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The Team
Lead surgeon Second surgeon
Driver
WM Ambulance service
Liaise with local theatre team Set up trolley & equipment Discuss with local coordinator re perfusion Run through the portal venous perfusion fluid Ice for later +/-Back bench liver perfusion Packing liver Swab & instrument count
BSD criteria satisfied & recorded Cause of death recorded & appropriate Consent of family +/- coroner recorded Relevant PMH, blood tests, current history of I/P stay
Hypo/hypertension, inotropes, sepsis, CR arrest, urine output, etc.
Retrieval Methods
Standard Rapid
technique
Very unstable donor Immediate cannulation of aorta and SMV Cold perfusion Careful dissection
En
Bloc
Donor Procedure
Preparation of vessels for cannulation & warm dissection of liver (approx 40-90 mins) Cardiac surgeons may then explore heart/lungs and prepare for cannulation (approx 45-60 mins) Dissection of porta hepatis & identification of liver arterial anatomy Division of CBD, washout of GB Dissection & slooping of supracoeliac aorta
Full exploration exclude gross pathology, assess liver / kidneys Liver: Size, colour, texture, edges, pathology, vessels, perfusion / congestion
Heparinisation (30,000 units or 300 units/kg) L common iliac artery ligated R common iliac artery ligated distally & cannulated SMV ligated distally & cannulated
Ensuring tip of cannulae is in common trunk of PV
Thoracic surgeons cannulate Approx 20 mins Aorta ligated Perfusion commenced Bleed out via IVC in pericardial sac & infra renal
distal IVC ligated If thoracic organs then venting only via abdominal IVC
Cannulation
Tie distal SMV. Cut & introduce cannula Check position of tip & secure cannula If low - may perfuse splenic vein If high - unilateral perfusion of the liver
SMV Cannulation Tie distal CIA/aorta, clamp vessel proximally, Cut and introduce cannula (avoid dissection), first asst. fixes cannula
Anaesthetist should
disconnect anaesthetic machines Cut tape holding ET tube (prevents facial mark)
Surgeon can now provide spleen and lymph nodes for cross match and tissue typing for cardiac / renal grafts
Perfusion in Adult
Aortic cannula
3 litres of Marshalls solution at 80-100mmHg 4th litre of Marshalls trickled no pressure
Etiology: ?multifactorial CIT, damage by inspissated cold bile, poor perfusion of arterially supplied biliary tree Early division of CBD Open and washout gall bladder bile early Use low viscosity Marshalls aortic perfusion Pressurise arterial perfusion 80-100 mm Hg
Perfusion in Paediatrics
Donor Weight
<10kg
Aorta (ml)
In-Situ (Marshalls >15kg) Back Bench (UW)
Portal (ml)
In-Situ (UW) Back Bench (UW)
11-20Kg
21-30Kg 31-40Kg 41-50Kg Adults
Paediatric donor
? Total UW perfusion
Donor instability
Rapid cannulation all dissection in cold phase
Donor Procedure:
Cold Phase order of removal
Heart/lungs retrieved Liver retrieved Pancreas retrieved Kidneys retrieved Iliac arteries & veins, SMA Lymph nodes, spleen Tissue for research
Approx 30-90 mins
Mobilise liver, avoid tears (segment 6) Dissect and divide portal vein within pancreas Dissect arterial supply to aorta dividing splenic and LGA, check for accessory vessels Divide lower IVC above renal veins Cut through upper edge of right adrenal Divide diaphragm around upper IVC Cut aortic coeliac patch; include SMA if RHA from SMA Complete hepatectomy by cutting out wedge of diaphragm Liver into ice slush for bench perfusion
Packaging organs
Liver in 1-2l of Marshalls; 2 bags; NO AIR or ICE
Swab & instrument count Wound closure Packing of equipment Lead surgeon
Operation note (details essential in Coroners case) Organ specific forms
Liver on Ice
En-Bloc Kidney
The Donor
Recipients at Tx Games
Summary
Excellent senior trainee procedure Skills: Surgical technique Communication Team-working Leadership Responsibility
Acknowledgements
Multi-organ retrieval team Procurement co-ordinators; consultant colleagues SB Donor hospitals Donor families
Thank you!