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!