischemia time of37 hours.The trans- planted kidney had excellent function 17 years later when the recipient died of a rup- tured cerebral aneurysm. The technique of multiple-organ procurement (kidney,liver,pancreas,small bowel) was first described by Starzl and his colleaguesin 1984.Nakazato and his colleaguesin 1992 described the technique of total abdominal evisceration with ex vivo dissection. Most centers have now added their own modifications to these pioneering techniques and differ primarily in their degree of in vivo dissection.Some centers perform exten- sive dissection ofthe organs to be recovered prior to flushing the organs with preserva- tive solution. Other centers prefer to flush the organs early, remove the abdominal contents “en bloc”,and perform the separation and dissection of the individual organs on the back table. Each technique has its potential advantages and disadvantages. Regardless of personal technique and preference, it is paramount that the transplant surgeon develops a systematic approach to safely procure the liver, pancreas, and kidneys,even in the unstable donor. Surgical Technique 1. Incision and exposure:An incision extending from the sternal notch to the pubis, which is cruciated at the level ofthe umbilicus (Figure 1.1),provides maximal exposure for multiorgan procurements.The abdominal flaps can be folded back and held in place with sharp towel clips (Figure 1.2).This provides excellent exposure of the abdominal organs,without the need for a retractor.Only a sternal retractor is needed ifthe thoracic organs are to be procured.Sternotomy and division ofthe pericardium allows for exam- ination ofthe heart while division ofthe ligamentous attachments to the liver allows for complete examination of the liver.A thorough abdominal exploration is then quickly performed to rule out contraindications to procurement such as malignancy or intraab- dominal sepsis. Multiorgan Procurement from the Deceased Donor 3 Figure 1.1 Figure 1.2 4 Atlas of OrganTransplantation Figure 1.3 2. A Cattel-Braasch maneuver extending across the midline,with complete mobiliza- tion of the distal small bowel, right colon, and duodenum (Figure 1.3), allows for identification ofthe distal aorta,iliac bifurcation,and the distal inferior vena cava (IVC) (Figure 1.4). Figure 1.4 Multiorgan Procurement from the Deceased Donor 5 3. Division of the inferior mesenteric artery (black arrow) aids in the dissection of the distal aorta (yellow arrow and lines),which is then encircled with two umbilical tapes (Figure 1.5).This will be the site for later aortic cannulation for flushing (broken black line).The inferior vena cava sits just to the right (blue arrow). Figure 1.5 6 Atlas of OrganTransplantation Figure 1.6 4. The inferior mesenteric vein (IMV) (blue arrow) is identified lateral to the ligament of Treitz (yellow arrow) and encircled with two silk ties in preparation for future can- nulation into the portal venous circulation (Figures 1.6 and 1.7).The outline of the left renal vein (broken blue line) and its junction with the inferior vena cava is seen poste- rior to the IMV. Figure 1.7 Multiorgan Procurement from the Deceased Donor 7 Figure 1.8 5. The third portion ofthe duodenum is retracted cephalad,and the superior mesen- teric artery (SMA,yellow broken line) is identified,dissected free,and encircled with a vessel loop (Figures 1.8 and 1.9).This allows for occlusion of the SMA later,at the time of flushing.This limits the incidence of overperfusion injury to the pancreas.The left renal vein (broken blue line) is seen just inferior to the SMA,and the inferior mesen- teric vein (blue arrow) is just lateral. Figure 1.9 8 Atlas of OrganTransplantation Figure 1.10 6. In preparation to obtain control ofthe supraceliac aorta,the left triangular ligament ofthe liver is divided and the gastrohepatic ligament is examined and divided ifno aber- rant left hepatic artery is noted (Figure 1.10).Ifone is noted it will need to be preserved.The right diaphragmatic crus is divided,and the supraceliac aorta is identified and mobilized. 7. The supraceliac aorta is encircled with an umbilical tape (Figure 1.11).In the un- stable donor,cold perfusion may be done at this point. Figure 1.11 Multiorgan Procurement from the Deceased Donor 9 Figure 1.12 8. The portal triad is now examined,and if present,an aberrant right hepatic artery will be palpated on the right edge of the porta hepatis,posterior to the bile duct and lateral to the portal vein.The course of an accessory or replaced right (black arrow) is shown in broken lines (Figure 1.12). 9. The common hepatic artery is identified and traced to the celiac axis,allowing for visualization and limited dissection ofthe splenic artery and gastroduodenal artery.The hepatic artery does not need to be completely dissected out at this time – rather,just the origin of the above branches need to be identified (Figure 1.13). 10. Limited dissection of the common bile duct (CBD,yellow arrow),which lies just to the right and anterior to the main portal vein (broken blue lines) is performed followed by ligation of the distal CBD just proximal to the pancreas.The CBD is then Figure 1.13 10 Atlas of OrganTransplantation Figure 1.14 Figure 1.15 transected with a scalpel and the proximal end is left open (Figure 1.14).The gallblad- der is incised and flushed with saline to clear the CBD of retained bile (Figure 1.15). 11. Systemic heparinization (300 units/kg) is performed.The distal aorta is ligated and a 24-French (F) aortic cannula (red arrow) is placed at this site.The IMV is ligated and a 14-F perfusion cannula (blue arrow) is placed (Figures 1.16 and 1.17).Alterna- tively,the portal vein can be cannulated directly for portal flushing. Figure 1.16 Figure 1.17
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