**3.1. Dissection of the organs with normal circulation (warm dissection)**

#### *3.1.1. Open of the abdomen and chest*

An incision is made from suprasternal notch to the point just above the symphysis pubis (**Figure 1**). The abdominal cavity is entered first, and a Balfour retractor is placed to have adequate exposure of the abdomen (**Figure 2**). The round ligament of the liver is divided and tied as well as the falciform ligament of the liver. Examination of intra-abdominal organs is carried out to exclude potential malignant disease. The quality of the liver is usually assessed at this stage, and liver biopsy should be taken if any concern is raised. The biopsy is taken by using F18 Trucut needle from the left and right lobe. An additional wedge biopsy is also taken for the frozen section and histopathology examination. Following that, the soft tissue over the sternum is cut opened by diathermy along the line for sternotomy. A tunnel is created behind the sternum by insertion of a pair of long Metzenbaum scissors to ensure that the posterior side of the sternum is clean from soft tissue attachment. The sternum is sawed open with bone wax applied to the cut surface. Hemostasis is reassured by using diathermy to all active bleeders. A sternal retractor is placed to open the chest. The pleura and pericardium are remained intact at this stage (**Figure 2**). If the donor had previous sternotomy for cardiac surgery, then the wires

over the sternum are removed, and a resternotomy saw is used for precise cut with caution. A surgical pack is placed over the chest wound to give the cardiothoracic team a nice clean field for subsequent heart and lung dissection. Now, the concentration is directed to the dissection

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The retro peritoneum is incised along the white line of Toldt from the cecum to the hepatic flexure. The dissection is continued along the retroperitoneal avascular plane superiorly and

of abdominal organs.

*3.1.2. Dissection of the distal aorta*

**Figure 2.** Retractors placed for exposure of abdominal organs.

**Figure 1.** Incision for multi-organ procurement.

Procurement of Abdominal Organs in Multi-Organ Donation in Deceased Donor http://dx.doi.org/10.5772/intechopen.77308 35

**Figure 1.** Incision for multi-organ procurement.

The surgical technique for abdominal multi-organ procurement is based on the anatomy and has been evolved over the decades as a result of the increased demand for organ transplantation [2–5]. In this chapter, the surgical technique is described with some pictures inserted to

It is mandatory for the surgeon in charge to check the documents: certification of brain death of the donor, the consent form for organ and tissue donation, signature of the hospital delegation, and the patient serology test. The team time-out should be carried out. The communication is confirmed between the surgeon and anesthetist for administration of medications at various stages. One dose of intravenous antibiotics is given intravenously, as well as 1 g of methylprednisolone prior to surgery. One dose of mannitol 20 g is given after completion of abdominal dissection. Heparin 25,000 IU is administered following cardiac team dissection prior to the cold perfusion. If the pancreas is retrieved for organ transplantation, 100 ml of half-strength betadine (5%) is injected through the nasogastric tube that is then clamped off during procedure to retain

Preparation and drape: under sterile condition, the surgical area from the lower part of the chin to the proximal one-third of the thigh is prepared. The hairs are shaved. The dressing and central venous catheter or femoral catheter is reorganized to ensure the surgical field is clean

An incision is made from suprasternal notch to the point just above the symphysis pubis (**Figure 1**). The abdominal cavity is entered first, and a Balfour retractor is placed to have adequate exposure of the abdomen (**Figure 2**). The round ligament of the liver is divided and tied as well as the falciform ligament of the liver. Examination of intra-abdominal organs is carried out to exclude potential malignant disease. The quality of the liver is usually assessed at this stage, and liver biopsy should be taken if any concern is raised. The biopsy is taken by using F18 Trucut needle from the left and right lobe. An additional wedge biopsy is also taken for the frozen section and histopathology examination. Following that, the soft tissue over the sternum is cut opened by diathermy along the line for sternotomy. A tunnel is created behind the sternum by insertion of a pair of long Metzenbaum scissors to ensure that the posterior side of the sternum is clean from soft tissue attachment. The sternum is sawed open with bone wax applied to the cut surface. Hemostasis is reassured by using diathermy to all active bleeders. A sternal retractor is placed to open the chest. The pleura and pericardium are remained intact at this stage (**Figure 2**). If the donor had previous sternotomy for cardiac surgery, then the wires

**3.1. Dissection of the organs with normal circulation (warm dissection)**

facilitate understanding of the progress of the surgery.

34 Organ Donation and Transplantation - Current Status and Future Challenges

**2. Preparation in theater**

betadine solution in the duodenum.

and neat for preparation and drape.

*3.1.1. Open of the abdomen and chest*

**3. Surgical procedure**

**Figure 2.** Retractors placed for exposure of abdominal organs.

over the sternum are removed, and a resternotomy saw is used for precise cut with caution. A surgical pack is placed over the chest wound to give the cardiothoracic team a nice clean field for subsequent heart and lung dissection. Now, the concentration is directed to the dissection of abdominal organs.

#### *3.1.2. Dissection of the distal aorta*

The retro peritoneum is incised along the white line of Toldt from the cecum to the hepatic flexure. The dissection is continued along the retroperitoneal avascular plane superiorly and medially to mobilize and retract ascending colon medially. The right ureter is easily identified and preserved with the surrounding tissue. The dissection is continued by a Cattell-Braasch and Kocher maneuver. The inferior duodenal fold is divided allowing broad exposure of the inferior vena cava (IVC) and aorta (**Figure 3**). The left renal vein should be well visualized at this stage, and superior mesentery artery is palpated at its origin from the aorta. The distal segment of the aorta is dissected, and inferior mesentery artery is ligated and divided allowing the distal segment of aorta exposed adequately. A size 2 Dacron tie is placed around the aorta at the level proximal to the bifurcation of the common iliac arteries, which is used for ligation of distal aorta prior to cold perfusion (**Figure 4**). The second size 2 Dacron tie is placed around the aorta a few centimeters proximally that is used for tying the cannula after its insertion to the aorta for cold perfusion. At this stage, the inferior mesentery vein (IMV) is readily visualized along the edge of dissected mesentery of sigmoid colon lateral to the proximal jejunum. If the portal system perfusion is required, then a segment of IMV can be dissected, and a 2/0 tie is encircled for cannula placement at later stage immediately prior to aorta cannula insertion (**Figure 4**). Currently, most transplant units do not perform in situ portal perfusion but give 500 ml of cold UW perfusion to the portal vein on the back table when packing the liver.

#### *3.1.3. Dissection of the liver*

Following dissection of the aorta, the attention is directed to the liver. The left triangle ligament of the liver is divided to free the left lobe of the liver. The hepato-gastric ligament is divided, but it is usually checked for left accessory hepatic artery that usually arises from the left gastric artery. It should be preserved if present. The common bile duct is identified and transected at the level close to the duodenum (**Figure 5**). The portal vein is then visualized. At this stage, it is usually checked whether there is a right accessory or replacement of hepatic artery posteriorly to the portal vein by palpation via the omentum of foramen (Winslow). It

usually arises from the superior mesentery artery. The hepato-duodenal ligament is divided. The right gastric artery and veins are tied and divided. The proper hepatic artery as well as the gastroduodenal artery is identified. A short length of gastroduodenal artery is dissected (**Figure 6**). Dissection of proper hepatic artery is continued toward celiac trunk. Then, the splenic artery and left gastric artery is seen, and a short segment is dissected, respectively, which is readily for transection after cold perfusion during procurement. The left gastric vein may be encountered, which is ligated and divided. The liver dissection is now completed.

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**Figure 4.** The distal aorta and inferior mesentery vein dissected.

**Figure 5.** Transection of the common bile duct.

**Figure 3.** Cattell-Braasch and Kocher maneuver for exposure of retroperitoneal structure.

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**Figure 4.** The distal aorta and inferior mesentery vein dissected.

medially to mobilize and retract ascending colon medially. The right ureter is easily identified and preserved with the surrounding tissue. The dissection is continued by a Cattell-Braasch and Kocher maneuver. The inferior duodenal fold is divided allowing broad exposure of the inferior vena cava (IVC) and aorta (**Figure 3**). The left renal vein should be well visualized at this stage, and superior mesentery artery is palpated at its origin from the aorta. The distal segment of the aorta is dissected, and inferior mesentery artery is ligated and divided allowing the distal segment of aorta exposed adequately. A size 2 Dacron tie is placed around the aorta at the level proximal to the bifurcation of the common iliac arteries, which is used for ligation of distal aorta prior to cold perfusion (**Figure 4**). The second size 2 Dacron tie is placed around the aorta a few centimeters proximally that is used for tying the cannula after its insertion to the aorta for cold perfusion. At this stage, the inferior mesentery vein (IMV) is readily visualized along the edge of dissected mesentery of sigmoid colon lateral to the proximal jejunum. If the portal system perfusion is required, then a segment of IMV can be dissected, and a 2/0 tie is encircled for cannula placement at later stage immediately prior to aorta cannula insertion (**Figure 4**). Currently, most transplant units do not perform in situ portal perfusion but give 500 ml of cold UW perfusion to the portal vein on the back table when packing the liver.

36 Organ Donation and Transplantation - Current Status and Future Challenges

Following dissection of the aorta, the attention is directed to the liver. The left triangle ligament of the liver is divided to free the left lobe of the liver. The hepato-gastric ligament is divided, but it is usually checked for left accessory hepatic artery that usually arises from the left gastric artery. It should be preserved if present. The common bile duct is identified and transected at the level close to the duodenum (**Figure 5**). The portal vein is then visualized. At this stage, it is usually checked whether there is a right accessory or replacement of hepatic artery posteriorly to the portal vein by palpation via the omentum of foramen (Winslow). It

**Figure 3.** Cattell-Braasch and Kocher maneuver for exposure of retroperitoneal structure.

*3.1.3. Dissection of the liver*

**Figure 5.** Transection of the common bile duct.

usually arises from the superior mesentery artery. The hepato-duodenal ligament is divided. The right gastric artery and veins are tied and divided. The proper hepatic artery as well as the gastroduodenal artery is identified. A short length of gastroduodenal artery is dissected (**Figure 6**). Dissection of proper hepatic artery is continued toward celiac trunk. Then, the splenic artery and left gastric artery is seen, and a short segment is dissected, respectively, which is readily for transection after cold perfusion during procurement. The left gastric vein may be encountered, which is ligated and divided. The liver dissection is now completed.

mesentery is dissected posteriorly along the avascular retroperitoneal attachments. A short segment of the superior mesentery artery and vein is dissected inferiorly to the pancreas and anteriorly to the fourth part of the duodenum by dividing some small arterial branches or venous tributaries. Care must be taken to avoid injury to the inferior pancreaticoduodenal artery, which

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The last dissection before the cold perfusion is to dissect supra celiac aorta under the diaphragm. The hepato-esophagus ligament is divided, and the esophagus is retracted left laterally. The aorta pulse is palpated, and the overlayer crus is divided to expose the aorta. A thin fascia layer is incised, and the aorta is freed from the surrounding attachment. A nylon type is slung over this segment of the aorta that is subsequently tied when the cold perfusion is commenced to limit the perfusion to the abdominal organs (**Figure 7**). Care must be taken not to injure the aorta in particular when trying to free the posterior part of the aorta for bringing through the nylon type. This part can be done later if the risk of bleeding is predicted. Alternatively, the segment of

At this stage the warm dissection to the multi-abdominal organs is completed. The gallbladder is incised open and flushed with normal saline until the outflow at the common bile duct becomes clear. The cardiothoracic team is informed for scrubbing and proceeds to heart-lung

A cold perfusion line is set up at this stage, and a large cannula is connected to the perfusion

*3.1.7. Insertion of the perfusion cannula into the aorta for cold perfusion (in situ cooling of the* 

arises proximal to the origin of the middle colic artery and supplies pancreas head [6, 7].

thoracic aorta in the left chest can be dissected and slung with a nylon type.

**Figure 7.** A segment of the aorta under the diaphragm dissected and slung with a nylon tape.

*3.1.6. Dissection of the aorta under the diaphragm*

line. The air bubbles are removed from the line.

dissection.

*organs)*

**Figure 6.** The proper hepatic artery and gastroduodenal artery dissected.

#### *3.1.4. Pancreas dissection*

The superior edge of the pancreas is partly exposed after dissection of proper hepatic artery. Then, the gastrocolic ligament is divided and ligated between the stomach and transverse colon. So, the anterior surface of the pancreas is visualized. The division is continued along the greater curvature of the stomach to its fundus, and gastrosplenic ligament is divided. The texture of the pancreas is properly assessed for suitability of transplantation. The spleen is always remained with the pancreas for procurement as a handle to prevent manipulation over the pancreas and reduce the risk of pancreatitis. The transverse mesocolon is divided as well as splenic-colon ligament on the left and duodenocolic ligament on the right side, and the inferior edge of the pancreas is exposed. The dissection is continued along the sigmoid colon and ascending colon allowing the colon retracted inferiorly or outside of the abdomen (this part of dissection can be done after cold perfusion). The superior mesentery vein (SMV) and superior mesentery artery (SMA) are identified inferiorly to the pancreas and anteriorly to the third part of the duodenum, which are slung with a 2/0 Vicryl tie, respectively, and subsequently tied and divided during pancreas procurement after cold perfusion.

#### *3.1.5. Dissection of the small intestine*

In rare circumstance, procurement of the small intestine may be required as part of multi-organ donation. In such case, the abdominal multi-organ procurement should be performed by the team who performs intestinal transplantation. After the laparotomy, the intestine is examined and wrapped in a surgical pack. The entire large intestine is dissected and placed caudally outside of the abdomen. The ileal branches of the ileocolic artery are preserved. Proximally, the small intestine is divided at the jejunum 5–10 cm post Treitz, and distally the small intestine is divided near the ileocecal valve by GIA stapler. A mark suture is placed at the jejunal end for orientation of the intestinal graft at transplantation. The small intestine is lifting upward, and the mesentery is dissected posteriorly along the avascular retroperitoneal attachments. A short segment of the superior mesentery artery and vein is dissected inferiorly to the pancreas and anteriorly to the fourth part of the duodenum by dividing some small arterial branches or venous tributaries. Care must be taken to avoid injury to the inferior pancreaticoduodenal artery, which arises proximal to the origin of the middle colic artery and supplies pancreas head [6, 7].

#### *3.1.6. Dissection of the aorta under the diaphragm*

*3.1.4. Pancreas dissection*

**Figure 6.** The proper hepatic artery and gastroduodenal artery dissected.

38 Organ Donation and Transplantation - Current Status and Future Challenges

*3.1.5. Dissection of the small intestine*

The superior edge of the pancreas is partly exposed after dissection of proper hepatic artery. Then, the gastrocolic ligament is divided and ligated between the stomach and transverse colon. So, the anterior surface of the pancreas is visualized. The division is continued along the greater curvature of the stomach to its fundus, and gastrosplenic ligament is divided. The texture of the pancreas is properly assessed for suitability of transplantation. The spleen is always remained with the pancreas for procurement as a handle to prevent manipulation over the pancreas and reduce the risk of pancreatitis. The transverse mesocolon is divided as well as splenic-colon ligament on the left and duodenocolic ligament on the right side, and the inferior edge of the pancreas is exposed. The dissection is continued along the sigmoid colon and ascending colon allowing the colon retracted inferiorly or outside of the abdomen (this part of dissection can be done after cold perfusion). The superior mesentery vein (SMV) and superior mesentery artery (SMA) are identified inferiorly to the pancreas and anteriorly to the third part of the duodenum, which are slung with a 2/0 Vicryl tie, respectively, and

subsequently tied and divided during pancreas procurement after cold perfusion.

In rare circumstance, procurement of the small intestine may be required as part of multi-organ donation. In such case, the abdominal multi-organ procurement should be performed by the team who performs intestinal transplantation. After the laparotomy, the intestine is examined and wrapped in a surgical pack. The entire large intestine is dissected and placed caudally outside of the abdomen. The ileal branches of the ileocolic artery are preserved. Proximally, the small intestine is divided at the jejunum 5–10 cm post Treitz, and distally the small intestine is divided near the ileocecal valve by GIA stapler. A mark suture is placed at the jejunal end for orientation of the intestinal graft at transplantation. The small intestine is lifting upward, and the The last dissection before the cold perfusion is to dissect supra celiac aorta under the diaphragm. The hepato-esophagus ligament is divided, and the esophagus is retracted left laterally. The aorta pulse is palpated, and the overlayer crus is divided to expose the aorta. A thin fascia layer is incised, and the aorta is freed from the surrounding attachment. A nylon type is slung over this segment of the aorta that is subsequently tied when the cold perfusion is commenced to limit the perfusion to the abdominal organs (**Figure 7**). Care must be taken not to injure the aorta in particular when trying to free the posterior part of the aorta for bringing through the nylon type. This part can be done later if the risk of bleeding is predicted. Alternatively, the segment of thoracic aorta in the left chest can be dissected and slung with a nylon type.

At this stage the warm dissection to the multi-abdominal organs is completed. The gallbladder is incised open and flushed with normal saline until the outflow at the common bile duct becomes clear. The cardiothoracic team is informed for scrubbing and proceeds to heart-lung dissection.
