Transcript Procedures

OVERVIEW OF
ORGAN
RECOVERY
Elizabeth A. Davies, MD
January 18, 2010
Procurement of the Heart
Mobilizing the Heart
• Open the Chest & open the pericardium
• Assess the donor heart
• Evaluate the contractility and coronary
anatomy
• Surgeon procuring the heart makes final
decision
• Chest is not open on the recipient at this point
• If the donor heart unsuitable for transplant, the
procedure can still be abandoned at this point.
Mobilization of the Heart
Base and diaphragmatic surface of heart
Mobilizing the Great Vessels
The vessels are mobilized widely to allow
the organs to be removed expeditiously.
• (4) The superior vena cava is dissected free.
• (6) The innominate artery is completely mobilized
• (7) The aortic arch is encircled just below the
great vessels of the head and neck.
• Dissection is carried along the aorta to its root.
• (8,9) The left and right pulmonary arteries are
mobilized.
6
Mobilization of the Great Veins
Mobilization of the Great Arteries
Procurement of the Lungs
Pulmonary Assessment
• Pleural spaces are opened and the lungs
inspected.
• The left and right pulmonary arteries are
mobilized.
• The trachea is isolated from the
esophagus and encircled.
Pulmonary Vessels, seen in a dorsal view of the heart
& lungs.
Cannula Placement
• (10) A cardioplegia catheter is inserted
into the proximal ascending aorta and
held in by a pursestring suture.
• A pulmoplegia catheter is inserted into the
proximal pulmonary artery and held in by
a pursestring suture.
Mobilization of the Great Arteries
Procurement of Abdominal
Organs
Dissection of the Retroperitoneum
• The right colon and distal ileum are mobilized along
the avascular planes exposing the Inferior Vena
Cava and Aorta
• A Kocher maneuver is performed by dividing the
retroperitoneal attachments along the lateral border
of the second and third portion of the duodenum.
• (30) The duodenum is swept medially to provide access to
the left renal vein, infrahepatic vena cava and SMA.
• The left renal vein is identified crossing the aorta.
Mobilization of the Right Colon
The Duodenum and Pancreas
Exposure of the Right
Retroperitoneum
• The inferior mesenteric artery is identified
and divided exposing the left side of the
aorta.
• The distal aorta is mobilized just proximal to
its bifurcations.
• Care must be taken to not injure renal arteries
potentially arising from the common iliac arteries
The Retroperitoneum and Great Vessels
Mobilization of the Liver
• Take down the diaphragmatic
attachments of the left lobe of the liver.
• Identify the presence/absence of an
accessory left hepatic artery (branch of
left gastric artery) in gastrohepatic
ligament
• Divide the gastric and esophageal
branches of the left gastric artery.
Mobilization of the Liver; Identifying the hepatic artery
Isolation of the Supraceliac
Aorta
• (17) Mobilize the Aorta where it passes
through the crura of the diaphragm.
• This enables the surgeon to place clamps superior
to the celiac axis to perfuse the liver and kidneys
without perfusing the heart.
Isolation of Supraceliac Aorta
Procurement of the Pancreas
Exposing the Pancreas
• The omentum is taken off the transverse
colon in an avascular plane opening the
lesser sac and allowing visualization of
the pancreas body and tail.
• (4) This dissection is facilitated by upward
traction of the stomach and inferior
retraction of the transverse colon.
Dissection of the Inferior Border of the Pancreas
Mobilizing the Descending
Colon and the Left Kidney
• The left colon is mobilized along an
avascular plane between the colon
and the left kidney.
• The spleen is mobilized along its
diaphragmatic plane
• The inferior border of the pancreas is
divided allowing the spleen and
pancreas to be mobilized medially
Mobilization of the Distal Pancreas
Dividing the Stomach
• The short gastric arteries between the
stomach and spleen are ligated and
divided.
• The stomach is infused with 100-200
cc of betadine.
• A GIA stapler is used to divide the
duodenum just distal to the pylorus.
– The stomach is retracted toward the left
chest
Division of the Duodenum
Procurement of the Liver
Dissection of the Porta Hepatis
• Identify and divide the common bile duct
• (11) Identify the hepatic artery and trace back
towards the celiac axis.
• (12,13) The gastroduodenal artery (branch of
the hepatic artery) is isolated.
• The splenic and left gastric arteries are then
identified.
Division of Common Duct and Drainage of the Gallbladder
Normal Variants of Hepatic Arterial
Anatomy
•
Left Accessory Hepatic Artery: 23%
donors
–
branch from the left gastric artery and
supplies the left lobe of the liver.
• Replaced Right Hepatic Artery: 12 %
donors
branches
from the superior mesenteric
artery, passes behind the common duct
to the right lobe.
Division of Common Duct and Drainage of the Gallbladder
Dissection of the Porta Hepatis
• A longitudinal incision is made in the
inferior surface of the fundus of the
gallbladder.
• (32) The biliary tree is flushed with
saline through the gallbladder.
• This flushes bile before endothelium is
exposed
– bile is toxic to endothelial cells
Procurement of the Kidneys
Procurement of the Kidneys
• Isolate the ureters as they cross the common
iliac artery bifurcation
• If cannulating the inferior vena cava (lung
recovery), insure that no low-lying right renal
artery crosses anterior to the IVC
The Retroperitoneum and Great Vessels
Cannulating the Aorta, Vena Cava &
Portal Vein
• (45) An inflow catheter is placed in the
aorta
• (48) A cannula is passed into the portal
vein through a transverse venotomy made
in the inferior mesenteric vein.
Pancreatic Anatomy
Cannulation of the Aorta and the Vena Cava
Preparing for Cross-Clamp
• Heparin is given.
• Cold lactated ringers should begin
flushing through the portal vein
catheter.
• 1 - 2 liters of cold fluid should run
through the portal catheter every 20
minutes for adults (500 ml in children).
Cross-Clamp
• After heparin has circulated for three
minutes, (52) the aorta is cannulated.
• For lung procurement, PGE1 is infused
just prior to cross-clamp.
• The aorta is occluded at the level of the
diaphragm by a vascular clamp.
• Simultaneously, the perfusion solution
(LR, UW, HTK, etc.) is infused into the
heart, liver, kidneys, and pancreas via
inflow catheters.
Mobilization of the Suprahepatic Vena
Cava
• At crossclamp, the thoracic and
abdominal surgeons agree on the point
of division of the suprahepatic inferior
vena cava.
– Incidence of pacemaker dependency
reportedly less in cava to cava anastomosis
in heart transplant
– Need suprahepatic cava to perform
anastomosis in liver transplant
• A rim of the diaphragm is left attached
to the suprahepatic vena cava (37)
Mobilization of the Suprahepatic Vena Cava
Excision of the Donor Heart
• (55) Superior vena cava is ligated and
divided.
• (57) The aorta is cross-clamped at the
aortic arch and (58) divided just proximal
to the cross-clamp.
• (54) Cardioplegia is completely infused
(59,60)
• The pulmonary artery (main branches) are
divided, (61) the heart is elevated (next
slide) and the pulmonary veins (62) are
divided.
Excision of the Donor Heart
Division of the Pulmonary Veins
Excision of the Lungs
• Pulmonoplegia is completely infused.
• The pulmonary veins are divided with
consensus between heart and lung team
• The pulmonary artery main branches are
divided.
• The lungs continue to be fully ventilated.
• With full inspiration, the trachea is stapled
and divided.
• The lungs are removed from the pleural
cavities.
Division of the Small Bowel
Mesentery
• While the chest surgeons recover the
thoracic organs, the distal duodeum is
divided.
• The small bowel mesentery is divided
away from the pancreas at the base of the
mesentery.
• The arterial and venous branches are
ligated on the pancreatic side.
Isolation of the Infrahepatic Vena
Cava
• The inferior vena cava superior to the level
of the renal veins is mobilized.
• The liver is retracted upward and the right
adrenal gland is divided with the adrenal
vein going with the liver.
• The right and left renal veins are identified
and the inferior vena cava divided above
them.
The Retroperitoneum and Great Vessels
Removal of En bloc Liver-Pancreas
• Ligate the SMA at its origin
• Divide the SMA labeling the pancreas side
with a vascular suture
• Place a clamp above the SMA
• Divide the aorta just above the clamp to
continue perfusion to the kidneys.
• Divide the supraceliac aorta just distal to the
cross clamp
• The posterior and adventitial attachments of
the vena cava and aorta are divided and the
organs removed.
Splitting the Pancreas and the
Liver
• Divide the splenic artery just distal to
its origin from the celiac axis.
• The gastroduodenal artery is ligated
on the pancreatic side and divided.
• The portal vein is divided at the
superior border of the pancreas.
• Adventitial attachments are divided,
thus, splitting the liver and the
pancreas.
Posterior Aspect of the Entire Gland
Backtable Perfusion of the Pancreas
and Liver
• The portal vein is perfused with UW
• The hepatic artery, splenic artery and
SMA are each perfused UW
• Amphotericin B (50mg) is injected
into the distal duodenal segment.
Preparing the kidneys for
removal
• The vena cava and the aorta have been
divided above the renal veins and
arteries.
• They are now divided below the
cannulas’ insertion points.
• The ureters are divided near the bladder.
• The kidneys are mobilized outside
Gerota’s fascia and removed from the
abdomen en bloc.
Preparing the Kidneys for Removal
Backtable preparation of kidneys
• The kidneys are placed posterior side up.
• The proximal end of the aorta is oversewn
and the clamp removed.
• The lumbar arteries are clipped at their
origin from the aorta.
• The arterial anatomy of the kidneys is
identified.
• Gerota’s fascia is removed from the
kidneys.
– Care must be taken not to strip perihilar fat from the pelvis
of the kidneys and to preserve all vascular branches to
the ureters.
Backtable preparation of
kidneys
• The kidneys are placed anterior side up.
• The left renal vein is divided off the cava at
its insertion.
• The arterial anatomy of the kidneys is
confirmed.
• The kidneys are placed en bloc on pulsatile
preservation.
• For cold stored kidneys, the aorta is divide
down the middle and the kidneys split.
Splitting the Kidneys
Facts about Cannulation
Techniques
• Perfusing enbloc preserves maximum
renal arterial length and prevents
intimal damage to the renal arteries.
• Cannulating an aortic conduit is the
ideal technique for the perfusion of a
kidney with multiple renal arteries
because it permits the use of one or
more Carrel patches for renal arterial
anastomosis.
Pillings (Bulldog) Cannulation Technique
Straight Cannulation Technique