SUBJECT SEMINARORGAN DONATION

Speaker : Dr. Ajai Sasidhar PG Student

Chair Person : Dr. Shilpa S Huchchannavar Asso. Professor and Unit Chief

Dept. of General Surgery KIMS Hubli

Transplantation

• Transplantation is the process of transferring an organ, tissue, or cell from one place to another.

A miraculous transplantation of a leg

History of Transplant1. Technique of vascular anastomosis by Alexis Carrel.2. Process of rejection by Peter Medawar.3. 6-MP and Azathioprine by Gertrude Elion and George Hitchings

Carrels method of vascular anastomosis in 1902

“The termino-terminal anastomosis is effected by bringing the extremities of the vessels into contact, no traction being necessary. The ends are united by three retaining stitches located in three equidistant points of their circumference. By traction on the threads the circumference of the artery can be transformed into a triangle, and the perimeter can be dilated at will. Then the edges of each side of the triangle are united by a continuous suture whilst they are under tension. During the suture great care is taken to approximate exactly the surfaces of section of the wall.”

The Indian Scenario• Kidney – 1st Cadaveric transplant in may 1965,

1st live donor renal transplant in CMC Vellore in 1971• Liver – 1st unsuccessful attempt in 1995 AIIMS

1st successful attempt in 1998 New Delhi• Lung – 1st cadaveric transplant done in 1999 Madras Medical Mission• Intestine – 2013 in New Delhi.• Pancreas – 2005 in AIIMS• Heart - 1st in 1968 br Dr. P K Sen at KEM Hospital Mumbai

1st successful transplant by dr. venugopal in AIIMS in 1994

• Multivisceral – Data not available

• 1980 – Cyclosporine (Anti T Lymphocyte drug).• Graft survival increased to 80% in all types of grafts.

Definitions• Transplantation is the process of transferring an organ, tissue, or cell

from one place to another.• An organ transplant is a surgical procedure in which a failing organ is

replaced by a functioning one. • Orthotopically (implanted in the same anatomic location in the

recipient as it was in the donor).• Heterotopically (implanted in another anatomic location).

• Orthotopic transplants require the removal of the diseased organ (heart, lungs, liver, or intestine).• In heterotopic transplants, the diseased organ is kept in place (kidney,

pancreas).

• An autotransplant is the transfer of cells, tissue, or an organ from one part of the body to another part in the same person, so no immunosuppression is required. This type of transplant includes skin and vein, bone, cartilage, nerve, and islet cell transplants. • An allotransplant is the transfer of cells, tissue, or an organ from one

person to another of the same species. The immune system of the recipient recognizes the donated organ as a foreign body, so immunosuppression is required in order to avoid rejection.• A xenotransplant is the transfer of cells, tissue, or an organ from one

organism to another from a different species.

Graft Rejection• Allograft rejection can be divided into three distinct types• Hyperacute rejection (occurs immediately);• Acute rejection (usually occurs in the first six months);• Chronic rejection (occurs months and years after transplantation).

Hyper acute rejection• Due to preformed antibodies against HLA class I antigens expressed

by the donor.• Antibodies arise from a previous blood transfusion, a failed transplant

and pregnancy.• Also occurs due to ABO incompatibility.• Activation of the complement system causes extensive intravascular

thrombosis, interstitial haemorrhage and graft destruction within minutes and hours.

How to prevent hyper acute rejection• Ensure ABO blood group compatibility.• Cross-match test on recipient serum.

Acute rejection• This usually occurs during the first six months of transplantation but

may occur later.• It is mediated predominantly by T lymphocytes, but alloantibodies

may also play an important role.• Commonest mode of rejection.• Prevented by immune suppressive therapy.

Chronic rejection• Occurs after the first six months.• All types of grafts are susceptible for chronic rejection.• The pathophysiology of chronic rejection is not well understood.

Risk factors for chronic rejection• Previous episodes of acute rejection;• Poor HLA match;• Long cold ischaemia time;• Cytomegalovirus (CMV) infection;• Raised blood lipids;• Inadequate immunosuppression (including poor compliance)

Features• Kidney: glomerular sclerosis and tubular atrophy;• Pancreas: acinar loss and islet destruction;• Heart: accelerated coronary artery disease (cardiac allograft• Vasculopathy);• Liver: vanishing bile duct syndrome;• Lungs: obliterative bronchiolitis.

• Immuno suppressive therapy has no role in chronic graft rejection.

• Chronic rejection causes functional deterioration in the graft, resulting after months or years in complete graft failure.

ORGAN DONATION

Data source: http://optn.transplant.hrsa.gov/

Organ Donors• Deceased donors (DD)• Donation after brain death (DBD) – Brain stem dead heart beating donors.• Donation after circulatory death (DCD)

• Living Donors

• DBD donors provide almost all organs.• DCD donors provide kidneys, liver , pancreas and lungs.• Living donors – kidney, liver and lung lobe.

Donation after brain stem death donors• Also called heart beating deceased donor.• Result from stroke or traumatic brain injury.

Brain death• Brain death occurs when severe brain injury causes irreversible loss of

the capacity for consciousness combined with the irreversible loss of the capacity for breathing.

How to diagnose brain deathPre conditions for diagnosis• The patient must have suffered major brain damage of known aetiology,• Be deeply unconscious and require ventilatory support. • Particular care must be taken to ensure that muscle relaxant agents and

drugs with known CNS depressant effects are not contributing to the clinical picture.• Hypothermia, profound hypotension and metabolic or hormonal

conditions that may contribute to CNS depression and confound the diagnosis of brainstem death must also be excluded.

• If the pre conditions are satisfied, formal clinical assessment of the brainstem reflexes can be undertaken.• The UK guidelines state that the tests should be performed on two

separate occasions by two clinicians experienced in this area. At least one of the two clinicians should be a consultant and neither should be connected with the transplant team. • The time that must elapse between the two sets of brainstem tests is

not specified in the guidelines and is determined on the basis of clinical judgement.

Clinical testing for brain stem deathAbsence of cranial nerve relexes• Pupillary reflex• Corneal reflex• Pharyngeal (gag) and tracheal (cough) reflex• Oculovestibular (caloric) reflex.

Absence of motor response• The absence of a motor response to painful stimuli applied to the

head/face and the absence of a motor response within the cranial nerve distribution to adequate stimulation of any somatic area is an indicator of brainstem death. The presence of spinal reflexes does not preclude brainstem death.

Absence of spontaneous respiration• After pre-ventilation with 100% O2 for at least 5 minutes, the patient

is disconnected from the ventilator for 10 minutes to confirm absence of respiratory effort, during which time the arterial PCO2 level should be >8 kPa (60 mmHg) to ensure adequate respiratory stimulation. To prevent hypoxia during the apnoeic period, O2 (6 L/min) is delivered via an endotracheal catheter.

Who should declare brain death (In India)

Panel of 4 doctors need to declare the brain death twice in a span of 6 hours. 2 of these doctors must be from a panel approved by the government.

This panel includes:i. Registered Medical Practitioner in charge of the Hospital where brain

stem death has occurred.ii. Registered Medical Practitioner nominated from the panel of names

sent by the hospitals and approved by the Appropriate Authority.iii. Neurologist/Neuro-Surgeon (where Neurologist/Neurosurgeon is not

available, any Surgeon or Physician and Anaesthetist or Intensivist, Nominated by Medical Administrator In-charge from the panel of names sent by the hospital and approved by the Appropriate Authority shall be included.iv. Registered medical practitioner treating the aforesaid deceased person.

After circulatory death donorsDCD donors can be grouped according to the Maastricht• category 1: dead on arrival at hospital;• category 2: resuscitation attempted without success;• category 3: ‘awaiting cardiac arrest’ after withdrawal of support;• category 4: cardiac arrest while brain dead;• category 5: cardiac arrest and unsuccessful resuscitation in hospital.

• 1, 2 and 5 donors are sometimes referred to as uncontrolled DCD donors. The warm ischaemic time of organs from these three categories of donor is usually longer and less predictable than in the case of categories 3 and 4 (controlled) donors.

Evaluation of deceased donors.• Contra indications for donation – systemic infections and malignancy• Creutzfeldt–Jakob disease is an absolute contraindication to organ donation.• Organs from HIV-infected donors should not be used for transplantation,

except sometimes in recipients who are already infected by the HIV virus.• Hepatitis B infection and active systemic sepsis, e.g. major abdominal

infection, are contraindications to donation. • The presence of malignancy within the past five years is usually an absolute

contraindication to organ donation with the exceptions of primary tumours of the CNS, non-melanotic tumours of the skin and carcinoma in situ of the uterine cervix.

The warm ischaemia and cold ischaemia• Warm ischaemia : The warm ischaemic time has been assessed as the

time interval between onset of irreversible asystole and subsequent cold perfusion.• Cold ischaemia : The time interval between the start of cold perfusion

and subsequent reperfusion in the recipient body.• 1 hour of warm ischaemia is equivalent to 6 hours of cold ischaemia

Organ recovery from deceased donors• DBD donors• Maintain hemodynamic stability• Chest and abdomen opened by a midline sternotomy and abdominal

incision.• Dissection of organs followed by insitu perfusion of organs.

• The heart is perfused with cold cardioplegia solution via a cannula in the ascending aorta• The lungs are perfused via a cannula in the pulmonary artery.• The abdominal organs are perfused with chilled organ preservation

solution via an aortic and portal cannula.• The cold solution is vented out through inferior vena cava.

• Additional surface cooling of the abdominal organs may be achieved by application of saline ice slush.• The heart and lungs are excised followed by the liver and pancreas

and then the kidneys, either en bloc or separately.

Care about Anatomic variations• During recovery of the liver, care is taken to ensure that if there is an

aberrant hepatic artery arising from the superior mesenteric artery it is included in the aortic patch.• When removing the donor kidneys care is taken to ensure that any

polar renal arteries are included on an aortic patch with the renal artery.

• In DCD donors there is an inevitable period of warm ischaemia (up to 45 minutes is acceptable) between the diagnosis of death (cardiorespiratory arrest) and cold perfusion of the organs.• The aim during organ recovery is to minimise the period of warm

ischaemia.• After removal from the donor, the organs may undergo a further flush

with chilled preservation solution before they are placed in double or triple sterile bags and stored at 4°C by immersion in ice while they are transported to the recipient centre and await implantation.

Preservative solutions• University of Wisconsin (UW) solution and Euro-Collins solution are

the most used preservative solutions.• They all contain impermeants to limit cell swelling, buffers to counter

acidosis and electrolytes, the composition of which reflects that of intracellular rather than extracellular fluid.

Living donors• Most common organ donated is kidney, followed by liver.• Occasionally, living donors have provided segments of pancreas, small

bowel and lung for transplantation.

Live donor nephrectomy• Traditional method is either through a loin incision and

retroperitoneal approach or through a midline abdominal incision and transperitoneal approach.• nephrectomy is now undertaken laparoscopically (totally laparoscopic

or hand-assisted).• The mortality rate for live donation is less than 0.05 per cent, and

around one-half of reported deaths are due to pulmonary embolic disease.

Living liver donors• The concept was first pioneered to allow children to receive the left

lobe or left lateral segment from an adult donor.• Adult to adult transplant requires a portion of right lobe of donor.• For adult-to-adult live liver donation, the donor procedure has a

reported mortality rate of around 0.5 per cent and a major complication rate of up to 15 per cent. • One of the more common donor complications is bile leak.

• living donor combined kidney and segmental pancreas transplantation has been undertaken to treat insulin-dependent diabetics with end-stage renal disease.• Living-donor small bowel transplantation has been performed using a

small bowel graft, which comprises a length of around 1.5 m of ileum.• A small number of living-donor segmental lung transplants have been

performed. To provide sufficient pulmonary tissue without compromising the donor, it is necessary to use segments from two different donors for each recipient.

Resumption of function following organ transplantation• following heart, lung or liver transplantation the transplanted organ

should resumes satisfactory function immediately.• If primary non-function occurs, the only option is rapid re-

transplantation.• After kidney, pancreas or small bowel transplantation, immediate

graft function is desirable but not vital.

Organ donation in India• The primary legislation related to organ donation and transplantation

in India, Transplantation of Human Organs Act, was passed in 1994 and is aimed at regulation of removal, storage and transplantation of human organs for therapeutic purposes and for prevention of commercial dealings in human organs.• In India, matters related to health are governed by each state.

The main provisions of the Act A. Brain death identified as a form of death. Process and criteria for brain death certification defined.B. Allows transplantation of human organs and tissues from living donors and cadavers (after cardiac or brain death).C. Regulatory and advisory bodies for monitoring transplantation activity and their constitution defined.

Regulatory bodies consists of• Appropriate Authority• Advisory Committee• Authorization Committee• Medical board (Brain Death Committee)

• Appropriate Authority (AA): inspects and grants registration to hospitals for transplantation enforces required standards for hospitals, conducts regular inspections to examine the quality of transplantations. It may conduct investigations into complaints regarding breach of provisions of the Act, and has the powers of a civil court to summon any person, request documents and issue search warrants.• Advisory Committee: consisting of experts in the domain who shall

advise the appropriate authority.

• Authorization Committee (AC): regulates living donor transplantation by reviewing each case to ensure that the living donor is not exploited for monetary considerations and to prevent commercial dealings in transplantation. Proceedings to be video recorded and decisions notified within 24 hours. Appeals against their decision may be made to the state or central government.

• Medical board (Brain Death Committee): Panel of doctors responsible for brain death certification. In case of non-availability of neurologist or neurosurgeon, any surgeon, physician, anaesthetist or intensivist, nominated by medical administrator in-charge of the hospital may certify brain death.

D. Living donors are classified as either a near relative or a non-related donor.(i) A near-relative (spouse, children, grandchildren, siblings, parents and grandparents) needs permission of the doctor in-charge of the transplant center to donate his organ.(ii) A non-related donor needs permission of an Authorization Committee established by the state to donate his organs.E. Swap Transplantation: When a near relative living donor is medically incompatible with the recipient, the pair is permitted to do a swap transplant with another related unmatched donor/recipient pair.

F. Authorization for organ donation after brain death(i) May be given before death by the person himself/herself or(ii) By the person in legal possession of the body. A doctor shall ask the patient or relative of every person admitted to the ICU whether any prior authorization had been made. If not, the patient or his near relative should be made aware of the option to authorize such donation.(iii) Authorization process for organ or tissue donation from unclaimed bodies outlined.

G. Organ retrieval permitted from any hospital with ICU facility once registered with the appropriate authority. Any hospital having Intensive Care Unit (ICU) facilities along with manpower, infrastructure and equipment as required to diagnose and maintain the brain-stem dead person and to retrieve and transport organs and tissues including the facility for their temporary storage, can register as a retrieval center.

H. Cost of donor management, retrieval, transportation and preservation to be borne by the recipient, institution, government, NGO or society, and not by the donor family.I. Procedure for organ donation in medico-legal cases defined to avoid jeopardizing determination of the cause of death and delay in retrieval of organs.

J. Manpower and Facilities required for registration of a hospital as a transplant center outlined.K. Infrastructure, equipment requirements and guidelines and standard operating procedures for tissue banks outlined.L. Qualifications of transplant surgeons, cornea and tissue retrieval technicians defined.M. Appointment of transplant coordinators (with defined qualifications) made mandatory in all transplant centers.

N. Non-governmental organisations, registered societies and trusts working in the field of organ or tissue removal, storage or transplantation will require registration.O. The central government to establish a National Human Organs and Tissues Removal and Storage Network i.e. NOTTO (National Organ & Tissue Transplant Organisation).P. The central government shall maintain a registry of the donors and recipients of human organs and tissues.

• Q. Penalties for removal of organ without authority, making or receiving payment for supplying human organs or contravening any other provisions of the Act have been made very stringent in order to serve as a deterrent for such activities.

• Since the health is included in the state list, each state can adapt the central guidelines.

Organ Donation in Karnataka

• The Zonal Coordination Committee of Karnataka for Transplantation has been constituted by the Government of Karnataka (Government Order No. 264 PTD dated, 13th April 2004) for a sustained cadaveric transplantation programme in the state of . • ZCCK is the body appointed to oversee the implementation of the

Transplantation of Human Organs Act of 1994. • ZCCK oversees all the cadaveric organ transplantation in Karnataka.

Functions of ZCCK• Maintain a recipient waiting list of patients referred by hospitals. The

recipients will be registered at ZCCK office.• Allocate organs when available as per the criteria laid down. These

criteria will be revised from time to time in consultation with the medical fraternity.• Facilitate organ retrieval & transport.• Conduct public awareness programs.

• he only organisation in Karnataka through whom organ donations and transplants are co-ordinated is ZCCK• A list of patients awaiting transplant is maintained. On receiving

information about potential donors, ZCCK will assess suitability for organ donation. Based on the blood group and other criteria for the organ matching, the recipients will be selected, brought into hospital and prepared for the operation.

Organ donation in India

Functions of NOTTO• Apex centre for co ordination of activities regarding procurement and

networking between different centres.• Registry of Organs and tissue donation and transplantation.• Monitoring of transplantation activities.

Guidelines for managing brain dead donors• Management in ICU• Mangement in Operation Theatre

Management of brain dead donors in ICU – NOTTO Guidelines• A number of physiological changes which occur in the brain dead

patient lead ultimately to hypoperfusion of the various organs.• The guidelines which follow attempt to provide a road map to allow

for the largest possible yield of organs.• these guidelines are frequently based on low grade evidence,

opinion and anecdote. There is therefore substantial room for variations in practice.

Changes in brain dead ventilated patients

Changes in brain dead ventilated patients

Changes in brain dead ventilated patients

Specific Management of brain dead patientsCommunication• It is important to state to the relatives without ambiguity and

equivocation the fact of the patient's brain death. Following this, time should be given for the families to adjust to the fact of the patient's brain death.• Hierarchy of the family of the donor should be ascertained so that

the person responsible for giving consent for organ donation is established.• It is preferable that the ICU team which has conveyed the news of

brain death, should not be involved in counselling the relatives.

Nursing care• The general nursing care of the brain dead organ donor

(Prevention of decubitus ulcers, skin care, dressing changes, urinary and intravascular catheters and catheter site care).• This will aid in preventing the brain dead patient from developing

systematic sepsis.• Use of active or passive warmers.

Monitoring. The brain dead organ donor requires extremely close monitoring to detect decompensation and treat it urgently.Parameters to monitora. Core temperature (Either Nasopharyngeal, esophageal, rectal

or indwelling bladder catheter)b. ECGc. Invasive Blood Pressure (Arterial Catheter),d. CVP (Subclavian or IJV)e. Sp02f. End-tidal C02g. Hourly urine output

Investigations required

• a. CBC• b. Blood grouping and cross matching• c. Coagulation profile- PT/PTTK• d. RFT-BUN, Creatinine e. • E. Complete LFT• f. S Electrolytes- Ca, Mg, N a, K, Phosphate g. • G. Blood Sugar• h. Urine analysis• i. ABG with lactate

j. Cardiac evaluationECGEchocardiography

K. Imaging i.CXRii. USG for abdominal organs-liver, kidney, pancreas

L. Microbiology Surveillance cultures of ET Asp, Blood, urine, ascetic fluid m. Viral markers

1. HBsAg2. AntiHCV3. HIV 1&2

Specific Infection Prevention: Aseptic precautions to be continued and antibiotics if required for organ donation to be decided on centre/organ specific basis.

• Fluid Management:Replacement of volume deficit: With balanced salt solutions like Ringer lactate. May require large boluses of fluid depending on blood pressure.Maintenance fluid : Depending on the urine output on hourly basis. With balanced salt solutions or with 5%dextrose if the patient is hypernatremic due to diabetic insipidus. Fluid targets should be monitored by CVP and pulmonary artery wedge pressure.

Vasopressors• Vasopressors need to be started if the patient continues to be

hypotensive after adequate fluid resuscitation. • There is little evidence to show the superiority of one pressor over

the other in this particular setting. • Dopamine may improve kidney survival and nor adrenaline may

prevent arrhythmias.• May require physiological doses of vasopressin 0.4-2.5 Units/Hour

• Norepinephrine and Vasopressin are the first line vasopressors whereas dopamine, dobutamine and epinephrine are used selectively in some patients.• T3 hormone supplementation may be required for optimum action of

catecholamines.

• Ventilatory management: • Standard lung protective ventilation strategies are suggested, in

conjunction with closed suctioning, and targeting of PEEP to allow the Fi02 to be kept as low as possible to allow an Sp02 of >94% especially if lung transplantation is considered.

Management of Endocrine Dysfunction And Hormone Replacement• Vasopressin : To treat diabete insipidus administer nasal puffs or

intravenous desmopressin presumptively if two hours of urine output >4 ml/kg/hr have passed.• Methylprednisolone : 15 mg/kg every 24 hours to supplement

corticosteroids also extra benefit of increasing organ retrieval rate.• Insulin: It is important to avoid extreme hyperglycemia, especially

when pancreatic harvesting is considered. A blood sugar of 120-180 mg% should be aimed for with the judicious use of a low dose insulin infusion.

• Triodothyronine / Thyroxine: 4 microgram bolus followed by infusion at 3 micrograms/hour in the brain dead patient improving vasopressor responsiveness and organ salvage rates. intravenous tridothyronine is generally not available in India. Oral thyroxine in the dose of 300-400mcg/8hourly is an alternative to triiodothyronine.

Targets for resuscitationParameter Target Heart Rate 60-120 beats/mt Arterial Pressure Systolic pressure> 100 mm Hg Central Venous Pressure 6-10 mm Hg Urine Output 0.5-3 ml/kg/hr

Parameter TargetElectrolytes Serum Sodium 130-150 mmol/IitreNormal Potassium, Calcium, Magnesium, Glucose andPhosphate Blood Gases Ph-7.35-7.45PaC02-30-45 mmHg Pa02> 80 mmHg Sp02>95% Temperature >35°CBlood sugar 120-180mg%HB >10Gm%

Organ Retrieval in OT• The main aim of management is to avoid ischemia of the donor

organs and retrieve these organs in an optimal state.• All the documents including brain death certificate, consent from the

relatives and certificate from judicial authorities in case of MLC cases should be verified.• The ICU management should be continued on table.

Anaesthetic management• Anaesthesia is required ?• There is as yet no way to know whether these cases indeed

have no sensation.• Isoflurane and sevofluranecan cause ischemic preconditioning of

organs and this may improve graft organ function.• Inhalational anaesthetic may have a beneficial effect by causing

peripheral vasodilation.

Muscle relaxants• Mandatory as to prevent mass reflex and lazarus reflex.• Vecuronium O.1mg/kg is given to allow adequate surgical

exposure and suppress the possibility of spinal-reflex-induced patient movement.• Analgesia can be provided with Narcotic analgesic-Fentanyl 1-5

ug/kg.• Air and oxygen mixture can be given.

Surgical steps in organ harvesting surgery• After preparing the donor from neck to pubis and a long midline

incision is made from the suprasternal notch to the pubis. • In a haemodynamically stable donor, organ dissection is done insitu.

It may even be possible to plan in-situ splitting of the liver graft.• In an unstable donor with imminent haemodynamic collapse,

harvesting of thoracic organs is abandoned, the abdominal organs should be rapidly flushed and cooled and organs are removed en bloc for further dissection on bench.

• If the pancreas is to be harvested, the duodenum is flushed with an antibiotic or betadine solution through a nasogastric tube.• The portal circulation is cannulated.• The abdominal aorta is ligated and cannulated just above the

bifurcation.• The heart is arrested, the aorta is clamped at the diaphragm,

and the organs are flushed with preservative solution.• In general the order of organ removal is as follows: heart and lungs

first, followed by removal of liver, pancreas and both kidneys. Corneas are the last to be retrieved.

Retrieval of Heart - Standard operative procedures• Instruments required• a sternal saw,• a sternal spreader,• aortic cross clamp,• long vascular clamp for IVC,• needle holders for 3'0' and 4'0'prolene sutures,• long scissors,

• large right angle clamps and long forceps.• Long silk ties, one 4 -'0' prolene suture,• one aortic root or root-vent cannula.• Cotton tapes. Two sterile packed basins.• Three nos bowel bags.• Additional few 3'0' and 4'0'prolene sutures.• Silk sutures for pericardial cradle and needle holders.

• CUSTODIOL or St. Thomas cardioplegia solution 4 Ltrs• 3-5 litres of ice slush and chilled saline solution in an ice chest.• Triple bag technique• a. First bag contains 1 litre chilled custodiol and heart • b. Second bag contains first bag and 1 litre of ice slush • c. Third bag contains the second bag.

• The first bag is placed in the second bag face down and second bag is placed in the third bag face down.

Steps for Heart retrieval• Heparinize with 30000 IU Heparin• Secure tie the azygous between triple ties.• Ask the anaesthetist to withdraw CVP line, Tie SVC above the

Azygous.• Clamp IVC flush with the diaphragm (be aware of abdominal surgeons

commencing perfusion prior to IVC clamp, the right heart would distend and heart would be rendered unusable.)• aortic cross clamp.• Infuse with Custodiol solution (30-40 mLlkg) at a hydrostatic pressure

of 50 mm Hg for 6 to 8 minutes

• Hemisect the IVC anteriorly to vent the right heart.• Cut left superior pulmonary vein to vent the left heart.• Submerge the heart in slush solution• Place a sucker in the IVC to collect warm effluent.• Once the cardioplegia is completed excise the heart

Liver harvest• Instruments required• Large Finochietto retractor• Very large self-retaining abdominal retractor • 30" long Artery forceps• Laparotomy set• Cannulae for aortic and portal vein perfusion• Cannulae for bench perfusion.• Satinsky and bulldog clamps • Gigli/Sternal Saw• 4 plastic bowls and sets of plastic bags with strings• Ice box

Finochietto retractor

• Satinsky Clamp • Bulldog Clamp

• The order of organ retrieval is as follows.• I. Heart/lung• II. Liver• Ill. Pancreas/intestine• IV. Kidneys • v. Corneas

Steps• Incision: Long midline laparotomy • Complete exploratory laparotomy• Divide falciform ligament and check that the liver is suitable for

donation.• Check for accessory hepatic arteries• I. Right hepatic artery from superior mesenteric artery behind the

bile duct• II. Left hepatic artery from left gastric in the hepatogastric ligament

• mobilizing the colon on both sides to expose the retroperitoneum• Identify Ureters at pelvic brim• Pass ties around the origin of common iliac arteries • Prepare iliac veins and inferior vena cava for venting

Warm Phase dissection• Divide peritoneal attachments to the base of the liver• Expose retroperitoneum up to right/left renal vein and superior

mesenteric artery• Mobilise duodenum to expose infra-hepatic inferior vena cava.• Expose renal capsules on both sides and check kidneys for

cysts/tumours.• Pass two silk ties around the superior mesenteric vein at the

root of the tranverse mesocolon or around the inferior mesenteric vein.

• Ligate the inferior mesenteric vein• Pass a finger through the foramen of Winslow and open the

lesser omentum• Divide the common bile duct just above the duodenum and

ligate the duodenal side• Open the gall bladder and wash and such out bile with saline

using a 50 ml bladder syringe.• Identify and loop the common hepatic artery between the

gastroduodenal and splenic artery.

Cold perfusion• Ligate left common iliac artery• Cannulate right common iliac artery - INPUT• Cannulate superior/inferior mesenteric vein: place catheter tip

at level of the pancreas.- OUTPUT

Cold dissection• Mobilise duodenum downwards, dividing gastroduodenal artery and

expose portal vein• Divide neck of pancreas anterior to portal vein/superior mesenteric

vein.• Removal portal cannula and divide confluence of superior mesenteric

vein/splenic vein.• Divide left gastric artery distal to any accessory left hepatic artery• Then divide superior mesenteric artery distal to right hepatic artery

and carefully dissect right hepatic artery off head of pancreas.

• Divide infrahepatic inferior vena cava above renal veins by opening in midline and visualizing renal vein onsite clearly.• Mobilise right lobe of the liver exposing right adrenal and cutting

through it (requires gentle traction by the assistant to avoid tearing the liver capsule).• Divide remaining attachments and remove liver and inferior vena

cava with attached tissues.

Retrieval kidney• Kidney and vessel removal with aortic patches and inferior

vena cava patches by splitting both vessels in midline.• Divide ureters below pelvic brim. • Perfuse renal artery with' 200 ml HTK and pack in double bags in

ice box

• THANK YOU