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Liver donation: surgical techniques
Transplantation Reviews 19 (2005) 108 – 114 www.elsevier.com/locate/trre
Liver donation: surgical techniques Andrew M. CameronT, Hasan Yersiz, Ronald W. Busuttil Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-7054, USA
Abstract Efficient and technically sound graft procurement is an integral component of a liver transplant recipient’s immediate and eventual outcome. Furthermore, the current era of organ scarcity increases the demand on the donor surgeon to extract the maximum potential from the existing pool, including the assessment and use of expanded criteria donors, nonheart beating donors, and the splitting of deceased donors to supply 2 recipients. The techniques described here represent the authors’ combined experience with over 20 years and 3000 procurements. They are widely applicable to a broad patient population and can be routinely performed at donor hospitals without specialized equipment or staff. D 2005 Elsevier Inc. All rights reserved.
1. The donor operation: conventional adult deceased donor procurement The procedure described here is an adaptation of the initial procurement technique of Starzl et al [1-3]. The time from skin incision to aortic cross-clamping is typically less than 30 minutes, and the entire harvest takes approximately 1 hour. Good communication with the donor hospital’s operating room (OR) staff and the other teams present at the procurement is essential for maximal efficiency. Positioning of the donor is supine with arms tucked at the sides. Two Bovies and 2 Yankauer tipped suckers will be required. The prep is with Betadine from chin to thigh. The incision is midline and extends from the suprasternal notch to the pubis (Fig. 1). If 2 experienced surgeons are present, the surgeon on the patient’s left (referred to as bthe assistant Q) begins by opening the chest whereas the surgeon on the patient’s right (bthe donor surgeonQ) enters the abdomen. First, the round ligament is divided between heavy silk sutures, and the falciform ligament is divided back to the inferior vena cava (IVC)-hepatic vein confluence. The left triangular ligament is taken down and the liver evaluated for quality (color, texture, parenchyma quality, and size). A large Balfour retractor is placed and secured with penetrating towel clamps. The chest is then opened with a pneumatic sternal
T Corresponding author. Tel.: +1 310 206 3781; fax: +1 310 206 7760. E-mail address: [email protected] (A.M. Cameron). 0955-470X/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.trre.2005.06.001
saw or Lebsche knife while ventilation is held; 2 blue towels are inserted after which a Finochietto’s sternal retractor is placed. The pericardium is entered through a midline incision at the diaphragm and extended to above the right atrium. Lastly, the right side of the chest is opened widely through the parietal pleura. Next, the hepatic arterial (HA) anatomy is evaluated. The donor surgeon retracts the left lateral segment to the patient’s right and examines the gastrohepatic ligament for the presence of a replaced left hepatic artery, which originates from the left gastric artery approximately 10% to 15% of the time [4,5]. If present, this variant can be identified crossing transversely from the lesser curve of the stomach across the gastrohepatic ligament to the umbilical fissure. The pars flaccida overlying the caudate lobe is lifted and Bovied in a clear thin area, and if no replaced left HA is present, the lesser omentum is completely divided. If a replaced left HA is present, the gastrohepatic ligament is divided above and below the replaced vessel. Now, a Cattell-Braasch maneuver is performed mobilizing the right colon and duodenum medially [6]. The right colon and small bowel are moved out of the incision to the donor’s left exposing the IVC, aorta, and ultimately the inferior mesenteric vein (IMV) lateral to the ligament of Treitz and duodenum. The IMV is dissected close to the root of the transverse mesocolon and twice encircled with 2-0 silk ties (Fig. 2). Portal infusion bprecoolQ is now begun with plasmalyte solution. If donor serum sodium is greater than 160, then D5W should be used for precool instead of plasmalyte solution [7].
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Fig. 1. The incision extends from suprasternal notch to symphysis pubis. A large Balfour retractor with deep blades is used in the abdomen. Reprinted with permission from Emre et al [3].
Portal perfusion is preferred by the authors and is routinely used though it is ultimately an optional step in liver procurement. Theoretic disadvantages are prolonged operative time and handling of organs, especially in unstable donors. Arguments in favor of portal perfusion invoke faster cooling and more thorough perfusion of the liver, perhaps especially important with extended criteria donors. Multiple studies show no statistical difference in graft performance or patient outcome with or without portal perfusion, but these studies were low in patient number and did not involve extended criteria donors [8,9]. In our experience, portal perfusion adds very little time to the procurement procedure and is felt to be advantageous especially in cases of donors with high serum sodium or other extended criteria. After portal perfusion is established, attention is turned to the distal aorta, which is dissected at the bifurcation below the takeoff of the inferior mesenteric artery. Using a blunt right angle clamp with care to avoid injury to the neighboring IVC, the aorta is surrounded with 2 pieces of umbilical tape. The more proximal of which is captured with a Rommel pump tourniquet in preparation for eventual cannulation.
The ascending colon and the small bowel are returned to the abdomen, and the attention is next turned to the distal common bile duct (CBD) and the gallbladder. The CBD is identified and isolated with a 2-0 silk tie avoiding the portal vein just beneath and medial. The donor surgeon inserts an index finger into the foramen of Winslow and palpates the porta hepatis to feel for a replaced right hepatic artery lateral and posterior to the CBD. This variant will be present about 10% of the time [4]. The CBD is nicked anteriorly at the 12 o’clock position using Metzenbaum scissors. Next, the gallbladder fundus is incised and the bile is evacuated (Fig. 3). An asepto syringe filled with cold saline is inserted and the gallbladder flushed until clear effluent is seen to issue from the distal CBD knick. The left colon is now mobilized medially to make space for the upcoming placement of ice slush around the left kidney. The donor surgeon retracts the descending colon, and the assistant liberates it at the white line of Toldt. The donor surgeon covers and lifts the left kidney and spleen as the assistant mobilizes the viscera medially ultimately exposing the psoas muscle.
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Fig. 2. The portal vein is cannulated via the IMV. The distal aorta is cannulated just above the bifurcation with care to place the tip of the perfusion cannula below the renal artery orifices. Reprinted with permission from Emre et al [3].
The supraceliac aorta is now encircled. The donor surgeon retracts the left lateral segment to the patient’s right side, and using the Bovie, a vertical incision is made in the right diaphragmatic crus at the midline. The esophagus is retracted out of the way to the patient’s left by the assistant. The donor surgeon inserts a finger and lifts the soft tissue toward the ceiling. The aorta is identified and the assistant surgeon lifts the perivascular soft tissue with forceps. The donor surgeon incises this tissue on each side downward toward the floor. Now, a right angle is passed by the donor surgeon from the patient’s right to left, and an umbilical tape is passed around the aorta to facilitate eventual crossclamp. A straight vascular clamp will be used for this purpose, and its availability should be confirmed. The pleura is opened in the chest and the suprahepatic IVC identified for venting. Thirty thousand units of heparin are given (500 U/kg for pediatric donors) along with 25 g of mannitol and 100 mg of intravenous Lasix. Three minutes later, the aorta is cannulated with a 22-F reinforced cardiac catheter. The catheter tip is positioned approximately 4 cm above the aortotomy, below the takeoff of the superior mesenteric artery (SMA) and renal arteries. In cases of severe atherosclerosis or aneurysm, the right iliac artery may be cannulated instead and the left iliac artery ligated or vice versa. The Organ Procurement Organization (OPO) coordinator, other recovering teams, and the anesthesia team are now notified that abdominal dissection is complete and that cross-clamp and cold perfusion are now imminent.
Proceeding rapidly but carefully, the supraceliac aorta is cross-clamped. Next, the suprahepatic IVC is deeply incised at the cavoatrial junction if there is no heart team. (Otherwise, the vena cava is cut by the cardiac team; if a lung team is present and prefers exsanguination into the abdomen, then the distal inferior vena cava can be vented using a 28-F chest tube.) The aortic flush is opened and the liver is perfused with cold University of Wisconsin solution (UW) by both aortic and portal cannulas. Ice slush is dumped into the abdomen: first, on top of the liver, next, in the left gutter if the kidneys are to be procured, and lastly, down the right paracolic gutter. Slush should be placed within the lesser sac as well if the pancreas will be procured. University of Wisconsin flow is verified with the perfusionist, and the liver is assessed for uniform sanguinity and softness. The team also assesses the suprahepatic IVC eluate for clarity: typically, 2 L of aortic flush and 1 L of portal flush are used (50 mL/kg for pediatric donors is usually sufficient). All anesthesia monitoring and support is discontinued. The endotracheal tube may be detached from the ventilator. The heart fibrillates. The elapsed time is typically less than 30 minutes from skin incision and approximately one-half hour remains before the liver will be removed. The authors’ experience is based almost exclusively on the use of UW solution for preservation. However, new options in organ preservation are emerging [10 -12], especially histidine-tryptophan-ketoglutarate (HTK) (Custodiol) solution. Histidine-tryptophan-ketoglutarate was approved by the Food and Drug Administration for use in the protection and storage of donor livers in February of 2003, though it had been approved for the protection of kidneys in 2000 and has been used as a cardioplegia solution since 1971. Furthermore, HTK has been in routine use in Europe since 1987, and several large randomized studies show outcomes similar to that obtained with UW solution in
Fig. 3. The distal CBD is opened and the gallbladder incised and flushed through with saline. Reprinted with permission from Emre et al [3].
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settings of both short and prolonged cold ischemia time [13,14]. Our center is currently engaged in a prospective randomized study comparing the use of UW preservation to HTK solution in liver preservation. When the suprahepatic eluate has cleared, the cold perfusion may be stopped. The donor surgeon cuts the diaphragm to the left of the IVC as the assistant retracts the esophagus out of the way to the patient’s left. The scissors are passed to the assistant who cuts the diaphragm to the right of the liver low enough to let the slush spill into the right chest. The liver is now allowed to fall back into the right chest and, covered with ice, slush in a laparotomy pad to keep it cold during subsequent dissection. The OR nurse assists by gently retracting the duodenum with a laparotomy pad to display the porta hepatis, and a pool tipped sucker is inserted into the foramen of Winslow to provide a dry field. The assistant uses 2 forceps to display the portal structures whereas the donor surgeon dissects with the Metzenbaum scissors. The gastroduodenal artery (GDA) is identified first just cephalad to the duodenum and traced up to the hepatic artery visualizing the proximal and distal trajectory of the HA. The GDA can now be ligated with a silk tie and divided, the tie left long, snapped, and laid on the chest. Dissection proceeds down the common hepatic artery to the splenic artery, which is dissected, ligated with a silk tie, and likewise snapped with gentle retraction in a cephalad direction. The celiac trunk is now identified emerging from the aorta. If there is a replaced left hepatic artery, the left gastric artery must be preserved. In such cases, the lesser omentum is mobilized off the stomach before dissecting the celiac trunk. The muscle and soft tissue overlying the aorta are divided distal to the cross-clamp, and the aorta is divided. Attention is now turned to the CBD, which is transected at the previous knick site. The portal vein is identified beneath and followed inferiorly where it passes beneath the pancreas. If the pancreas is to be procured, then the portal vein is divided just distal to the coronary vein. Otherwise, the head of the pancreas overlying is divided in the direction of the superior mesenteric vein. The superior mesenteric vein is encircled with a silk, ligated, and divided. The splenic vein is cut for eventual back table cannulation. The aorta is transected below the celiac trunk and the left lateral wall is divided in a cephalad direction. Once the cut joins the more proximal opening, the right side of the aorta is visualized from the inside and the right lateral wall is cut. The aortic button can now be liberated. If a replaced right hepatic artery exists, it is followed to the SMA, and the SMA is mobilized toward the aorta so that the aortic patch will include both the celiac and SMA openings. Lastly, attention is turned to the infrahepatic IVC. The renal veins are identified and the anterior IVC wall opened just above. The IVC back wall is cut and the donor surgeon inserts his finger into the distal (cephalad) IVC as the assistant cuts away the remaining attachments in the left gutter. The assistant now uses the right hand to come behind the liver from above and display the remaining diaphragmatic
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soft tissue attachments posteriorly, which are cut by the donor surgeon. The liver can now be removed. On the back table at the donor hospital, the CBD is flushed with 20 mL of cold UW solution, and the liver is bagged according to OPO protocol and put into the transport cooler. Other organs are procured as needed, and lastly, lymph nodes, spleen, and vessels are obtained according to OPO policy. Iliac arteries and veins are typically satisfactory for use as vessel conduit during reconstruction in the recipient case. However, if the iliac artery is atherosclerotic, as is often the case in elderly donors, then other medium-sized arteries such as the carotid or SMA can be taken. In pediatric donors, the iliacs may be too small, and in such cases, the right axillary artery can be used. 2. Nonheart beating donors The goal in these cases is the rapid accomplishment of aortic cannulation, cross-clamping, and organ cold perfusion. A donor arrest during transport is likewise best managed by initiation of cardiopulmonary resuscitation and nonheart beating donor techniques. Nonheart beating donation proceeds with sharp dissection. The skin is opened with a knife from the xiphoid to pubis. Dissection continues sharply into the abdomen. The Balfour retractor is inserted and the abdominal aorta is exposed using the Metzenbaum scissors. The abdominal aorta is rapidly cannulated and UW flushing is started. The pericardium is opened, the thoracic aorta is cross-clamped in the lower mediastinum, and the suprahepatic IVC is transected below the right atrium. The white line of Toldt is opened along the descending colon to expose the left kidney, and ice slush is applied to the organs. The SMV can now be identified and cannulated for portal flushing. The gallbladder is opened and flushed and all dissection is done bcoldQ after UW flushing. 3. In situ splitting the deceased donor liver Most commonly, this technique is used to generate 2 grafts from a single deceased donor: a left lateral segment graft (segments 2 and 3) appropriate for transplantation into a pediatric recipient and a right trisegment graft (segments 1 and 4 –8) appropriate for transplantation into an adult recipient. Another alternative is a btrueQ left-right split generating a left lobe graft (segments 1–4) and a right lobe graft (segments 5–8), both of which can be used for appropriate-sized adults. Splitting the whole graft can be accomplished at the donor hospital before cold perfusion: bin situQ splitting in the cadaveric donor, or alternatively on the back table at the recipient hospital after a conventional procurement, so-called ex situ splitting. European efforts led by Pichlmayr et al [15] and Bismuth et al [16] have advocated ex situ splitting. This technique reduces time and effort spent at the donor hospital and focuses efforts and expertise at the recipient institution.
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Fig. 4. With a replaced right hepatic artery originating from the SMA, reconstruction is accomplished by anastomosing proximal SMA (B1A1) to the celiac trunk (AB) with inflow provided via distal SMA. Reprinted with permission from Emre et al [3].
Potential disadvantages included long cold ischemia times and the risk of graft rewarming during manipulation. Broelsch and Busuttil have described and advocated in situ splitting, which reduces cold ischemia, simplifies identification of biliary and vascular structures, and reduces reperfusion hemorrhage [17,18]. However, in situ splits require specialized skills, prolonged OR time, and increased logistical coordination at the donor institution. Preliminary reports of in situ split liver transplantation data from the University of Hamburg and the University of California at Los Angeles showed results in both their pediatric and adult recipients equal to or exceeding whole cadaveric grafts [19]. Since these initial reports, both Universities have published expanded results confirming their earlier observations. At the University of California at Los Angeles, more than 150 in situ splits have been performed, and this technique has become the authors’ default when an optimal donor is available [20]. The technique is described briefly below. The initial steps of the standard multiorgan procurement procedure are completed before further dissection to allow for rapid perfusion in the event of donor instability. In conventional in situ splitting, the dissection begins with isolation of the left hepatic artery along its length. Special
attention is paid to the segment 4 arterial branch, which is preserved whenever possible. Next, the right hepatic artery is identified at the level of the common hepatic artery but not dissected free. The left branch of the portal vein is dissected free. Portal vein branches entering segment 4 are ligated and divided to the right of the umbilical fissure. Lastly, the extrahepatic left hepatic vein is isolated. After the vascular control of the left lateral segment has been obtained, the line for parenchymal transection is scored with the Bovie cautery. The line will be 1 cm above the left bile duct in the umbilical fissure and transverses 1 cm to the right of the falciform ligament. The superior aspect of the liver is divided with electrocautery. The left hilar plate and the bile duct are cut sharply. The rest of the liver parenchyma is divided using cautery and suture ligation as needed. When this is complete, the left lateral segment [2,3] and the rest of the liver [1,4-8] are separate, each with its own vascular pedicle and drainage. The liver is now perfused as above: 2 L of UW are given in the aortic cannula and 1 L via the portal cannula. After perfusion is completed, the left hepatic artery, the left portal vein, and the left hepatic vein are divided. The left bile duct is flushed with UW solution, and the left lateral segment graft is bagged in cold UW. The right trisegment graft is
Fig. 5. A replaced right HA can also be reconstructed via anastomosis to the splenic artery. Reprinted with permission from Emre et al [3].
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Fig. 6. In cases of size discrepancy, a smaller replaced right hepatic artery may be reconstructed via the GDA. Reprinted with permission from Emre et al [3].
then removed in the usual fashion described above and stored for transport. 4. Back table/arterial variation and reconstruction The purpose of this intermediary procedure is to remove diaphragm and excessive soft tissue from the liver and its vessels and to provide a single arterial inlet if an anatomic variation requiring reconstruction exists. Any damage to vessels can also be carefully identified and repaired at this juncture. This procedure is performed on the slush machine to avoid excessive rewarming. The btrimming Q is begun with liver in anatomic position. The suprahepatic IVC is the first structure examined. The diaphragm is carefully removed and the IVC is cleaned of soft tissue and checked for phrenic veins or iatrogenically created holes. The infrahepatic IVC is next examined, cleaned, and followed along its posterior aspect up to the suprahepatic cuff. The right adrenal vein is identified and ligated. The portal vein is cleared to its bifurcation, cannulated via the splenic vein orifice, and perfused with UW solution to check for holes that must be tied or oversewn. The hepatic artery is cleaned of soft tissue and examined carefully for holes proceeding from the aortic Carrel patch to the splenic artery to the GDA. Dissection beyond the GDA is unnecessary and discouraged because blood supply to the extrahepatic bile duct may become compromised. The hepatic artery is cannulated with an 18 gauge IV and irrigated to look for small holes. Once this is accomplished, the prepared liver is returned to its bag with UW solution, covered with ice, and brought up to the operating table field to be implanted. The replaced left hepatic artery does not require reconstruction if it originates from the left gastric artery. It will, however, require careful ligation of the many small side branches, which can originate from the vessel. If a replaced left hepatic artery originates off the aorta, it must be reconstructed via anastomosis to the splenic or GDA. The replaced right hepatic artery originating from the SMA requires reconstruction. In this case, the proximal end
of the SMA is anastomosed to the celiac Carrel patch (Fig. 4). The distal SMA below the right HA takeoff is then used for inflow. Alternatively, the replaced right HA can be anastomosed to the splenic artery or gastroduodenal stump (Figs. 5 and 6). The left lateral segment split graft does not require any back table preparation. The right trisegment split graft is trimmed as per the whole graft above with vessel or bile duct openings identified and oversewn as needed. The left hepatic vein opening on the suprahepatic IVC and the left portal vein opening are closed using 7-0 Prolene sutures. The left hepatic artery stump is closed using 7-0 Prolene. The left bile duct opening on the cut surface is oversewn using 6 -0 Prolene. The bile duct is flushed with cold UW solution, and the cut surface is observed for any leak that can be closed with a 6 -0 Prolene.
References [1] Starzl TE, Hakala T, Shaw B, et al. A flexible procedure for multiple cadaveric organ procurement. Surg Gynecol Obstet 1984;158:223. [2] Miller C, Mazzaferro V, Makowka L, et al. Rapid flush technique for donor hepatectomy: safety and efficacy of an improved method of liver recovery for transplantation. Transplant Proc 1988;20:948 - 50. [3] Emre S, Schwartz ME, Miller CM. The donor operation. In: Busuttil RW, Klintmalm GB, editors. Transplantation of the liver. 1st ed. Philadelphia (Pa)7 Saunders; 1996. [4] Hiatt JR, Gabbay J, Busuttil RW. Surgical anatomy of the hepatic artery in 1000 cases. Ann Surg 1994;220:50. [5] Todo S, Makowka L, Tzakis A, et al. Hepatic artery in liver transplantation. Transplant Proc 1987;19:2406 - 11. [6] Cattell R, Braasch J. A technique for exposure of the third and fourth portions of the duodenum. Surg Gynecol Obstet 1960;111:379. [7] Figueras J, Busquets J, Grande L, et al. The deleterious effect of donor high plasma sodium and extended preservation in liver transplantation. A multivariate analysis. Transplantation 1996;61:410 - 3. [8] Gabel M, Liden H, Norrby J, et al. Early function of liver grafts preserved with or without portal perfusion. Transplant Proc 2001;33: 2427 - 528. [9] Chui AK, Thompson JF, Lam D, et al. Cadaveric liver procurement using aortic perfusion only. Aust NZ J Surg 1998;68:275 - 7. [10] Nydegger U, Carrel T, Laumonier T, et al. New concepts in organ preservation. Transpl Immunol 2002;9:215 - 25. [11] McLaren A, Friend P. Trends in organ preservation. Transpl Int 2003; 16:701 - 8.
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[12] Mulligan DC, Reddy KS, Moss AA. New preservation solutions for use in liver transplantation. Curr Opin Org Transpl 2004;9:159 - 62. [13] Erhard J, Lange R, Scherer R, et al. Comparison of histidinetryptophan-ketoglutarate (HTK) solution versus University of Wisconsin (UW) solution for organ preservation in human liver transplantation. A prospective, randomized study. Transpl Int 1994; 7:177 - 81. [14] Pokorny H, Rasoul-Rockenschaub S, Langer T, et al. Histidinetryptophan-ketoglutarate solution for organ preservation in human liver transplantation — a prospective multi-centre observation study. Transpl Int 2004;17:256 - 60. [15] Pichlmayr R, Ringe B, Gubernatis G. Transplantation of a donor liver to 2 recipients (splitting transplantation) — a new method in the further development of segmental liver transplantation. Langenbecks Arch Chir 1989;373:127 - 30.
[16] Bismuth H, Morino M, Castaing D, et al. Emergency orthotopic liver transplantation in two patients using one donor liver. Br J Surg 1989;76:722 - 4. [17] Rogiers X, Malago M, Gawad K, et al. In situ splitting of cadaveric livers. The ultimate expansion of a limited donor pool. Ann Surg 1996;224:331 - 9. [18] Goss JA, Yersiz H, Shackleton CR, et al. In situ splitting of the cadaveric liver for transplantation. Transplantation 1997;64:871 - 7. [19] Ghobrial RM, Yersiz H, Farmer DG, et al. Predictors of survival after in vivo split liver transplantation: analysis of 110 consecutive patients. Ann Surg 2000;232:312 - 23. [20] Yersiz H, Renz JF, Farmer DG, et al. One hundred in situ split-liver transplantations. A single center experience. Ann Surg 2003;238: 496 - 507.
Liver donation: surgical techniques Andrew M. CameronT, Hasan Yersiz, Ronald W. Busuttil Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-7054, USA
Abstract Efficient and technically sound graft procurement is an integral component of a liver transplant recipient’s immediate and eventual outcome. Furthermore, the current era of organ scarcity increases the demand on the donor surgeon to extract the maximum potential from the existing pool, including the assessment and use of expanded criteria donors, nonheart beating donors, and the splitting of deceased donors to supply 2 recipients. The techniques described here represent the authors’ combined experience with over 20 years and 3000 procurements. They are widely applicable to a broad patient population and can be routinely performed at donor hospitals without specialized equipment or staff. D 2005 Elsevier Inc. All rights reserved.
1. The donor operation: conventional adult deceased donor procurement The procedure described here is an adaptation of the initial procurement technique of Starzl et al [1-3]. The time from skin incision to aortic cross-clamping is typically less than 30 minutes, and the entire harvest takes approximately 1 hour. Good communication with the donor hospital’s operating room (OR) staff and the other teams present at the procurement is essential for maximal efficiency. Positioning of the donor is supine with arms tucked at the sides. Two Bovies and 2 Yankauer tipped suckers will be required. The prep is with Betadine from chin to thigh. The incision is midline and extends from the suprasternal notch to the pubis (Fig. 1). If 2 experienced surgeons are present, the surgeon on the patient’s left (referred to as bthe assistant Q) begins by opening the chest whereas the surgeon on the patient’s right (bthe donor surgeonQ) enters the abdomen. First, the round ligament is divided between heavy silk sutures, and the falciform ligament is divided back to the inferior vena cava (IVC)-hepatic vein confluence. The left triangular ligament is taken down and the liver evaluated for quality (color, texture, parenchyma quality, and size). A large Balfour retractor is placed and secured with penetrating towel clamps. The chest is then opened with a pneumatic sternal
T Corresponding author. Tel.: +1 310 206 3781; fax: +1 310 206 7760. E-mail address: [email protected] (A.M. Cameron). 0955-470X/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.trre.2005.06.001
saw or Lebsche knife while ventilation is held; 2 blue towels are inserted after which a Finochietto’s sternal retractor is placed. The pericardium is entered through a midline incision at the diaphragm and extended to above the right atrium. Lastly, the right side of the chest is opened widely through the parietal pleura. Next, the hepatic arterial (HA) anatomy is evaluated. The donor surgeon retracts the left lateral segment to the patient’s right and examines the gastrohepatic ligament for the presence of a replaced left hepatic artery, which originates from the left gastric artery approximately 10% to 15% of the time [4,5]. If present, this variant can be identified crossing transversely from the lesser curve of the stomach across the gastrohepatic ligament to the umbilical fissure. The pars flaccida overlying the caudate lobe is lifted and Bovied in a clear thin area, and if no replaced left HA is present, the lesser omentum is completely divided. If a replaced left HA is present, the gastrohepatic ligament is divided above and below the replaced vessel. Now, a Cattell-Braasch maneuver is performed mobilizing the right colon and duodenum medially [6]. The right colon and small bowel are moved out of the incision to the donor’s left exposing the IVC, aorta, and ultimately the inferior mesenteric vein (IMV) lateral to the ligament of Treitz and duodenum. The IMV is dissected close to the root of the transverse mesocolon and twice encircled with 2-0 silk ties (Fig. 2). Portal infusion bprecoolQ is now begun with plasmalyte solution. If donor serum sodium is greater than 160, then D5W should be used for precool instead of plasmalyte solution [7].
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Fig. 1. The incision extends from suprasternal notch to symphysis pubis. A large Balfour retractor with deep blades is used in the abdomen. Reprinted with permission from Emre et al [3].
Portal perfusion is preferred by the authors and is routinely used though it is ultimately an optional step in liver procurement. Theoretic disadvantages are prolonged operative time and handling of organs, especially in unstable donors. Arguments in favor of portal perfusion invoke faster cooling and more thorough perfusion of the liver, perhaps especially important with extended criteria donors. Multiple studies show no statistical difference in graft performance or patient outcome with or without portal perfusion, but these studies were low in patient number and did not involve extended criteria donors [8,9]. In our experience, portal perfusion adds very little time to the procurement procedure and is felt to be advantageous especially in cases of donors with high serum sodium or other extended criteria. After portal perfusion is established, attention is turned to the distal aorta, which is dissected at the bifurcation below the takeoff of the inferior mesenteric artery. Using a blunt right angle clamp with care to avoid injury to the neighboring IVC, the aorta is surrounded with 2 pieces of umbilical tape. The more proximal of which is captured with a Rommel pump tourniquet in preparation for eventual cannulation.
The ascending colon and the small bowel are returned to the abdomen, and the attention is next turned to the distal common bile duct (CBD) and the gallbladder. The CBD is identified and isolated with a 2-0 silk tie avoiding the portal vein just beneath and medial. The donor surgeon inserts an index finger into the foramen of Winslow and palpates the porta hepatis to feel for a replaced right hepatic artery lateral and posterior to the CBD. This variant will be present about 10% of the time [4]. The CBD is nicked anteriorly at the 12 o’clock position using Metzenbaum scissors. Next, the gallbladder fundus is incised and the bile is evacuated (Fig. 3). An asepto syringe filled with cold saline is inserted and the gallbladder flushed until clear effluent is seen to issue from the distal CBD knick. The left colon is now mobilized medially to make space for the upcoming placement of ice slush around the left kidney. The donor surgeon retracts the descending colon, and the assistant liberates it at the white line of Toldt. The donor surgeon covers and lifts the left kidney and spleen as the assistant mobilizes the viscera medially ultimately exposing the psoas muscle.
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Fig. 2. The portal vein is cannulated via the IMV. The distal aorta is cannulated just above the bifurcation with care to place the tip of the perfusion cannula below the renal artery orifices. Reprinted with permission from Emre et al [3].
The supraceliac aorta is now encircled. The donor surgeon retracts the left lateral segment to the patient’s right side, and using the Bovie, a vertical incision is made in the right diaphragmatic crus at the midline. The esophagus is retracted out of the way to the patient’s left by the assistant. The donor surgeon inserts a finger and lifts the soft tissue toward the ceiling. The aorta is identified and the assistant surgeon lifts the perivascular soft tissue with forceps. The donor surgeon incises this tissue on each side downward toward the floor. Now, a right angle is passed by the donor surgeon from the patient’s right to left, and an umbilical tape is passed around the aorta to facilitate eventual crossclamp. A straight vascular clamp will be used for this purpose, and its availability should be confirmed. The pleura is opened in the chest and the suprahepatic IVC identified for venting. Thirty thousand units of heparin are given (500 U/kg for pediatric donors) along with 25 g of mannitol and 100 mg of intravenous Lasix. Three minutes later, the aorta is cannulated with a 22-F reinforced cardiac catheter. The catheter tip is positioned approximately 4 cm above the aortotomy, below the takeoff of the superior mesenteric artery (SMA) and renal arteries. In cases of severe atherosclerosis or aneurysm, the right iliac artery may be cannulated instead and the left iliac artery ligated or vice versa. The Organ Procurement Organization (OPO) coordinator, other recovering teams, and the anesthesia team are now notified that abdominal dissection is complete and that cross-clamp and cold perfusion are now imminent.
Proceeding rapidly but carefully, the supraceliac aorta is cross-clamped. Next, the suprahepatic IVC is deeply incised at the cavoatrial junction if there is no heart team. (Otherwise, the vena cava is cut by the cardiac team; if a lung team is present and prefers exsanguination into the abdomen, then the distal inferior vena cava can be vented using a 28-F chest tube.) The aortic flush is opened and the liver is perfused with cold University of Wisconsin solution (UW) by both aortic and portal cannulas. Ice slush is dumped into the abdomen: first, on top of the liver, next, in the left gutter if the kidneys are to be procured, and lastly, down the right paracolic gutter. Slush should be placed within the lesser sac as well if the pancreas will be procured. University of Wisconsin flow is verified with the perfusionist, and the liver is assessed for uniform sanguinity and softness. The team also assesses the suprahepatic IVC eluate for clarity: typically, 2 L of aortic flush and 1 L of portal flush are used (50 mL/kg for pediatric donors is usually sufficient). All anesthesia monitoring and support is discontinued. The endotracheal tube may be detached from the ventilator. The heart fibrillates. The elapsed time is typically less than 30 minutes from skin incision and approximately one-half hour remains before the liver will be removed. The authors’ experience is based almost exclusively on the use of UW solution for preservation. However, new options in organ preservation are emerging [10 -12], especially histidine-tryptophan-ketoglutarate (HTK) (Custodiol) solution. Histidine-tryptophan-ketoglutarate was approved by the Food and Drug Administration for use in the protection and storage of donor livers in February of 2003, though it had been approved for the protection of kidneys in 2000 and has been used as a cardioplegia solution since 1971. Furthermore, HTK has been in routine use in Europe since 1987, and several large randomized studies show outcomes similar to that obtained with UW solution in
Fig. 3. The distal CBD is opened and the gallbladder incised and flushed through with saline. Reprinted with permission from Emre et al [3].
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settings of both short and prolonged cold ischemia time [13,14]. Our center is currently engaged in a prospective randomized study comparing the use of UW preservation to HTK solution in liver preservation. When the suprahepatic eluate has cleared, the cold perfusion may be stopped. The donor surgeon cuts the diaphragm to the left of the IVC as the assistant retracts the esophagus out of the way to the patient’s left. The scissors are passed to the assistant who cuts the diaphragm to the right of the liver low enough to let the slush spill into the right chest. The liver is now allowed to fall back into the right chest and, covered with ice, slush in a laparotomy pad to keep it cold during subsequent dissection. The OR nurse assists by gently retracting the duodenum with a laparotomy pad to display the porta hepatis, and a pool tipped sucker is inserted into the foramen of Winslow to provide a dry field. The assistant uses 2 forceps to display the portal structures whereas the donor surgeon dissects with the Metzenbaum scissors. The gastroduodenal artery (GDA) is identified first just cephalad to the duodenum and traced up to the hepatic artery visualizing the proximal and distal trajectory of the HA. The GDA can now be ligated with a silk tie and divided, the tie left long, snapped, and laid on the chest. Dissection proceeds down the common hepatic artery to the splenic artery, which is dissected, ligated with a silk tie, and likewise snapped with gentle retraction in a cephalad direction. The celiac trunk is now identified emerging from the aorta. If there is a replaced left hepatic artery, the left gastric artery must be preserved. In such cases, the lesser omentum is mobilized off the stomach before dissecting the celiac trunk. The muscle and soft tissue overlying the aorta are divided distal to the cross-clamp, and the aorta is divided. Attention is now turned to the CBD, which is transected at the previous knick site. The portal vein is identified beneath and followed inferiorly where it passes beneath the pancreas. If the pancreas is to be procured, then the portal vein is divided just distal to the coronary vein. Otherwise, the head of the pancreas overlying is divided in the direction of the superior mesenteric vein. The superior mesenteric vein is encircled with a silk, ligated, and divided. The splenic vein is cut for eventual back table cannulation. The aorta is transected below the celiac trunk and the left lateral wall is divided in a cephalad direction. Once the cut joins the more proximal opening, the right side of the aorta is visualized from the inside and the right lateral wall is cut. The aortic button can now be liberated. If a replaced right hepatic artery exists, it is followed to the SMA, and the SMA is mobilized toward the aorta so that the aortic patch will include both the celiac and SMA openings. Lastly, attention is turned to the infrahepatic IVC. The renal veins are identified and the anterior IVC wall opened just above. The IVC back wall is cut and the donor surgeon inserts his finger into the distal (cephalad) IVC as the assistant cuts away the remaining attachments in the left gutter. The assistant now uses the right hand to come behind the liver from above and display the remaining diaphragmatic
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soft tissue attachments posteriorly, which are cut by the donor surgeon. The liver can now be removed. On the back table at the donor hospital, the CBD is flushed with 20 mL of cold UW solution, and the liver is bagged according to OPO protocol and put into the transport cooler. Other organs are procured as needed, and lastly, lymph nodes, spleen, and vessels are obtained according to OPO policy. Iliac arteries and veins are typically satisfactory for use as vessel conduit during reconstruction in the recipient case. However, if the iliac artery is atherosclerotic, as is often the case in elderly donors, then other medium-sized arteries such as the carotid or SMA can be taken. In pediatric donors, the iliacs may be too small, and in such cases, the right axillary artery can be used. 2. Nonheart beating donors The goal in these cases is the rapid accomplishment of aortic cannulation, cross-clamping, and organ cold perfusion. A donor arrest during transport is likewise best managed by initiation of cardiopulmonary resuscitation and nonheart beating donor techniques. Nonheart beating donation proceeds with sharp dissection. The skin is opened with a knife from the xiphoid to pubis. Dissection continues sharply into the abdomen. The Balfour retractor is inserted and the abdominal aorta is exposed using the Metzenbaum scissors. The abdominal aorta is rapidly cannulated and UW flushing is started. The pericardium is opened, the thoracic aorta is cross-clamped in the lower mediastinum, and the suprahepatic IVC is transected below the right atrium. The white line of Toldt is opened along the descending colon to expose the left kidney, and ice slush is applied to the organs. The SMV can now be identified and cannulated for portal flushing. The gallbladder is opened and flushed and all dissection is done bcoldQ after UW flushing. 3. In situ splitting the deceased donor liver Most commonly, this technique is used to generate 2 grafts from a single deceased donor: a left lateral segment graft (segments 2 and 3) appropriate for transplantation into a pediatric recipient and a right trisegment graft (segments 1 and 4 –8) appropriate for transplantation into an adult recipient. Another alternative is a btrueQ left-right split generating a left lobe graft (segments 1–4) and a right lobe graft (segments 5–8), both of which can be used for appropriate-sized adults. Splitting the whole graft can be accomplished at the donor hospital before cold perfusion: bin situQ splitting in the cadaveric donor, or alternatively on the back table at the recipient hospital after a conventional procurement, so-called ex situ splitting. European efforts led by Pichlmayr et al [15] and Bismuth et al [16] have advocated ex situ splitting. This technique reduces time and effort spent at the donor hospital and focuses efforts and expertise at the recipient institution.
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Fig. 4. With a replaced right hepatic artery originating from the SMA, reconstruction is accomplished by anastomosing proximal SMA (B1A1) to the celiac trunk (AB) with inflow provided via distal SMA. Reprinted with permission from Emre et al [3].
Potential disadvantages included long cold ischemia times and the risk of graft rewarming during manipulation. Broelsch and Busuttil have described and advocated in situ splitting, which reduces cold ischemia, simplifies identification of biliary and vascular structures, and reduces reperfusion hemorrhage [17,18]. However, in situ splits require specialized skills, prolonged OR time, and increased logistical coordination at the donor institution. Preliminary reports of in situ split liver transplantation data from the University of Hamburg and the University of California at Los Angeles showed results in both their pediatric and adult recipients equal to or exceeding whole cadaveric grafts [19]. Since these initial reports, both Universities have published expanded results confirming their earlier observations. At the University of California at Los Angeles, more than 150 in situ splits have been performed, and this technique has become the authors’ default when an optimal donor is available [20]. The technique is described briefly below. The initial steps of the standard multiorgan procurement procedure are completed before further dissection to allow for rapid perfusion in the event of donor instability. In conventional in situ splitting, the dissection begins with isolation of the left hepatic artery along its length. Special
attention is paid to the segment 4 arterial branch, which is preserved whenever possible. Next, the right hepatic artery is identified at the level of the common hepatic artery but not dissected free. The left branch of the portal vein is dissected free. Portal vein branches entering segment 4 are ligated and divided to the right of the umbilical fissure. Lastly, the extrahepatic left hepatic vein is isolated. After the vascular control of the left lateral segment has been obtained, the line for parenchymal transection is scored with the Bovie cautery. The line will be 1 cm above the left bile duct in the umbilical fissure and transverses 1 cm to the right of the falciform ligament. The superior aspect of the liver is divided with electrocautery. The left hilar plate and the bile duct are cut sharply. The rest of the liver parenchyma is divided using cautery and suture ligation as needed. When this is complete, the left lateral segment [2,3] and the rest of the liver [1,4-8] are separate, each with its own vascular pedicle and drainage. The liver is now perfused as above: 2 L of UW are given in the aortic cannula and 1 L via the portal cannula. After perfusion is completed, the left hepatic artery, the left portal vein, and the left hepatic vein are divided. The left bile duct is flushed with UW solution, and the left lateral segment graft is bagged in cold UW. The right trisegment graft is
Fig. 5. A replaced right HA can also be reconstructed via anastomosis to the splenic artery. Reprinted with permission from Emre et al [3].
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Fig. 6. In cases of size discrepancy, a smaller replaced right hepatic artery may be reconstructed via the GDA. Reprinted with permission from Emre et al [3].
then removed in the usual fashion described above and stored for transport. 4. Back table/arterial variation and reconstruction The purpose of this intermediary procedure is to remove diaphragm and excessive soft tissue from the liver and its vessels and to provide a single arterial inlet if an anatomic variation requiring reconstruction exists. Any damage to vessels can also be carefully identified and repaired at this juncture. This procedure is performed on the slush machine to avoid excessive rewarming. The btrimming Q is begun with liver in anatomic position. The suprahepatic IVC is the first structure examined. The diaphragm is carefully removed and the IVC is cleaned of soft tissue and checked for phrenic veins or iatrogenically created holes. The infrahepatic IVC is next examined, cleaned, and followed along its posterior aspect up to the suprahepatic cuff. The right adrenal vein is identified and ligated. The portal vein is cleared to its bifurcation, cannulated via the splenic vein orifice, and perfused with UW solution to check for holes that must be tied or oversewn. The hepatic artery is cleaned of soft tissue and examined carefully for holes proceeding from the aortic Carrel patch to the splenic artery to the GDA. Dissection beyond the GDA is unnecessary and discouraged because blood supply to the extrahepatic bile duct may become compromised. The hepatic artery is cannulated with an 18 gauge IV and irrigated to look for small holes. Once this is accomplished, the prepared liver is returned to its bag with UW solution, covered with ice, and brought up to the operating table field to be implanted. The replaced left hepatic artery does not require reconstruction if it originates from the left gastric artery. It will, however, require careful ligation of the many small side branches, which can originate from the vessel. If a replaced left hepatic artery originates off the aorta, it must be reconstructed via anastomosis to the splenic or GDA. The replaced right hepatic artery originating from the SMA requires reconstruction. In this case, the proximal end
of the SMA is anastomosed to the celiac Carrel patch (Fig. 4). The distal SMA below the right HA takeoff is then used for inflow. Alternatively, the replaced right HA can be anastomosed to the splenic artery or gastroduodenal stump (Figs. 5 and 6). The left lateral segment split graft does not require any back table preparation. The right trisegment split graft is trimmed as per the whole graft above with vessel or bile duct openings identified and oversewn as needed. The left hepatic vein opening on the suprahepatic IVC and the left portal vein opening are closed using 7-0 Prolene sutures. The left hepatic artery stump is closed using 7-0 Prolene. The left bile duct opening on the cut surface is oversewn using 6 -0 Prolene. The bile duct is flushed with cold UW solution, and the cut surface is observed for any leak that can be closed with a 6 -0 Prolene.
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