The Donor Operation

The Team
Lead surgeon Second surgeon

Renal surgeon, paediatric surgeon, visiting surgeon

Third surgeon (if available)

Scrub person
ODP, scrub nurse

Driver
WM Ambulance service

The Travelling Team

Responsibilities of Scrub Person

Ensure all specialist equipment is packed & transported to local hospital

Swabs, drapes, gowns & gloves provided locally

Liaise with local theatre team Set up trolley & equipment Discuss with local coordinator re perfusion Run through the portal venous perfusion fluid Ice for later +/-Back bench liver perfusion Packing liver Swab & instrument count

Responsibilities of Lead Surgeon

BSD criteria satisfied & recorded Cause of death recorded & appropriate Consent of family +/- coroner recorded Relevant PMH, blood tests, current history of I/P stay
Hypo/hypertension, inotropes, sepsis, CR arrest, urine output, etc.

Blood group Virology

HBV, HCV, HIV, CMV

Responsibilities of Lead Surgeon

Discussion with anaesthetist

Antibiotics (Ceftazidime 2g, Augmentin 1.2g or Ciprofloxacin 400mg, Metronidazole 500mg) Muscle relaxation Administration of heparin (300u/kg) & timing

Discussion with cardiac (& renal/pancreatic surgeons)

Sternotomy Heparinisation IVC clamping Bleed out Perfusion

Retrieval Methods
Standard Rapid

technique

Very unstable donor Immediate cannulation of aorta and SMV Cold perfusion Careful dissection
En

Bloc

Donor Procedure

If thoracic organs involved (approx 30-60 mins):

Flotation of Swann catheter Bronchoscopy

Midline laparotomy & midline sternotomy

Sternotomy will probably be performed by thoracic surgeons if involved

Preparation of vessels for cannulation & warm dissection of liver (approx 40-90 mins) Cardiac surgeons may then explore heart/lungs and prepare for cannulation (approx 45-60 mins) Dissection of porta hepatis & identification of liver arterial anatomy Division of CBD, washout of GB Dissection & slooping of supracoeliac aorta

Laparotomy & Sternotomy

Full exploration exclude gross pathology, assess liver / kidneys Liver: Size, colour, texture, edges, pathology, vessels, perfusion / congestion

Arterial access (common iliac or aortic bifurcation)

Portal Venous access (SMV or IMV)

Dissection of Porta Hepatis Arterial anatomy variants common

Single Left from LGA 73% 9%

Right from SMA 12%

Both Other 5% 1%

Dissection of supra-coeliac Aorta

Retract left lateral segment Divide diaphragmatic crus avoiding oesophagus Identify and encircle infradiaphragmatic aorta with Semb clamp and tape If left accessory artery is present do not dissect infra-diaphragmatic aorta. Aorta should be encircled in the chest or accessed to left of gastric fundus

Allow cardiac team to continue

Be helpful and polite Allow them to inspect the heart during your dissection ? Remain scrubbed while they are working in the chest Maintain good communication:
Bypass Cross-clamping Clamping of supra-diaphragmatic IVC Length of IVC Damage oesophagus or trachea Time of liver perfusion

Resume abdominal retrieval procedure

Abdominal team return to table

If thoracic retrieval both teams will be scrubbed

Heparinisation (30,000 units or 300 units/kg) L common iliac artery ligated R common iliac artery ligated distally & cannulated SMV ligated distally & cannulated
Ensuring tip of cannulae is in common trunk of PV

Thoracic surgeons cannulate Approx 20 mins Aorta ligated Perfusion commenced Bleed out via IVC in pericardial sac & infra renal
distal IVC ligated If thoracic organs then venting only via abdominal IVC

Cannulation

Tie distal SMV. Cut & introduce cannula Check position of tip & secure cannula If low - may perfuse splenic vein If high - unilateral perfusion of the liver

SMV Cannulation Tie distal CIA/aorta, clamp vessel proximally, Cut and introduce cannula (avoid dissection), first asst. fixes cannula

Right CIA Cannulation

IVC ready for Bleed Out (venting before perfusion essential)

Coordinate aortic cross clamp with cardiac team. Vent: divide supradiaphragmatic IVC. If cardiac team refuses, divide infrahepatic IVC Start perfusion

Next Few Minutes

a bit chaotic Cries of :

ICE. SLUSH ! IS THE SUCTION WORKING ? IS THE PERFUSION RUNNING ?

Anaesthetist should
disconnect anaesthetic machines Cut tape holding ET tube (prevents facial mark)

Surgeon can now provide spleen and lymph nodes for cross match and tissue typing for cardiac / renal grafts

Perfusion (cooling with slush, good bleedout, check perfusion)

Perfusion in Adult

Aortic cannula
3 litres of Marshalls solution at 80-100mmHg 4th litre of Marshalls trickled no pressure

Portal venous cannula

1 litre University of Wisconsin fluid no pressure

Back bench perfusion with U of W

Artery 250ml Bile duct 250ml Portal vein 500ml

Steps to minimise ischaemic type biliary strictures (ITBS)

Etiology: ?multifactorial CIT, damage by inspissated cold bile, poor perfusion of arterially supplied biliary tree Early division of CBD Open and washout gall bladder bile early Use low viscosity Marshalls aortic perfusion Pressurise arterial perfusion 80-100 mm Hg

Padbury et al Transplantation 1993 Pirenne et al, Transplantation 2002

Perfusion in Paediatrics
Donor Weight
<10kg

Aorta (ml)
In-Situ (Marshalls >15kg) Back Bench (UW)

Portal (ml)
In-Situ (UW) Back Bench (UW)

11-20Kg
21-30Kg 31-40Kg 41-50Kg Adults

600 1200 1800 2400 3000 3000

50 100 150 200 250 250

200 400 600 800 1000 1000

100 200 300 400 500 500

Perfusion in Special Cases

Paediatric donor
? Total UW perfusion

Small bowel retrieval

Total UW No SMV cannulation PV perfusion via IMV

Whole pancreas perfusion

If pancreas team require total UW then they provide this SMV perfusion as normal, Venting via IMV / SMV Accessory RHA contraindication to whole pancreas retrieval (arguments)

Pancreas for islets

As normal, vent portal venous system

Donor instability
Rapid cannulation all dissection in cold phase

Total heart lung bypass (Harefield)

Cannulate after cytoprotective temperature has been reached on bypass

Donor Procedure:
Cold Phase order of removal
Heart/lungs retrieved Liver retrieved Pancreas retrieved Kidneys retrieved Iliac arteries & veins, SMA Lymph nodes, spleen Tissue for research
Approx 30-90 mins

Hepatectomy cold phase

Mobilise liver, avoid tears (segment 6) Dissect and divide portal vein within pancreas Dissect arterial supply to aorta dividing splenic and LGA, check for accessory vessels Divide lower IVC above renal veins Cut through upper edge of right adrenal Divide diaphragm around upper IVC Cut aortic coeliac patch; include SMA if RHA from SMA Complete hepatectomy by cutting out wedge of diaphragm Liver into ice slush for bench perfusion

Hepatectomy aortic arterial patch!

Back Bench Perfusion/Dissection

Liver on Back Bench

Kidney Block on Back Bench

Donor Procedure: Cold Phase

Back bench perfusion

Liver, Kidneys

Packaging organs
Liver in 1-2l of Marshalls; 2 bags; NO AIR or ICE

Swab & instrument count Wound closure Packing of equipment Lead surgeon
Operation note (details essential in Coroners case) Organ specific forms

Thanks & Goodbyes

Total time 2-6 hrs

Additional vessels (Split Tx, Regrafts, PVT)

Iliac artery and veins, superior mesenteric artery (graduated vessel); long splenic artery

The End Result

Liver on Ice

En-Bloc Kidney
The Donor

The Results of Your Hard Work

Recipients at Tx Games

Split Liver Recipients

Liver Ready for Implantation

Summary

Excellent senior trainee procedure Skills: Surgical technique Communication Team-working Leadership Responsibility

Acknowledgements

Multi-organ retrieval team Procurement co-ordinators; consultant colleagues SB Donor hospitals Donor families

Thank you!