Surgical Technique of the Abdominal Organ Procurement Andrzej Baranski Surgical Technique of the Abdominal Organ Procurement Step by Step Andrzej Baranski, MD, PhD Department of Surgery and Organ Transplantation Leiden University Medical Centre Leiden The Netherlands ISBN: 978-1-84800-250-0 e-ISBN: 978-1-84800-251-7 DOI: 10.1007/978-1-84800-251-7 British Library Cataloguing in Publication Data © Springer-Verlag London Limited 2009 Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or transmitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms of licences issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms should be sent to the publishers. The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore free for general use. Product liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. Printed on acid-free paper 9 8 7 6 5 4 3 2 1 springer.com This book is dedicated to the following people who have been – and are still – important in my life: Prof. Dr. J. Nielubowicz (1915–2000), Prof. Dr. J. K. Szmidt, Prof. Dr. J. Polanski, S. Frunze: my surgery teachers from Warsaw University Medical School, Warsaw, Poland who taught and guided me during my first steps in surgery. W.S.L. Kowalski, BChD, LDSRCS (Eng), MA who, for many years, has been both a friend and a sounding board whom I trust and respect. Prof. Dr. J.H. van Bockel from Leiden University Medical Centre, Leiden, The Netherlands, who has inspired me to write this book. Finally, I want to express my respect, thanks and love to my wife, Ewa Anna Baranska Szczepanowska, my daughters Katarzyna and Julia, my parents, Zofia and Bernard, and my parents-in-law Wieslawa and Jan Szczepanowscy – my dearest, who always love and believe in me. Preface The intention of this book is to promote a surgical technique of abdominal organ procurement in order to avoid organ damage and thus enhance the quality of retrieved organs. Organ procurement from a brain death donor is an essential part of organ trans- plantation. In donors where more than one organ is removed, the surgical procedure is critically important and could be challenging both for the procurement and recipient surgeons. Surgical injury or inadequate preservation of organs at this stage may cause irreversible organ damage or can lead to serious complications in the recipient. Nowadays, local or regional surgical teams, whereby the transplant surgeon is not always one of the team members, perform most multiorgan donor (MOD) procurement procedures. To trust each other and to avoid surgical mistakes, ade- quate training and standardization of the surgical techniques is required. Teaching and training future procurement surgeons to adopt a standard operating procedure could be the right way to prevent technical mistakes and damage during abdominal multiorgan procurement. I hope that in the near future, every transplant surgeon involved in organ procurement will have to be certified. The different national and international transplant organiza- tions in Europe have been already started to establish the teaching programs, which will lead to high expertise in the field of abdominal organ procurement. My personal view is to recommend mandatory registration of the quality of procured organs by the national transplant organizations and that this data should be published both in the interest of the transplant community and in the interest of the public who have a right to this information. I wish to help every reader to experience the pleasure and satisfaction of successful multiorgan procurement. Leiden, May 9th 2008 Andrzej G. Baranski vviiii Contents Introduction .................................................................................................... xv 1 Transplant Coordinator–Procurement Team: Bilateral Aid and Understanding, Before, During and After Abdominal Organ Procurement ................................................................................. 1 1.1 Introduction ....................................................................................... 1 1.2 The Services of the Donor Coordinator ............................................ 2 1.3 The Most Important Moments of Communication: Priority of Interests ........................................................................... 3 1.3.1 Before Organ Procurement ................................................... 3 1.3.2 During Organ Procurement ................................................... 5 1.3.3 After Organ Procurement ...................................................... 6 1.4 Conclusion ........................................................................................ 7 Literature .................................................................................................... 8 2 Preoperative Arrangements for Organ Donation ................................. 9 2.1 Donor Preoperative Arrangements .................................................... 9 2.1.1 Arrival of the Abdominal Procurement Team at the Donor Hospital ............................................................ 9 2.1.2 Donor Verification................................................................. 12 2.1.3 Positioning Donor on the Operating Table ........................... 13 2.1.4 Shaving.................................................................................. 14 2.1.5 Scrubbing .............................................................................. 15 2.1.6 Draping: Covering the Body with Sterile Operating Sheets and Incision Drapes ................................. 17 2.1.7 Installation of the Abdominal Retractor ............................... 19 Literature .................................................................................................... 20 3 Incision and Exposure ............................................................................. 21 3.1 Abdominal and Thoracic Incision ..................................................... 21 3.1.1 Abdominal Incision ............................................................... 21 3.1.2 Median Sternotomy ............................................................... 26 iixx x Contents 3.1.3 Wide, Stable Thoracic and Abdomen Operating Field: The Retractors ....................................................................... 30 Literature .................................................................................................... 32 4 Detailed and Thorough Abdominal Organ Inspection ......................... 33 4.1 Introduction ....................................................................................... 33 4.2 Liver .................................................................................................. 34 4.2.1 General Examination ............................................................ 34 4.2.2 Size of the Liver .................................................................... 34 4.2.3 Parenchyma Inspection with Respect to Micro and Macrosteatosis ................................................................ 35 4.2.4 Examination of Arterial Blood Supply to the Liver .............. 36 4.3 The Pancreas ..................................................................................... 39 4.3.1 Routes for Surgical Access ................................................... 39 4.3.2 Pancreas Inspection – Organ Assessment ............................. 42 4.4 Inspection of Other Abdominal Organs ............................................ 43 4.4.1 Gut Inspection ....................................................................... 43 4.4.2 Additional Investigations During Organ Inspection ............. 43 Literature .................................................................................................... 44 5 Retroperitoneal Right-Sided Visceral Mobilisation: The Cattel–Braasch Manoeuvre ............................................................. 45 5.1 Introduction ....................................................................................... 45 5.2 Right Colon Mobilisation ................................................................. 46 5.2.1 Surgical Steps ........................................................................ 46 5.3 Extended Kocher Manoeuvre – Duodenopancreatic Mobilisation ... 48 5.3.1 Surgical Steps ........................................................................ 48 5.4 Small Bowel Mobilisation ................................................................ 51 5.4.1 Surgical Steps ........................................................................ 51 Literature .................................................................................................... 53 6 Infrarenal and Superior Mesenteric Artery Major Vessel Dissection ....................................................................................... 55 6.1 Abdominal Aorta and Inferior Vena Cava ........................................ 55 6.1.1 Surgical Steps .......................................................................