Ddlt Retrieval
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Transcript of 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!