ddlt retrieval

7/29/2019 Ddlt Retrieval

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The Donor Operation


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The Team

Lead surgeon

Second surgeon

Renal surgeon, paediatric surgeon, visitingsurgeon

Third surgeon (if available)Scrub person

ODP, scrub nurse Driver

WM Ambulance service


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The Travelling Team


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Responsibilities of Scrub Person

Ensure all specialist equipment is packed &transported to local hospital Swabs, drapes, gowns & gloves provided locally

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


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Responsibilities of Lead Surgeon

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.

Blood group

Virology

HBV, HCV, HIV, CMV


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Responsibilities of Lead Surgeon

Discussion with anaesthetist Antibiotics (Ceftazidime 2g, Augmentin 1.2g or Ciprofloxacin 400mg,

Metronidazole 500mg)

Muscle relaxation Administration of heparin (300u/kg) & timing

Discussion with cardiac (& renal/pancreatic surgeons) Sternotomy

Heparinisation IVC clamping

Bleed out

Perfusion


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Retrieval Methods

Standard

Rapid techniqueVery unstable donor

Immediate cannulation of aorta and SMV

Cold perfusion

Careful dissection

En Bloc


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Donor Procedure If thoracic organs involved (approx 30-60 mins):

Flotation of Swann catheter

Bronchoscopy

Midline laparotomy & midline sternotomy Sternotomy will probably be performed by thoracic surgeons if involved

Preparation of vessels for cannulation & warmdissection of liver (approx 40-90 mins)

Cardiac surgeons may then explore heart/lungs andprepare for cannulation (approx 45-60 mins)

Dissection of porta hepatis & identification of liverarterial anatomy

Division of CBD, washout of GB

Dissection & slooping of supracoeliac aorta


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Laparotomy & Sternotomy

Full explorationexclude gross pathology, assess liver / kidneys

Liver: Size, colour, texture, edges, pathology, vessels, perfusion /

congestion


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Arterial access (common iliac or

aortic bifurcation)


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Portal Venous access (SMVor IMV)


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Dissection of Porta Hepatis

Arterial anatomy variants common

Single 73%

Left from LGA 9%

Right from SMA 12%

Both 5%

Other 1%


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Dissection of supra-coeliac Aorta

Retract left lateral segment

Divide diaphragmatic crus

avoiding oesophagus

Identify and encircle infra-diaphragmatic aorta with

Semb clamp and tape

If left accessory artery is

present do not dissectinfra-diaphragmatic aorta.

Aorta should be encircled in

the chest or accessed to left

of gastric fundus


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Allow cardiac team to continue

Be helpful and polite

Allow them to inspect the heart during your dissection

? Remain scrubbed while they are working in the chestMaintain good communication:

Bypass

Cross-clamping

Clamping of supra-diaphragmatic IVC

Length of IVC

Damage oesophagus or trachea

Time of liver perfusion


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Resume abdominal retrieval procedure

Abdominal team return to table If thoracic retrieval both teams will be scrubbed

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

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

Approx 20 mins


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Cannulation

SMV Cannulation

Right CIA Cannulation

Tie distal SMV. Cut & introduce cannulaCheck position of tip & secure cannula

If low - may perfuse splenic vein

If high - unilateral perfusion of the live

Tie distal CIA/aorta, clamp

vessel proximally, Cut and

introduce cannula (avoid

dissection), first asst. fixes

cannula


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IVC ready for Bleed Out (venting

before perfusion essential)

Coordinate aortic

cross clamp with

cardiac team.

Vent: divide

supra-

diaphragmatic

IVC. If cardiac

team refuses,

divide infra-

hepatic IVC

Start perfusion


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Next Few Minutes

a bit chaotic

Cries of :

ICE. SLUSH !

IS THE SUCTION WORKING ? IS THE PERFUSION RUNNING ?

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


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Perfusion (cooling with slush, good

bleedout, check perfusion)


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Perfusion in Adult

Aortic cannula 3 litres of Marshalls solution at 80-100mmHg

4thlitre of Marshalls trickled no pressure

Portal venous cannula 1 litre University of Wisconsin fluidno pressure

Back bench perfusion with U of W

Artery 250ml

Bile duct 250ml

Portal vein 500ml


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Steps to minimise ischaemic type

biliary strictures (ITBS)

Etiology: ?multifactorialCIT, damage byinspissated cold bile, poor perfusion of arteriallysupplied 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

Padbury et al Transplantation 1993

Pirenne et al, Transplantation 2002


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Perfusion in Paediatrics

Donor

Weight

Aorta (ml) Portal (ml)

In-Situ

(Marshalls >15kg)

Back Bench

(UW)

In-Situ (UW) Back Bench

(UW)


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Perfusion in Special Cases

Paediatric donor ? Total UW perfusion

Small bowel retrieval Total UW

No SMV cannulation PV perfusion via IMV

Whole pancreas perfusion If pancreas team require total UW then they provide this

SMV perfusion as normal, Venting via IMV / SMV

Accessory RHA contraindication to whole pancreas retrieval (arguments)

Pancreas for islets As normal, vent portal venous system

Donor instability Rapid cannulationall dissection in cold phase

Total heart lung bypass (Harefield)

Cannulate after cytoprotective temperature has been reached on bypass


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Donor Procedure:Cold Phaseorder 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


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Hepatectomycold phase

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 fromSMA

Complete hepatectomy by cutting out wedge ofdiaphragm

Liver into ice slush for bench perfusion


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Hepatectomyaortic arterial patch!


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Back Bench Perfusion/Dissection

Kidney Block on Back Bench

Liver on Back Bench


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Donor Procedure: Cold Phase

Back bench perfusion Liver, Kidneys

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

Thanks & Goodbyes Total time 2-6 hrs


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Additional vessels (Split Tx, Regrafts, PVT)

Iliac artery and veins, superior mesenteric artery (graduated

vessel); long splenic artery


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The End Result

En-Bloc KidneyLiver on Ice The Donor


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Recipients at Tx Games

Split Liver Recipients

Liver Ready for Implantation

The Results of Your Hard Work


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Summary

Excellent senior trainee procedure

Skills: Surgical technique

Communication

Team-working

LeadershipResponsibility

Acknowledgements

Multi-organ retrieval team Procurement co-ordinators; consultant colleaguesSB

Donor hospitals

Donor families


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Thank you!

ddlt retrieval

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