*3.2.1. Procurement of the small intestine*

After completion of the cold perfusion, the small intestine is harvested first. The superior mesentery artery and vein are divided below the origin of inferior pancreaticoduodenal artery, and the entire small intestine is removed and placed in ice-slush filled basin for package and transportation. The bowel contents are remained in the intestine and are managed at the time of transplantation. The small intestine can be harvested en bloc with liver and pancreas, and separation is performed on the back table [6, 7].

#### *3.2.2. Procurement of the liver*

Following procurement of the heart and lung by cardiothoracic team, the liver is taken first for the abdominal organs if the small intestine is not for procurement. The gastroduodenal artery is tied and divided. The portal vein is divided at the level of 1 cm proximal to the junction of splenic vein and superior mesentery vein if the pancreas is retrieved for transplantation. Otherwise, the division can be at the level of the confluence of splenic vein and SMV. The splenic artery is divided 0.5 cm from its origin arising from the celiac trunk as well as left gastric artery. However, if the left accessory hepatic artery is present arising from the left gastric artery, then the left gastric artery is preserved on the celiac trunk for its continuity to the left hepatic accessory artery. Along the celiac trunk, the celiac complex and lymphatic tissues are divided at the left side of aorta, and the aorta is exposed. An aortic patch is excised around the ostium of the celiac trunk. If the right accessory or replacement hepatic artery is present, then the SMA is better included in the aortic patch with celiac trunk. If the pancreas is also harvested for transplant, then the SMA is divided just above the level where the accessory hepatic artery arises. So, both liver and pancreas are suitable for transplant without jeopardizing its vasculature. After that the attention is directed to the IVC. The anterior wall of the IVC is incised transversely above the level of renal vein. Both entrance of left and right renal vein is checked, and the IVC is transected. The IVC is lifted anteriorly by insertion of a finger from the suprahepatic end, and its posterior side is dissected to reach the suprahepatic end. The posterior side of the IVC is dissected superiorly to the level of division just below the atrium. Care is taken during IVC dissection without jeopardizing the quality of renal vein for kidney transplantation. The right hepatic triangle ligament is dissected, and part of the diaphragm is taken with the liver during the procurement. The liver is now removed freely from the abdomen and immersed in the ice-slush filled basin (**Figure 8**). One technical point is that the liver laceration is easy to occur at the location where the adhesion band is present. Therefore, gentle handling of the liver is emphasized during the dissection and procurement of the liver at all times to avoid the potential injury.

#### *3.2.3. Procurement of the pancreas*

After heart-lung dissection, Heparin 25,000 IU is given intravenously. The distal part of the aorta is tied by pre placed Dacron tie just above the bifurcation of the common iliac arteries. A vascular clamp is placed onto the aorta about 5 cm proximally to this tie to block the blood flow to this segment of the aorta where an arteriotomy is made. The cannula is inserted via arteriotomy and is tied by a pre placed Dacron tie. The cannula is secured and the vascular clamp is removed. At this point, the cold perfusion is commenced simultaneously with cardiothoracic perfusion. The IVC is divided just below the right atrium above the diaphragm for draining the blood and perfusion fluid. Attention is made to leave adequate length of IVC with the liver at suprahepatic end. Alternatively, incision of IVC can be made at the lower part just proximal to the level of confluence of common iliac veins. A suction tube can be placed into the vena cava for adequate drainage of the perfusion fluid. At least, three sets of suction line are used to have proper evacuation of the blood and fluid during perfusion period. At the same time, the ice slush is poured into the abdominal cavity over the liver, pancreas, kidney, and intestine for immediate topical cooling of the organs. Usually, 2 L of Hartman fluid is used for initial flush of the blood followed by 4 L of UW preservation solution. The organs are checked in the meantime to ensure that the

progression of perfusion is adequate. The in situ cold perfusion takes about 20 min.

After completion of the cold perfusion, the small intestine is harvested first. The superior mesentery artery and vein are divided below the origin of inferior pancreaticoduodenal artery, and the entire small intestine is removed and placed in ice-slush filled basin for package and transportation. The bowel contents are remained in the intestine and are managed at the time of transplantation. The small intestine can be harvested en bloc with liver and pancreas, and

Following procurement of the heart and lung by cardiothoracic team, the liver is taken first for the abdominal organs if the small intestine is not for procurement. The gastroduodenal artery is tied and divided. The portal vein is divided at the level of 1 cm proximal to the junction of splenic vein and superior mesentery vein if the pancreas is retrieved for transplantation. Otherwise, the division can be at the level of the confluence of splenic vein and SMV. The splenic artery is divided 0.5 cm from its origin arising from the celiac trunk as well as left gastric artery. However, if the left accessory hepatic artery is present arising from the left gastric artery, then the left gastric artery is preserved on the celiac trunk for its continuity to the left hepatic accessory artery. Along the celiac trunk, the celiac complex and lymphatic tissues are divided at the left side of aorta, and the aorta is exposed. An aortic patch is excised around the ostium of the celiac trunk. If the right accessory or replacement hepatic artery is present, then the SMA is better included in the aortic patch with celiac trunk. If the pancreas is also harvested for transplant, then the SMA is divided just above the level where the accessory hepatic artery arises. So, both liver and pancreas are suitable for transplant without jeopardizing its vasculature. After that the attention is directed to the IVC. The anterior wall of the IVC is incised transversely above the level of renal vein. Both entrance of left and right renal vein

**3.2. Procurement of abdominal organs (cold procurement)**

40 Organ Donation and Transplantation - Current Status and Future Challenges

*3.2.1. Procurement of the small intestine*

*3.2.2. Procurement of the liver*

separation is performed on the back table [6, 7].

The pancreas can be retrieved in favor with liver as an en bloc as described in a separate paragraph. Here, we describe a technique for pancreas retrieval as a subsequent procedure following the liver procurement. A 6/0 Prolene suture is placed at the transection of the port vein and splenic artery, respectively, as a mark during the liver procurement if known the pancreas is also procured. A segment of duodenum is routinely procured with the pancreas as exocrine drainage. A GIA stapler is used to divide the duodenum from the stomach distal to the pylorus. Care is taken to ensure that the NGT tube is positioned proximal to the pylorus without being caught in the GIA stapler. A reload GIA is needed to divide the distal part of the duodenum at the level of the fourth part of the duodenum or at the beginning of the jejunum. The distal part of the SMA and SMV is tied, respectively, by pre placed 2/0 Vicryl tie and divided. The transverse mesocolon is divided to free the inferior edge of the pancreas. On the left the dissection is continued to the splenic flexure and on the right to the duodenocolic ligament, which are divided together with the root of mesentery. So, the pancreas with attached duodenum is now free from its attachment. Then, the pancreas is lifted

**Figure 8.** Liver graft harvested and immersed in ice slush.

anteriorly by holding the spleen, and the dissection to its posterior attachment is performed from the tail toward the body of the pancreas. At this point, the SMA is excised with a small aortic patch, and the pancreas is removed from abdomen and placed in the ice-slush filled basin. Care must be taken during excision of the SMA without jeopardizing the renal artery.2

#### *3.2.4. Procurement of the liver and pancreas as an en bloc*

The liver and pancreas are preferred to have en bloc procurement to minimize warm ischemic injury to these organs. Following cold perfusion, the proximal and distal part of the duodenum is transected by using GIA stapler at the level distal to the pylorus and the fourth part of the duodenum, respectively. The distal part of the SMA and SMV is tied by pre placed 2/0 Vicryl tie and divided. The Transverse mesocolon is divided, and the division is continued on the left to the splenic flexure and on the right to the duodenocolic ligament, which are also divided and the colon retracted inferiorly. The spleen is lifted anteriorly as a handle of the pancreas for dissection posterior to the pancreas. The SMA is excised at the inferior edge with a small aortic patch that is extended superiorly to include the celiac trunk on the same aortic patch. The left gastric artery is divided. The attention is directed to the IVC. The IVC is divided just proximal to the level of the entrance by the renal veins, and the dissection to its posterior is continued superiorly to reach the suprahepatic end of the IVC. At this stage, the liver and pancreas are free to be removed from the abdominal cavity and immersed in an ice basin for separation from each other on the back table [2].

*3.2.6. Procurement of the kidney on en bloc*

**Figure 9.** Right kidney harvested and immersed in ice slush.

*3.2.7. Procurement of the iliac vessels*

kidneys with ureters anteriorly to facilitate the dissection.

kidney is inspected as described above and packed for transportation.

Alternatively, the kidneys can be procured on en bloc [5] and separated in the ice basin on a back table. The technique is faster to remove the kidney from the abdomen and minimize the risk of warm ischemic injury. In particular, it is preferred for procurement of the kidneys in DCD donors. The bowel is retracted anteriorly and superiorly. The kidneys, the aorta, and the vena cava are left in situ. The aorta and vena cava is transected at the level of its arteriotomy for the cannula. The right ureter is identified and divided at the level crossing over the iliac vessels as well as the left ureter. The ureter is dissected toward the renal hilum with plenty of surrounding tissues to prevent the injury to its blood supply. The dissection is continued superiorly along the plane posterior to Gerota's fascia but anterior to the psoas muscle and spine until reaching the superior end of the aorta and vena cava. Both kidneys are procured and placed in an ice basin on the back table. During the dissection, the assistant holds up both

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The kidneys are separated on the back table. The left renal vein is excised with a patch at its entrance to the IVC. The anterior side of the aorta is cleaned and incised along its midline allowing the equivalent patch to each side of the renal artery. Similarly, the posterior side of the aorta is incised along the midline. The ostium of the renal artery is inspected as well as the numbers of the renal artery are checked. The kidneys are now separated from each other. The

A segment of the iliac arteries and veins are harvested as long as possible toward the distal part of the femoral artery and veins. The iliac artery and vein can be taken separately or together as one bundle. Care is taken to avoid injury by over pulling on the vessels. The vessels are stored in a sterile jar with UW solution and parked with two more layers of sterile bags for transportation.

#### *3.2.5. Procurement of the kidneys*

The kidneys are the lastly procured abdominal organs. Therefore, care must be taken during cooling and procurement phase to ensure that the kidneys are properly cooled by placing enough ice slush at its surrounding, in particular at its posterior and lateral sides [8].

The right kidney is retrieved first. The bowel is placed superiorly, and the kidneys, the vena cava, and the aorta are left in situ. The perfusion cannula is removed, and the aorta is transected at this level. The superior end of the aorta is also transected at the level where the SMA aortic patch is excised. The left renal vein is excised with a small patch from the vena cava and dissected away from the aorta. The anterior part of the aorta is split open as well as the posterior part of the aorta. Care is taken to keep an equal aortic patch with each side of the renal artery. The renal arteries are inspected at this point and are remained on its patch. The IVC is transected at the level of the confluence of common iliac veins. The right ureter is divided at the level of iliac vessels. The ureter is lifted anteriorly, and its posterior is dissected toward the kidney along the plane anterior to the major psoas muscle. Care is taken to retain plenty of surrounding tissues with the ureter. Then, the kidney is lifted anteriorly within Gerota's fascia together with the ureter, and its posterior side is dissected from the psoas muscle. The dissection is continued posteriorly to the IVC, and the right half of the aortic patch until the kidney is free from the attachment. The right kidney is then removed as a pack from the abdomen and placed in the basin filled with ice slush (**Figure 9**). Care is taken to ensure that the dissection is along the surface of the psoas muscle and spine. So, the injury to the renal artery and renal vein is prevented. The left kidney is procured in the same method as the right kidney.

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**Figure 9.** Right kidney harvested and immersed in ice slush.

#### *3.2.6. Procurement of the kidney on en bloc*

anteriorly by holding the spleen, and the dissection to its posterior attachment is performed from the tail toward the body of the pancreas. At this point, the SMA is excised with a small aortic patch, and the pancreas is removed from abdomen and placed in the ice-slush filled basin. Care must be taken during excision of the SMA without jeopardizing the renal artery.2

The liver and pancreas are preferred to have en bloc procurement to minimize warm ischemic injury to these organs. Following cold perfusion, the proximal and distal part of the duodenum is transected by using GIA stapler at the level distal to the pylorus and the fourth part of the duodenum, respectively. The distal part of the SMA and SMV is tied by pre placed 2/0 Vicryl tie and divided. The Transverse mesocolon is divided, and the division is continued on the left to the splenic flexure and on the right to the duodenocolic ligament, which are also divided and the colon retracted inferiorly. The spleen is lifted anteriorly as a handle of the pancreas for dissection posterior to the pancreas. The SMA is excised at the inferior edge with a small aortic patch that is extended superiorly to include the celiac trunk on the same aortic patch. The left gastric artery is divided. The attention is directed to the IVC. The IVC is divided just proximal to the level of the entrance by the renal veins, and the dissection to its posterior is continued superiorly to reach the suprahepatic end of the IVC. At this stage, the liver and pancreas are free to be removed from the abdominal cavity and immersed in an ice

The kidneys are the lastly procured abdominal organs. Therefore, care must be taken during cooling and procurement phase to ensure that the kidneys are properly cooled by placing

The right kidney is retrieved first. The bowel is placed superiorly, and the kidneys, the vena cava, and the aorta are left in situ. The perfusion cannula is removed, and the aorta is transected at this level. The superior end of the aorta is also transected at the level where the SMA aortic patch is excised. The left renal vein is excised with a small patch from the vena cava and dissected away from the aorta. The anterior part of the aorta is split open as well as the posterior part of the aorta. Care is taken to keep an equal aortic patch with each side of the renal artery. The renal arteries are inspected at this point and are remained on its patch. The IVC is transected at the level of the confluence of common iliac veins. The right ureter is divided at the level of iliac vessels. The ureter is lifted anteriorly, and its posterior is dissected toward the kidney along the plane anterior to the major psoas muscle. Care is taken to retain plenty of surrounding tissues with the ureter. Then, the kidney is lifted anteriorly within Gerota's fascia together with the ureter, and its posterior side is dissected from the psoas muscle. The dissection is continued posteriorly to the IVC, and the right half of the aortic patch until the kidney is free from the attachment. The right kidney is then removed as a pack from the abdomen and placed in the basin filled with ice slush (**Figure 9**). Care is taken to ensure that the dissection is along the surface of the psoas muscle and spine. So, the injury to the renal artery and renal vein is prevented. The left

enough ice slush at its surrounding, in particular at its posterior and lateral sides [8].

*3.2.4. Procurement of the liver and pancreas as an en bloc*

42 Organ Donation and Transplantation - Current Status and Future Challenges

basin for separation from each other on the back table [2].

kidney is procured in the same method as the right kidney.

*3.2.5. Procurement of the kidneys*

Alternatively, the kidneys can be procured on en bloc [5] and separated in the ice basin on a back table. The technique is faster to remove the kidney from the abdomen and minimize the risk of warm ischemic injury. In particular, it is preferred for procurement of the kidneys in DCD donors. The bowel is retracted anteriorly and superiorly. The kidneys, the aorta, and the vena cava are left in situ. The aorta and vena cava is transected at the level of its arteriotomy for the cannula. The right ureter is identified and divided at the level crossing over the iliac vessels as well as the left ureter. The ureter is dissected toward the renal hilum with plenty of surrounding tissues to prevent the injury to its blood supply. The dissection is continued superiorly along the plane posterior to Gerota's fascia but anterior to the psoas muscle and spine until reaching the superior end of the aorta and vena cava. Both kidneys are procured and placed in an ice basin on the back table. During the dissection, the assistant holds up both kidneys with ureters anteriorly to facilitate the dissection.

The kidneys are separated on the back table. The left renal vein is excised with a patch at its entrance to the IVC. The anterior side of the aorta is cleaned and incised along its midline allowing the equivalent patch to each side of the renal artery. Similarly, the posterior side of the aorta is incised along the midline. The ostium of the renal artery is inspected as well as the numbers of the renal artery are checked. The kidneys are now separated from each other. The kidney is inspected as described above and packed for transportation.

#### *3.2.7. Procurement of the iliac vessels*

A segment of the iliac arteries and veins are harvested as long as possible toward the distal part of the femoral artery and veins. The iliac artery and vein can be taken separately or together as one bundle. Care is taken to avoid injury by over pulling on the vessels. The vessels are stored in a sterile jar with UW solution and parked with two more layers of sterile bags for transportation.

The iliac arteries and veins are routinely retrieved for vascular reconstruction during liver and pancreas transplantation. In pancreas transplantation, the common iliac artery, the external iliac artery, and the internal iliac artery are used as a "Y" graft for reconstruction to the stumps of the splenic artery and SMA and then anastomosed to the recipient common iliac artery at the transplantation. Generally, one set of iliac vessels is sent with the liver, and another set is sent with the pancreas.

**4.3. Kidneys**

**5. Conclusion**

**Acknowledgements**

**Conflict of interest**

**Author details**

Bulang He1

There is no conflict of interest.

Nedlands, Perth, Australia

\*, Xiuwu Han2

The University of Melbourne, Austraila

tion with the document enclosed.

Each kidney is inspected by dissection open the perinephric fat. The quality of perfusion is checked and the mass lesion is excluded. The kidney is placed in the first sterile plastic bag that is filled with 500 ml of UW solution and tied. The first bag is placed into the second bag that is filled with 1 L cold normal saline and tied. The second bag is placed into the third bag and tied. The kidney is placed in the Iskey and buried in the ice blocks for transporta-

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Multi-organ procurement is essential for organ transplantation, and proper training is mandatory. It usually involves a few transplant units for organ allocation prior to confirmation of the surgical time. The communication between all parties is very important to minimize the ischemic time and achieve the good outcome for organ transplantation. It should be bore in mind that the anatomical variation may be encountered during the surgery, and care must be taken to avoid any damage to the vessels and organs, which may jeopardize the organ transplantation. Establishment of a surgical protocol is encouraged to achieve a national-wide

standard and consistence for organ sharing among the transplant units.

and Michael A. Fink3

1 Medical School, The University of Western Australia, Sir Charles Gairdner Hospital,

2 Beijing Chaoyang Hospital (West Campus), Capital Medical University, Beijing, China

3 Department of Surgery/Austin Health, Medicine Dentistry and Health Sciences,

\*Address all correspondence to: bulang.he@health.wa.gov.au

We would like to acknowledge DonateLife of Western Australia for their contribution.
