Multiorgan Procurement from the Deceased Donor

33 Pages·2006·2.31 MB·English

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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.
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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
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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
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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
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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