**7.2 Starting the operation**

**Table 2** shows the checklist for essential pre-requisites of the donor characteristics before starting the operation. The surgical team should confirm that all the data in this checklist is ready and acceptable before starting the operation. Usually in most transplant units, the "liver team" is in charge of the whole operation and the operation is started by the most experienced and self- sufficient surgeon in this team by a long midline incision from jugular notch to symphysis pubis in the stable patient. In unstable patients all the steps of the operation may be omitted and replaced by femoral artery and vein cannulation for cold infusion of the preservative fluid and evacuation of the blood and after that all the dissections should be done after in situ cooling and aortic cross clamping below or above the diaphragm.

The time of the starting of the incision must be fully coordinated by all the other team members, coordinators and the in-hospital and out of hospital transport system to decrease the total ischemic time to the lowest possible time. It is better not to transfer the donor to other hospitals and in most countries, it is the procurement team that should go the donor hospital and they should have all the equipment, drugs, preservative solutions, organ bags, cool-boxes and surgical instruments that is essential with themselves. The leader of the team should finally check all the prerequisites of the organ donation operation including informed consent of donation,


#### **Table 2.**

*Checklist for donor preparedness before starting the operation.*

brain death confirmation (patient identity and certificate of death), important blood tests (especially the blood group and viral tests), previous history (especially history of untreated cancer and previous surgeries) and suitability of the donor just before the operation. Discussion of the steps of the operation with other teams will decrease potential injury to the retrievable organs.

A general physical exam is absolutely necessary because all palpable masses in the unexposed area such as breasts, genitalia, axillary and inguinal regions or any skin lesions which are suspicious for malignancies should be excised for pathologic examination.

Every surgeon has to use his or her maximum delicate surgical art to prevent any harm to any of the transplantable organs. For example, if the donor has previous midline sternotomy incision with potential adhesions of the heart, the thoracic incision should be delayed until all abdominal dissections are completed. Sternum may be incised by Gigli's saw or Stryker® sternal saw if available. After incision, complete hemostasis of all cutting surfaces is essential to prevent obscuring bleeding and suitable retractors such as large Finochietto retractors are placed for maximum exposure of the organs. All the organs should be explored for potential contraindications for donation such as congenital anomalies, malignancies or severe infective processes such as colon perforation or peritonitis.
