13 jan 2026 BTK procurement whole _mixdown-esv2-58p-bg-14p
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[00:00:00] Welcome back to Behind the Knife. I'm Dr. Maddie Kan, a general surgery resident at the University of Nebraska Medical Center. I'm joined today by three phenomenal members of our transplant team, Dr. Evelyn. Wow.

I'm Evelyn. I'm the Senior transplant fellow at UNMC.

Dr. Jackie Dow.

Hi, I'm one of the abdominal transplant surgeons at UNMC

and Dr.

Alex Mask.

I'm the Kidney and Thinkers transplant surgeon at UNMC, and I'm also a co-medical director of our local organ procurement organization.

We will discuss abdominal organ procurement in both brain dead and donation after circulatory death. Donors covering the warm and cold phases. Donor hospital logistics and considerations for pancreas, small bowel and multivisceral transplants, all while emphasizing both the technical and non-technical aspects of procurement surgery.

This is such an important operation for both donors and recipients, but it can be surprisingly hard to find detailed, practical teaching about it. We wanna open up that black box. Before we dive into the technique, can we zoom out for a second? What actually has to be in place before [00:01:00] we even go to the OR for an abdominal recovery?

Yeah, thanks Maddie. Happy to talk about kind of the beginnings of organ procurement which mainly involve organ procurement organization before the surgeons actually step in. So there are a few things that must be in placed before a donor procurement can happen and they don't involve transplant teams or surgeons.

So first, there's a medical determination that ongoing life sustaining therapy is inappropriate. So for patients who are brain dead, the IC or neurology team must complete or document a formal brain death evaluation. Once a patient is declared brain dead, the local organ procurement organization takes over the care of the donor until the organ procurement for DCD donors, the ICU team must.

Complete the withdrawal care plan and is solely responsible for monitoring and managing the patient until the official declaration of death. So once a donor is identified by the hospital and they're legally obligated to call the local procurement organization to evaluate local procurement organization, evaluate the patient, we have a team of family support coordinators who go into the hospital to obtain [00:02:00] authorization.

So patients can either be registered on their driver's license or unregistered when the OVO comes in. They obtain the authorization for donation. So like I said, that may be first person authorization to the donor registry or they can obtain consent from the family. And third is donor suitability and acceptance.

So the OPO confirms which organs are being potentially allocated and compiles everything into a packet, which includes the donor history authorization documentation of the brain death, or DCD declaration plan lab data, and lists of organs to be recovered. Oregon Acceptance is done through the UNOS Match Run, which is the national matching system, and then the OPO calls the separate Oregon Acceptance Teams and coordinates the donor procurement.

It's really interesting to hear how much goes on before the operation even takes place. So let's set the scene. You're a second year resident and it's your first day on your transplant rotation. You receive a text from your fellow, hey, leaving for a donor at 10:00 PM You grab your loops and frantically try to review for the case.

When you arrive to the donor hospital, there are about [00:03:00] 30 people in the operating room and you're trying to make sense of everything. Dr. Makin, can you walk us through who's in the operating room for a donor recovery?

Sure. When you, when you walk into a donor org, there are many people doing different things, but the roles are actually very clear.

A donor case generally involves three separate teams with distinct responsibilities. This patient is initially in the ICU. Um, the IC team manages the donor from the time of care begins until death is formally declared. We said before, one's brain death is declared. The OPO takes over. This is different from DCD donors in which the hospital medical team cares for the donor until the procurement.

They are also the ones who declare death in the or. And here's the key point. In the transplant teams ed, the teams coming in to recover the organs are not legally allowed to declare death ever. Not in brain dead donors or in DCD. That separation is intentional both ethically and legally. So once the donor has been stabilized and deemed eligible for donation, organ procurement process, and the OPO becomes a central coordinator, and their role is broad and [00:04:00] highly regulated, they're responsible for confirming the authorization of donation and ensuring the documentation, reviewing medical history and imaging, coordinating the organ offers and matching and ranging infectious disease testing, serologies.

Once all this is done, they prepare the, or they plan for the organ storage with preservation solution and ICE notifying and coordinating with all the different recovery teams, especially in a multi-organ donor, and briefing the hospital staff at which the donor resides about what will also happen. So the donor or hospital staff, in conjunction with some of the OPO.

Including the circulating nurse, scrub tech, anesthesia support the actual procurement. They prep and drape the donor. They manage the donor's hemodynamics during brain dead donor cases, hand instrumentation to help gather equipment. At smaller hospitals, they sometimes have limited experience of procurement.

So the OPO and recovery teams often help guide the workflow

helpful.

So there really is some method to the madness. Before we really dive into cases, Dr. Doubt, can you take listeners through the donor categories and why Warm ischemia [00:05:00] underpins everything we do.

Sure, absolutely. Honestly, this is one of the most important foundations for understanding how these operations work.

When we talk about deceased donors, we're really talking about two major categories that differ in both physiology and workflow. First is donation after brain death. In brain, dead donors, donor hemodynamics are supported until the moment of procurement because circulation is intact. There's no warm ischemia until we physically apply the aortic cross clamp in the or.

So for brain dead donors, warm ischemia is short and predictable. The next site is donation after cardiac death. DCD donors follow a very different sequence, and this is where warm ischemia becomes critically important. In A DCD donor, life sustaining therapy is withdrawn. After withdrawal, the donor's vitals are monitored continuously.

If the donor reaches circulatory arrest and is declared dead by the ICU team, then we begin the recovery process, and only then a mandatory no touch period begins, which lasts [00:06:00] five minutes. After the no touch period, the ICU practitioner listens again and confirms time of death only after that team's allowed to begin the procurement.

So you can already see that warm ischemia accumulates throughout this entire sequence, warm ischemia. It is the time the organs spend at body temperature without adequate perfusion, total warm ischemic time. This is the broadest measure. It starts at withdrawal of life sustaining therapy, and ends at aortic flush or cross clamp.

We also consider functional warm ischemic time. Functional warm ischemic time starts at the first sign of inadequate perfusion, which is accepted to be the first systolic blood pressure less than 50 or a first oxygen saturation. Less than 70 functional warm ischemia ends when the organ receives cold preservation solution at flush or aortic cross clamping during standard rapid recovery.

Warm ischemic time is associated with early allograft dysfunction, delayed graft function in kidneys, biliary [00:07:00] complication in livers, and ultimately graft survival. So everything we do from the pre withdrawal huddle to minimizing delays to coordinating the teams is about limiting ischemic time to maximize organ function and utilization.

Great. Let's move into cases Dr. Wall. You are told you'll be performing a kidney and liver recovery on a 22-year-old male who is in an MBC and was declared brain dead by the ICU team after a devastating urologic injury. Before you walk into the or, how do you prepare surgically? So you may receive a lot of

information about the donors and the donor summary, which you would have access to before even leaving on the procurement.

But sometimes these histories are incomplete or inaccurate as oftentimes, uh, this information comes from the patient's family members. What I really care about is the CT and the past surgical history. If I could review only one thing about the donor would be the CT scan. I always look at the vasculature.

To see if there's any arterials variance, like an abberant right or an abberant left eye. I look to see if there's any aortic plaque and [00:08:00] I use the CT to plan where I'm dividing the aorta. I look to see where the SMA comes off versus the renal arteries, and this will help me plan how much room I have to divide the aorta and how much angle I need to cut at.

I also look for any evidence of previous surgery. Such as an abdominal mesh or previous sternotomy with wires. Uh, have they had a RU on y gastric bypass or cholecystectomy, really looking for anything that could mean scar tissue or, or potentially previous injury to the liver's blood supply.

So you review of the

ct,

it's a trauma protocol, chest, ab, and pelvis.

And the contrast of the timing is not perfect. You can't clearly delineate anatomy, but the SMA appears robust, so you're prepping for a possible accessory or replaced rate. There's no evidence of previous surgery. And this aligns with the O P's report.

What do you do when you arrive to the donor hospital?

First of all, I make sure to introduce myself to the entire team in the or, uh, and the OPO team members. I do an armband check, uh, to verify the donor id, uh, with the OPO personnel. I do the OPO [00:09:00] paperwork, which means confirming the identity, the A BO, uh, the authorization for donation, and that the documentation of death is complete.

Next, I go over the back table. I wanna make sure they have a functioning external saw with the saw blade facing in my preferred direction, uh, and that they actually test it in front of me. I also look at the TTO as occasionally this is assembled upside down. For a brain dead donor, we need four penetrating towel clamps, mayo and met scissors, a Babcock, some hemostats debakeys, a right angle, and a non-penetrating towel clamp, as well as a blue towel.

I also look at what they have available for an aortic cross clamp. I, I'll ask for some basic sutures and ties. I then ask to see what they have for an aortic cannula Typically. Pick between a 20 and 24 French for this, depending on the donor size. And I also want an IMV cannula for a brain dead donor, which is often an eight to 10 French pediatric Foley.

I'll also need another eight French cannula cut in [00:10:00] half and a balled syringe to flush the gallbladder. Finally, we need a Bovie and ideally four sections. If I don't bring a headlight, then I'll ask for one and I always double check that they have ICE prepared.

Great. I think this is really important because these scrub techs are, not only are they gonna be assisting you, but they're also obviously gonna be assisting the chess teams, and so it's nice to go over your most important instruments with them.

Dr. Dow, your resident asked to review the operation prior. Can you walk us through the high level steps that you run through to someone who has never seen this operation?

Yeah. Here at UNMC we teach our fellows to make a cruciate incision. The first thing we do is take down the falciform and biopsy our liver to send that off for pathology.

Um, and then we perform a curtail brush in coker basically to be able to see our left renal vein, right renal vein In the SMA following that we tend to take down Latrell s fascia and swaddle our small bowel and write colon so that we can cannulate our IMD for portal flush. Um, and then we get around our aorta [00:11:00] and dissect out our common bile duct and flush our

gallbladder and the common bile duct itself.

Um, and then dissect out our GDA.

After that we, uh, will mobilize our liver if we have enough time, depending on what other procurement surgeons are in the room. And then. We'll proceed by getting super of celiac control. And then depending if there's a heart team or not, one of the teams will perform the sternotomy.

At this point, we ask our anesthesia colleagues to give the heparin and then we will proceed by cannulating our aorta and flushing as well as venting our heart. And then performing cross clam at that point, what we'll do is take our liver out and then move on to get our kidneys mobilized. And then last but not least, we'll take out our iliac vessels as well, just in case we meet the transplant side of the operation.

Great. Let's go through a little more

granular detail. Can you make sure to point out where residents can help the most? Yeah, absolutely. So I start by making an incision from the sternal notch all the way down to the pubis and enter the abdominal cavity using cautery. [00:12:00] Uh, we'll then lift the umbilicus with two penetrating towel clamps on either side and create a cruciate incision.

The assistant can help by lifting both sides with the piercing towel clamps as the surgeon divides the right abdominal wall. And then I'll have my hand behind the abdominal wall, keeping the small bowel outta the way. The left side is similarly opened with the assistant holding up on the abdominal wall.

And once our cruciate incision is complete, uh, we'll put the clamps out laterally to provide the maximal exposure. Next, I'll take down the FALs iForm ligament all the way to the level of the hepatic veins, uh, slash upper IVC by retracting the liver downwards with my left hand. At this point, I'll get a biopsy and inspect the liver, as well as ask, uh, our donor coordinator to take some photos and send back to the accepting surgeon.

At this point, I'll also take down the left triangular ligament by placing, uh, my right hand on either side of the left lobe, pulling down towards the feet, and then using the Bovie to divide the ligament with my left hand. Dr. Doubt, can you walk us [00:13:00] through what we mean when we say catel brash, an extended coker?

What actually happens during these maneuvers and why do we care?

Absolutely. This is a core part of abdominal organ recovery, and it's much easier to understand if you visualize it as a single continuous right-sided kisser rotation. It's based on the anatomy of the white line. Hold the lateral peritoneal reflection where the right colon and small bowel mesentary fused to the retroperitoneum.

It allows you to rotate the entire right colon to denna and small bowel mesentary immediately and expose the entire retroperitoneum, including the IVC aorta all the way down to the bifurcation, SMA and IMA left renal vein and left adrenal vein, both ureters, head of the pancreas and the duodenum. You can break it down into a couple of steps first, right colon mobilization.

The assistant lifts the ascending colon medially. You incise the lateral peritoneal reflection from the right iliac crest to the hepatic flex air, and then the hepatic duodenal ligament. Identifying the uter early in protecting it is essential. In [00:14:00] this part of the case, the colon rolls toward. The midline.

This exposes the retroperitoneum and lets you approach the duodenum and pancreas head without tension. Next, the extended cooker maneuver, you incise the peritoneum along the right border of the duodenum open, inferior avascular border of the frame, and of Winslow, continue freeing tissue between the posterior pancreas and duodenum and the IV.

Mobilizing the duodenum and pancreas all the way to the SMA and aorta. You know it's complete when you have mobilized the entire duodenum and the pancreas head is lifted off of the IBC and aorta exposing all major vessels, and you can actually see the left renal vein at that point. Lastly, it is the small bowel mobilization, placing the duodenum colon back to the right, briefly, then moving the entire small bowel to the right side of the abdomen.

In sizing the peritoneum from the ligament of trites to the right iliac artery, freeing the small bowel mere, also retro peritoneum until it is completely mobile. The end point is the when the small bowel and colon can be lifted out of the abdomen and placed on the chest.

[00:15:00] Next. At this point, I find the SMA, so I'll swaddle the small bowel and colon in a blue towel and secure it with a clamp.

Then have the assistant retract the bowel cephalad, or into the chest. I'll palpate at the root of the mesentary, just superior to the left renal vein, and use a Bovie and DeBakey to dissect through, uh, sometimes dense perineural tissue, encasing the artery to expose the posterior surface of the vessel.

After this, I identify the IMV, uh, and cannulated for the portal flush. We can find the IMV just left of the root of the mesentery, and I'll dissect out a couple centimeters placing one tie proximal wrapped doubly around the vein, uh, but not tied down. And then one distal, which I tie down. I'll then partially transect the vein and insert an eight French beveled cannula.

While I'm doing this, I'll have the assistant gently retracting the lower tie towards the feet. While I insert the cannula and tide in place here, we will start a drip of LR just to keep this [00:16:00] cannula open. Occasionally this cannula will get inadvertently displaced by the assistant, so I always remind them to be mindful of it at this point.

After that, uh, we move on to the aortic dissection just to make sure it is completely done in case the donor becomes unstable throughout the procurement operation. Typically what we do is dissect around the aorta with a BO V because there's a lot of lymphatic tissue in the area that can bleed pretty easily.

Um, what we do once we're down at the bottom of the aorta is take a right angle and, um, maneuver underneath the aorta just on top of the spine. Taking care to look for any lumbar vessels that are coming off in that space. When we get around the aorta, we're typically about two centimeters above the bifurcation.

When you're looking down at the aorta on the patient's left side of their body, the INA will kind of come into view there. So just wanna make sure that you stay away from it and don't cause it to bleed. Although if that happens, we usually just kind of clip it. In that space. Once we get our right angle around the aorta completely, [00:17:00] we put two number two silks.

These are used later when we cannulate to keep our cannula in place. Of note, you should always just keep an eye on where the ureters are in the in this location. Once we're around the aorta, we move on to dissecting out our portal structures. Will come across our common bile duct. I'm dissecting this out and flushing our gallbladder and our common bile duct.

Typically what we do is just snip into the common bile duct and place a little cannula in it to flush it. And then we'll go on to dissect out our artery. So we find our GDA and tie it off with the 2.0 silk and then we'll open our pars plus, um, checking for any of barren anatomy. We then find our splenic artery and dissect that back to the celiac.

It's worth noting that if we do find any abar anatomy, that what we should consider doing, especially if its on the rib, is, um, main maintaining the pancreatic head, um, so that we can protect that artery, the root replace. Right? And then lastly, the portal D. So typically what we'll do is divide the [00:18:00] coronary thing early and dissect back to the splenic s of the confluence.

Sometimes at this point. Especially if the donor is becoming unstable or we've finished our dissection in other places, that some of the portal dissection can happen in the Kohl's.

At this point, you've completed most of the dissection and you're gonna be getting ready. To flush and cross clamp and take out the organs.

So you have a couple options for where you're in a cross clamp, and it kind of depends on if there is a thoracic team or not. Uh, if there is a thoracic team, it's a good idea to discuss plans for cross clamp and flush with them. And typically, you would plan to gain super celiac control of the aorta.

I'd recommend doing this right before uh, you're ready to start your flush. Because, uh, this dissection can cause some bleeding, especially if you get into the lumbars. Uh, so you wanna do it as late as possible. Uh, one method to do this is, uh, identifying the hiatus and easing, uh, long Alice to pull up and then Bovie straight down through the [00:19:00] fibers.

And then you can use your fingers to bluntly dissect around the aorta on either space to make sure there's room for the clamp. Uh, another option is to just. Complete this dissection bluntly, it does cause a bit more bleeding that way. But if you're ready to flush and clamp, um, that's not a big deal.

So you can just use your fingers, uh, identify either side of the aorta with your middle finger and index finger, and feel down to the spine, then create that space around it bluntly. If you're gonna cross clamp in the chest, uh, you'll wanna make a sternotomy for this. If there's no chest team, typically I'll wait until after heparin is given, and right before I'm ready to flush, uh, and cross clamp.

Since the sternum can bleed, uh, you'd wanna sneak a finger at the sternal notch and under the x fo. To create some space here bluntly, and then insert the sternal saw. I typically start at the xiphoid and, uh, saw upwards towards the sternal notch, but you can saw downwards as well. Be [00:20:00] aware of any sternal wires, uh, if they've had a prior sternotomy and have a plan for opening them.

Um, once the sternum is open, you can insert the finished shadow. Retract the sternum, opening up the chest and open the pericardium. Uh, you'll be able to palpate the descending thoracic aorta in the left side of the chest here.

Okay, you have wires in your chest. What is your normal go to get a wall.

If there's wires in the chest, I'll either try to open them up at a lower aspect of the incision prior to cross glamp or open them up all the way.

Um, if you're doing a kidney only case and you don't actually need to get into the chest to remove the liver, you can even just. Uh, cross claf, super celiac and then vent through the upper vena cava and the abdomen.

So I just avoid the wires entirely and go off center and have just a bunch of ribs that are just cross.

That's my go-to move.

Let's say during the case, while you're dissecting out the SMA anesthesia, pulls down the drapes and say they're [00:21:00] struggling with some hypotension. What steps do you take when a donor becomes unstable?

So it's pretty simple. You just essentially pause the operation and you can discuss with the cardiac teams kind of their situation and the stability with anesthesia.

You have discussion with the opioid coordinator and take a quick look at the organs and sometimes the operation needs to be sped up or slowed down based on how the donor's doing. So, as Dr. Wa and Dr. Doc mentioned before, you have to be ready to be able to cross claim. So just kind of look around and assess the situation.

I

think from an abdominal perspective as well, you can consider things that you might be doing that are compromising stability, like flipping the liver itself. That tends to be something that we see quite often, even in the hepatectomy on the recipient side, bring that doners can be very unstable in the OR from time to time, so it's really just all about communication.

You return the liver to normal position and the vitals improve, but the dormant remains hypotensive. After discussing with the chest teams, you decide it's time to proceed with cannulation. Walk us through the next steps. [00:22:00]

The next steps that are basically the critical point of the operation, I need to be communicated with all the OR teams, the anesthesia, and the OPO staff.

So prior to canulation, it's generally standard practice to give the donor a big dose of heparin, similar to plane taking off. Uh, this is the final checkoff between the pilots and so the heparin should generally be given three minutes before cannulation or cross clamping and marine dead donors. It's also important to talk to the other teams to make sure they're also ready for heparin.

In DCD donors, it's different. It's generally given approximately three minutes before they extubate the donor.

Pepin has been given you. Spend the next couple of minutes completing liver mobilization and taking down the gallbladder anesthesia, lets you know at the three minute mark, the chest teams both confirm it's okay to cannulate, but request you hold off and flush until they have their cross

clamp on.

Can you take us through cannulation? Yeah. So you wanna make sure that you have your aortic cannulas sitting right next to your right hand, and make sure that it's been forward flushed with no air bubbles in the line, [00:23:00] uh, before this process begins. You also wanna make sure that you've got someone there ready to run the flush.

When the time comes, I'll then tie down the distal aorta with that number two tie that I've already placed there right above the bifurcation. I'll then pinch the aorta just proximal to this with my left hand to occlude it, and then cut straight down on the aorta between my ties with my right hand.

If my left fingers still pinched, I bring the cannula into the atomy. I'll then ask my assistant to hold the cannula steady while I tie down the proximal tie, and I will hold their hand in the exact position. I want them to keep it in while I'm doing this. I'll then tie the upper and lower silks together.

If there's no chest team, it's okay to start the flush now. However, if there is a chest team, I'll check in to confirm with them when I can start my flush. We are trying to avoid the potassium rich preservation solution from the abdominal flush. From damaging the heart once it's time, um, either after you've started your flush, if you're an abdominal only recovery, or [00:24:00] after you've discussed cross clamp timing with the chest team, um, you'll proceed with that.

Uh, so if you're doing the super celiac. Cross clamp, you can have your assistant gently pull the stomach down, place your middle, and point your fingers of your left hand on either side of the aorta. If the flush is running, it'll feel cold and you can slide the cross clamp over your fingers and push hard towards, uh, the spine.

You'll actually end up sliding the clamp to the left of the spine and all the way to the back to make sure that you're on either side of the aorta. If there's no chest steam in your cross clamping in the chest, uh, you can bluntly get around the aorta with your left hand again. Being able to feel it with the cold solution, running through it, and make sure at this point to double check that you don't have the esophagus in your hand.

Oftentimes, there'll be an NG tube in, and then you place the clamp with your right hand sliding it again to the left of the spine, all the way down towards the back to ensure it's completely clamped. Next, you have to vent the heart to ensure that there's adequate forward flow of [00:25:00] the flush. Uh, you'll retract the heart cephalad and cut into the right atrium, and you can place a suction, uh, down the cave at this point.

Next, you're gonna fill the belly with slush, and don't forget to place slush around the kidneys as well

in doing this. You cannulate and cross clamp without issue, you begin dissecting out the splenic artery. However, the OP coordinator calls out the flush is no longer running well. Can you take us through troubleshooting the flush and what you're looking for to know that the flush is running well?

Yeah, sure. So the, the flush of the organs is really a crucial aspect of the procurement. So we typically flush with about four to eight liters of preservation solution through the aorta. And if possible, another two liters through the portal system. So initially the bowel, the small bowel should glance and lighten uniformly.

The literature take on a homogenous, almost light, brown waxy color note and the affluent from the IVC that gradually become clear and clear. Now, if the OPO coordinator says the flush isn't running well, there're three, three, issues and areas that you can look at. The first is the cannula at the [00:26:00] aortic bifurcation.

It's not deep enough in the aorta. It may be too deep or abutting a posterior wall. The, the clamp you place around where the cannula is constricting it, the cell ties are too placed too tightly, or the cannula is kinked. And usually taking a good hard look at the cannula that can make your flush flow better.

The second is the order cross clamp. Um, if the chest team didn't fully cross clamp the order, if you didn't fully cross clamp theorum above the liver, um, you lose forward pressure and the flush can slow way down. And so you make sure the clamp is completely crossed, the aorta not catching any diaphragm or ura or sitting crooked, and sometimes you just need to reposition it.

And finally, is the outflow. Obstruction the solution has. Cannot escape the abdomen and be stuffed out through your suction. So the IVC is inventing well or the liver bowel compressed by your tractor. And the blue tau that you use is, is somehow limiting the escape of fluid. And so if you don't vent well, the organs get engorged in the flesh stalls

After manipulation, the flesh is running better and you continue the dissection.

You have completed six liters of aortic [00:27:00] flush and two liters of portal flush. And the affluent is clear. Take us through the steps to completing the liver recovery.

The next thing we typically do is take down the left and right diaphragm. Um, I normally take the right down all the way down to the spine and the left down to the esophagus.

At that point, we look for our splenic artery and dissect that back to the celiac and then move on to taking the duodenum off of the pancreatic head. At that point, what we can do is find the portal splenic confluence and we'll cut that. The last thing we'll need to do in the abdomen is cut the vena caba, which will be very close to your right kidney.

So we just need to make sure that we protect our left renal vein and our right renal vein whenever we're cutting or across the caba. And then what we'll do is cut the aorta just below the SA. Avoiding the renals. Um, so typically what I do is kind of snip into the aorta itself and then look for the renal orifices that will come either right at the level of the SNA.

And if that's the case, you kind of bevel up your scissors to cut on an angle or [00:28:00] at the orifices of the renal arteries further down. Then you can just cut straight down on the aorta itself. Um, after that we're, we go back up into the chest and cut the, the aorta as well as the upper cava just right at the level, the heart to take it out.

We normally put our index finger through the aorta and our middle finger through the cava, picking up a liver itself in one hand, and then our thumb actually will hold back our lennic artery portal, Dana, and come and bile duct just to protect them as we are. Cutting underneath, um, along the spine.

Great.

You safely complete the liver recovery. Can we walk through taking out the kidneys?

Sure. So once the liver is out of the body, I remove the aorta, cross clamp, and pull out the aorta. Volcans. The next important thing to do is identify the left renal vein, which crosses the aorta. And I cut it right as it enters the IVC.

So once that's done, I take the curve man and I go right down the middle of the anterior aorta and split the aorta basically into two halves. Once I can see where the two renal arteries are from the inside, then I split [00:29:00] the posterior order down the middle, and usually the lumbar arteries will guide you.

So now you have two basically separate systems. So I first moved to the right kidney, I cut the distal IBC, that's not already cut, and I identify the ureter at its most distal point and cut it. Remember the proximal IBC is already cut during the liver procurement. So with the assistant pulling the right kidney gently, all the body holding the ureter up, I'd use a big.

To safely cut the aorta and I stay right on the spine and the assistant generally pulls it out the body until it's green passed off. For the left kidney we move to the left colon, it dissected free from the lateral wall. Again, we cut the distal ureter and using a similar motion to cut free from the aorta from the spine.

Sometimes the kidney is still adhesed a little bit to the colon and so we cut the kidney off the colon until it's safely free.

You have safely recovered the kidneys now as well. Can someone reiterate the division points of the different vasculature?

Sure. So the sup hepatic cava within the chest is divided above the right atrial appendage.

This [00:30:00] may happen in the chest by the chest team if they're present, uh, but it should be done with both abdominal and thoracic surgeons in conjunction and in agreement about where that cut will take place. The infra hepatic cava is divided just above the left and right. Renal veins

are mentioned here, just that the right renal vein is very thin, so if you're pulling her out in this area, you can easily rip the right renal vein off.

For the aorta, we divide super celiac. Above the celiac trunk, an infrarenal just below the SMA, but above the renal arteries, the splenic artery is taken a few centimeters off the celiac. Uh, the GDA is tied at its origin and divided, and the portal vein is divided at the SMB splenic vein confluence. Um, let's say you do have an aberrant right or

left.

How does this change the process of cutting out the liver?

For N Baren or replace right hepatic artery. Coming off the SA, the key is to preserve the SMA and [00:31:00] the pancreatic head arcade. That artery often runs right behind the portal vein and hugs the pancreatic head. So usually what we do is when we're taking the duodenum off, we'll actually keep the pancreatic head.

And divide just the neck there. Protecting where the right hepatic artery is coming out of the SMA itself. Um, it's important not to pull on this or strip it and divide it. Um, anything in the, in the pancreatic head itself, 'cause you can always enter the right hepatic artery There. Preserve a lapa barrant artery After mobilizing the left leg of the liver, usually what we do is we retract the stomach downwards and divide the parts blast about two or three centimeters beneath.

And above the left ab, barren hepatic artery after cross clamp and flush, um, we dissect the lesser momentum close to the lesser curvature of the stomach wall, together with the left gastric and left ab barren hepatic artery after the diaphragm. I should also mention these are the two that most residents know about, but there's always a two chance that the [00:32:00] ab barrant left hepatic is actually coming directly off the aorta, so you have to protect it there as well.

Can we talk a little bit about pancreas recovery and how it changes,

The operation in these division points? Yeah, so if we're recovering the pancreas, then we need to ensure that there's adequate vasculature. So you wanna divide the splenic artery near its takeoff from the celiac and send that with the pancreas and divide the SMA near its takeoff from the aorta, and send that with the pancreas as well.

The portal vein is then divided, uh, just distal to the splenic SMV confluence to ensure that they, uh, have enough vein to go with the pancreas and. You send part of the duodenum as well and staple off the antrim and D four and all of that gets sent with the graft.

I would like to add that in the cases where you actually have a replaced right hepatic artery, it's very difficult to recover the pancreas because the replaced right generally goes through the head of the pancreas.

[00:33:00] So if it's a young or healthy donor, these discussions need to be had between the center accepting the liver and the center accepting the pancreas.

Anything else you do before you unscr?

Yeah, so you need to recover the iliac vessels in case they're needed to be utilized in the recipient surgery.

They're crucial in pancreas and liver transplant. Maybe not so much in kidney, but once in a while we do need them. Once the kidneys are out, you have to do a quick anatomy report with the OPO coordinator and I always check in with the scrubs to see if they need help with the quick closing.

Uh, let's move on to the next case where we'll be talking about DCD.

Can someone highlight the trends in DCD in regards to abdominal organ transplantation?

Sure. So if you looked at portion, the shift in the United States is, is quite marked. 10 years ago only about 6% of the liver donors were DCD Now could be over 50%. Kidneys. Con have risen to also about 50%, however, have been a steady, predictable growth.

[00:34:00] But liver, DCD transplantation in the United States has absolutely exploded, basically due to the rise of liver pumps, uh, which makes these allografts very highly recoverable and, and, uh, increases the, uh, utilization rate and. Found outcomes.

So DCD organ recovery is becoming routine for those in the transplant world.

That takes us into case two. You're told about a 45-year-old woman with a devastating anoxic brain injury after prolonged out of hospital rest. She does not meet brain death criteria, but her neurologic prognosis is considered poor. And after multiple family meetings of family. Chooses comfort measures and consents to DCD liver and kidney donation.

There's no heart team involved. She's at a medium-sized community hospital. They do some cardiac and general surgery cases, but they have limited experience with donation after circulatory death. Your center accepts the grass and transportation is arranged to the donor hospital. Can you walk us through how the preoperative planning and timeout differ between DCD and brain dead donors?

What do we have to plan [00:35:00] for before the operation starts and how does it change the choreography in the or?

Sure. So the preoperative planning in a brain dead donor versus a DCD donor is markedly different, and it can change the whole rhythm of the case. So for a brain dead donor generally. Proceeds as a straightforward two to three day course, and the timeout is pretty, um, routine.

The donor already declared dead by the neurologic criteria. They're still being ventilated for a DCD donor, it's much different. And it's, it's a little more of a fire drill, so the timeout becomes a timeline meeting. We have to walk through everything that happens where withdrawal will happen, whether it be in the or in the recovery room.

Some DCD donors are withdrawn in the pacu. What time heparin is given. A member of the hospital who's not part of the transplant team has to declare death. They have to confirm circulatory arrest. There is a five minute no touch period after death is declared on the, on the monitor. Um, and this physician or nurse also listens to the patient's chest with a stethoscope to [00:36:00] confirm there's no, um, cardiac activity.

And then in the OR who is documenting the blood pressure, he's documenting oxygenation, saturations and things like that. So it's much more a choreography and mechanics. In a brain dead donor, you're timing your cross lamp with the other teams. And in the DCD case, you're kind of timing everything from, from withdrawal to arrest, to incision to cannulation.

Okay, we've covered a lot already, but let's highlight the differences between DCD and or preparation and the surgical steps. So Dr. W is there anything

different with your back table for a DCD donor? Yeah, so the time to get that aortic cannula and start the flush and cross clamp is crucial and I wanna be able to do it as fast as possible.

So I make sure they have a separate mayo stand set up with just the bare essentials of what I need. Nothing additional that might get in the way. Uh, so I make sure to have four penetrating towel clamps, a 10 blade mayo and met scissors. Two goers, two babcocks. The sternal saw set up how I want it with the blade facing [00:37:00] up and making sure that it works.

The finished shadow set up correctly. Uh, long peon aortic clamp, some hemostats, a couple short debakeys, and a non-penetrating towel clamp. Sometimes they'll set up with extra right angles, ties, things like that, and I tell them to remove all of that. So it's just the

bare essentials. You complete the pre or huddle and scrub in while the scrub nurses prep and drape the patient.

The donor family is brought into the operating room. Heparin is given, and then three minutes later, life sustaining measures are withdrawn. The ICU delivers appropriate end of life medications for pain and anxiety. The donor passes with functional more ischemia, time of 12 minutes. The ICU declares death.

The family's escorted out of the OR by the OPO and your team mentors. The five minute no touch period passes and the ICU verifies death again, you are told you can begin the surgery. What is the differences in the order of steps that take place for abdominal organ recovery?

What we normally do is make a cruciate incision like we, we do in the brain, dead [00:38:00] donors and the cattel rash.

But then right after that, what we'll do is clamp the iliac and cannulate the aorta right away. Um, if the chest team is not a part of the procurement, then we open the chest ourselves and cross clamp the aorta immediately thereafter and vent our right heart. Uh, we then place ice throughout the entire ab abdominal cavity, making sure it's around the liver as well as the kidneys.

And then we go for, go ahead and flush the gallbladder. Take down our diaphragm, finish our cartel brush identifier, sm a left renal vein and right renal vein. Dissect our common bile duct. Gda and flush the bile duct. Find the splenic artery and then. Um, separate the stomach from the gastro hepatic g limine and open the diaphragm to the esophagus.

Pretty much getting ready, the liver to be able to deploy part of the body.

So the basic steps are the same at.

The important part and the donation after cardiac death is really time because of the functional, warm ischemic time. And what, basically what you need to do is get the liver and the kidneys outta the [00:39:00] body as fast as possible.

So, as soon as soon as we finish the catel brush, what we typically do is clamp our iliacs with Coors. And then, um, instead of getting around the aorta with the right angle clamp, what we do is actually pinch it between our fingers or. Kind of push it down against the spine itself and actually clip into it.

So you'll have blood coming outta that space, and then we'll throw our cannula in and hold it in place with a Babcock or two, depending on really the integrity of the AOR office. Sometimes it's quite calcified, so sometimes requiring two Babcock. I think it's worth noting, especially whenever you're setting up the bact table that we don't use Bovie cautery and DCD donors.

Um, this is all cold and cold and so basically it's mets and, and pickups. That's pretty much what you use. We'll always have three um, sections up, ready to help with getting the flush out of the abdominal cavity so that we can see better. I think it's worth noting too, that you're not gonna be able to look for your abberant anatomy.

So we [00:40:00] always just assume that it's there and, um, make our dissection very safe, um, and close to the stomach for the replace left. And then we actually take the pancreatic head to make sure we protect any replace right. And, uh, hepatic artery as well. Coming up the SNA.

You only need one minute to talk to your assistant prior to A DCD abdominal recovery, what advice would you give them or what would be the most important roles that they can play?

Well, typically I like to run through the whole operation with them, but if I had just a minute or a few seconds to tell them how they can best help me, it would be with the initial incision and cannulation. Uh, 'cause I wanna be able to do this, like I said, as fast as possible. So once we're in the abdomen, I tell them to hold up on the cecum and to hold back the small bowel so that I can enter the retroperitoneum below the cecum.

And I just bluntly spread here. Basically just using my fingers to be able to identify the aorta and its bifurcation. So it's very important for them to be able [00:41:00] to give me the proper exposure to do that. I also emphasize how important it is for them to suction while I'm working because the ice will start melting, uh, as you divide some smaller veins.

Um, you'll get the flush running into your field as well, and you can end up operating underwater pretty quickly.

I mean, I agree completely with Evelyn. The only other thing that I always did when, uh, I had an assistant was just tongue keep pulling harder because I feel whenever you're operating as a resident and you wanna be very gentle with what you're kicking up and moving around, but this is a procurement surgery.

So when we're asking them to move the small bowel or the colon around, or even the stomach itself, I always want them to pull harder than they anticipate pulling. That gives us a better view of where we're working and what we're dissecting out and keeps it safer for our recipients and the organs that we're recovering.

Timing is so important in these cases, so, can someone highlight gold standard times of what you guys are [00:42:00] aiming to recover these organs in?

For brain dead donors. Warm ischemia really starts at the CrossFit and most centers aim for liver out within about 20 minutes best. Or if the donor is unstable for donation after cardiac death.

Donors, A STS recommends liver out within 30 minutes and kidneys out within 60 minutes. In practically speaking in DCD cases, we often aim for skin incision to aortic cannulation in about two to three minutes, and we want the preservation flush running almost immediately after canal placement venting should happen right away within seconds, really to avoid any, any veinous congestion.

These timeliness aren't arbitrary. They directly affect delayed graft function in kidneys and ischemic cholangiopathy in livers. So when you hear your attending pushing for efficiency, it's because the clock really does matter. In transplant surgery,

these cases can be overwhelming and that's normal.

They're fast, they're crowded, and they can feel like a lot. But they're also an honor to participate in a donor and family has made an [00:43:00] extraordinary decision and we're responsible for carrying that forward. I think it always helps to follow the organs into the recipient or when you can, because it really reminds us of why this all matters, so we can close with some high.

Your clinical pearls. What do you hope your learners take away?

I think one of the most important things to take away from a procurement surgery is this is a. The best opportunity, especially as a resident you'll ever receive to really learning anatomy. You have the opportunity to go and participate in a procurement, especially as a resident or a med student.

I would take it every single time.

I think my takeaway from going through learning how to do the procurement operation as, uh, you should go in with the attitude. Owning this surgery and making it your own. This is your opportunity to truly become an independent surgeon. You're gonna learn quickly and you're gonna learn by making mistakes and you're gonna learn from your success as well.

Yeah. I think just to, um, Dr. [00:44:00] Dock and Dr. Wallace said, is this an extraordinary operation to be able to see stuff in the human body? You can't see in any. Operation with the patient and survives. But, but finally to think about this, the generous gift, as you mentioned, um, these are people that lived full and, uh, meaningful lives and they're, they're actually heroes for donating their organs.

And it's just a, a wonderful responsibility that we give to be able to save other people's lives for this gift and.

A huge thank you to Dr. Wa, Dr. Duck and Dr. Makin for this masterclass. And of course, to the donor families whose generosity makes transplant possible. This has been behind the knife. We hope this deep dive gives you the big picture, understanding and technical framework you need for your next procurement.

We'll see you next time.