**7.3 Dissection of abdominal organs and large vessel cannulation**

Every disturbing adhesion from previous surgeries should be released first to prevent jeopardizing the bowel wall. Superior mesenteric vein is dissected and controlled in the root of mesentery just to the right side of the Treitz ligament and the inferior mesenteric vein in the edge of this ligament. Cephalad retraction of the transverse mesocolon and caudal retraction of small bowel will better expose these two anatomic landmarks. After that, abdominal aorta and inferior vena cava (IVC) are fully exposed and controlled for cannulation by a complete right medial rotation of abdominal viscera from pelvic area till the infra-duodenal area superior to both renal veins. This step has to be done with caution to find all accessory renal arteries and prevent any inadvertent injury to lumbar arteries or veins which will result in uncontrollable or disturbing bleeding. If the distal aorta is not cannulable, the iliac arteries can be used instead. Inferior mesenteric artery (IMA) can be ligated and both ureters can be mobilized at this step but without any trauma to the tissues common between the ureters and genital veins.

Lesser sac is entered through the gastrohepatic ligament with caution not to injure potential left accessory hepatic artery. Left lateral segment of the liver is taken down from the diaphragm and supra-celiac aorta is exposed by blunt dissection of diaphragmatic crura and setting aside the abdominal esophagus and then controlled by an umbilical tape. If such dissections are impossible due to previous adhesions or any other reason, then thoracic aorta should be controlled in the left hemithorax just above the diaphragm and anterior to the lower thoracic vertebra.

At this stage, if "rapid flush technique" is chosen due to patient's instability, the operation is ended by full heparinization and aortic and portal cannulation, clamping the aorta and cutting the abdominal or infra-atrial IVC for blood evacuation along with the infusion of the preservative solution and covering all the viscera by slush ice.

If the patient is stable further dissections will be done. Bile duct is transected above the duodenum and flushed with 20 ml of cold normal saline. Cholecystectomy is performed. Gastroduodenal artery is explored in upper border of pancreas. If pancreas is suitable for transplantation, duodenum is prepared just next to the pylorus and after the pancreas uncinate process, posterior to transverse colon for transection at the end of operation and superior mesenteric artery is controlled just above the renal arteries root anterior to aorta. The cardiac team is now can come into the operation field.

## *7.3.1 Tips and tricks*

In patients with history of heart surgery or median sternotomy, thoracic incision should be postponed till all the abdominal dissections and cannulation of the great vessels have been finished.

In patients with history of previous abdominal operations, incision should be started as far as possible from the site of previous incision to prevent bowel perforation.

In fatty donors, it is better to perform superior or inferior mesenteric vein dissections, because after full Kocherization and right medial visceral rotation, finding the mesenteric vein will be very difficult.

If during each step of the dissections, any vascular damage is encountered, it is better to repair it with fine sutures only if the location of the damage is easily found and repairable. In other cases, no attempt should be done, because it is time consuming and may cause further damage to critical organs.

During the cannulation of the aorta, the cannula should not be advanced above the celiac artery. Clamping the supra-celiac aorta at the end of the procedure will
