Cadaveric Donor Nephrectomy: Multivisceral Procurement Home

The successful undertaking of multiple-organ recovery requires careful coordination among the teams involved to assure that there is no compromise in viability of any of the transplanted organs. Besides that, it is necessary to have anaesthesia support to monitor and maintain cardiovascular integrity of the donor during the extensive dissection, which may take 2-3 hours. Depending on the combination of organs to be removed, the details will differ but certain general principles remain. These include wide exposure, dissection of each organ to its vascular connection while the heart is still beating, placement of cannulas for in situ cooling and removal of organs while perfusion continues, usually in the order of heart, lungs, liver, kidneys and then pancreas.


The organs are exposed through a midline incision extending from the suprasternal notch to the pubis.


The organs are rapidly inspected to exclude unsuspected sepsis, neoplasia or other pathology and to confirm the gross suitability of the organs to be procured. If the heart is to be used, it is usually partially mobilised as the first manoeuvre so that it can be quickly removed at any later stage should uncorrectable vascular instability occur during dissection of the other organs. The preparatory steps for cardiectomy require opening of the pericardium, mobilisation of the superior vena cava and separation of the aorta from the pulmonary artery.
The chest and abdominal cavities are entered through a long midline incision1
 
Dissection is then undertaken to mobilise the liver and/or pancreas. The celiac axis is dissected to the aorta. If the pancreas is not to be used, the splenic and superior mesenteric arteries may be ligated and divided. The common bile duct is transacted and the gallbladder incised and flushed to prevent biliary autolysis. The portal vein is dissected to the confluence of the splenic and superior mesenteric veins where a cannula can be placed into the splenic vein for rapid portal perfusion
Splenic vein is cannulated for portal perfusion. Gastroduodenal and splenic arteries are divided if the pancreas is not to be used.1  
Skeletonisation of the liver is completed by isolating the vena cava posteriorly, ligating and dividing the right adrenal vein and freeing the suprahepatic vena cava.

If the pancreas is to be transplanted, the spleen is mobilised, the short gastric vessels are divided and the spleen and pancreas retracted to the right
For pancreas retrieval, dissection is begun from the left, retracting the spleen and pancreas to the right, carefully preserving the splenic artery and vein.1
 
The kidneys are elevated from the retroperitoneum and the distal aorta and vena cava are completely freed. The donor is heparinised, after which a perfusion cannula is placed in the aorta and a venous drainage cannula in the vena cava.
Returning to the right side, the duodenum and pancreas are retracted exposing the superior mesenteric artery1
 
Initial organ cooling is usually begun via the previously placed portal vein cannula (Figure 16). Precise coordination among the retrieval teams is required at this critical stage. Cardioplegic infusion into the ascending aorta is begun and cardiectomy and pneumonectomy are performed first. The liver is removed next. Finally, the remaining mobilisation of the kidneys is undertaken. Care is taken to free and section the ureters as far down toward the bladder as possible and to avoid dissection within the renal hilus. The distal aorta and vena cava are divided and the entire block is lifted anteriorly to expose the lumbar vessels posteriorly. The vessels are cut after being doubly clamped with vascular clips
Mobilisation of the kidneys and ureters from the retroperitoneum is completed and the distal vena cava and aorta are cannulated.1
 
Once these vessels are controlled, the entire block consisting of both kidneys and ureters, aorta and inferior vena cava can be lifted out of the abdomen and placed immediately in a basin of cooled perfusion solution. A more complete dissection and assessment of the detailed anatomy of the renal vessels can then be undertaken. Before closure of the abdominal incision, specimens of donor lymph nodes and spleen are removed for subsequent histocompatibility and other immunologic studies
The kidneys are removed by lifting the entire block (left kidney not shown) anteriorly, while clamping and dividing the lumbar vessels posteriorly.1