3. History of Transplant
1. Technique of vascular anastomosis by Alexis Carrel.
2. Process of rejection by Peter Medawar.
3. 6-MP and Azathioprine by Gertrude Elion and George Hitchings
5. âThe termino-terminal anastomosis is effected by bringing the
extremities of the vessels into contact, no traction being
necessary. The ends are united by three retaining stitches
located in three equidistant points of their circumference. By
traction on the threads the circumference of the artery can be
transformed into a triangle, and the perimeter can be dilated
at will. Then the edges of each side of the triangle are united
by a continuous suture whilst they are under tension. During
the suture great care is taken to approximate exactly the
surfaces of section of the wall.â
6.
7. The Indian Scenario
⢠Kidney â 1st Cadaveric transplant in may 1965,
1st live donor renal transplant in CMC Vellore in 1971
⢠Liver â 1st unsuccessful attempt in 1995 AIIMS
1st successful attempt in 1998 New Delhi
⢠Lung â 1st cadaveric transplant done in 1999 Madras Medical Mission
⢠Intestine â 2013 in New Delhi.
⢠Pancreas â 2005 in AIIMS
⢠Heart - 1st in 1968 br Dr. P K Sen at KEM Hospital Mumbai
1st successful transplant by dr. venugopal in AIIMS in 1994
⢠Multivisceral â Data not available
8. ⢠1980 â Cyclosporine (Anti T Lymphocyte drug).
⢠Graft survival increased to 80% in all types of grafts.
9. Definitions
⢠Transplantation is the process of transferring an organ, tissue, or cell
from one place to another.
⢠An organ transplant is a surgical procedure in which a failing organ is
replaced by a functioning one.
⢠Orthotopically (implanted in the same anatomic location in the
recipient as it was in the donor).
⢠Heterotopically (implanted in another anatomic location).
10. ⢠Orthotopic transplants require the removal of the diseased organ
(heart, lungs, liver, or intestine).
⢠In heterotopic transplants, the diseased organ is kept in place (kidney,
pancreas).
11. ⢠An autotransplant is the transfer of cells, tissue, or an organ from one
part of the body to another part in the same person, so no
immunosuppression is required. This type of transplant includes skin
and vein, bone, cartilage, nerve, and islet cell transplants.
⢠An allotransplant is the transfer of cells, tissue, or an organ from one
person to another of the same species. The immune system of the
recipient recognizes the donated organ as a foreign body, so
immunosuppression is required in order to avoid rejection.
⢠A xenotransplant is the transfer of cells, tissue, or an organ from one
organism to another from a different species.
12. Graft Rejection
⢠Allograft rejection can be divided into three distinct types
⢠Hyperacute rejection (occurs immediately);
⢠Acute rejection (usually occurs in the first six months);
⢠Chronic rejection (occurs months and years after transplantation).
13. Hyper acute rejection
⢠Due to preformed antibodies against HLA class I antigens expressed
by the donor.
⢠Antibodies arise from a previous blood transfusion, a failed transplant
and pregnancy.
⢠Also occurs due to ABO incompatibility.
⢠Activation of the complement system causes extensive intravascular
thrombosis, interstitial haemorrhage and graft destruction within
minutes and hours.
14. How to prevent hyper acute rejection
⢠Ensure ABO blood group compatibility.
⢠Cross-match test on recipient serum.
15. Acute rejection
⢠This usually occurs during the first six months of transplantation but
may occur later.
⢠It is mediated predominantly by T lymphocytes, but alloantibodies
may also play an important role.
⢠Commonest mode of rejection.
⢠Prevented by immune suppressive therapy.
16. Chronic rejection
⢠Occurs after the first six months.
⢠All types of grafts are susceptible for chronic rejection.
⢠The pathophysiology of chronic rejection is not well understood.
18. Features
⢠Kidney: glomerular sclerosis and tubular atrophy;
⢠Pancreas: acinar loss and islet destruction;
⢠Heart: accelerated coronary artery disease (cardiac allograft
⢠Vasculopathy);
⢠Liver: vanishing bile duct syndrome;
⢠Lungs: obliterative bronchiolitis.
19. ⢠Immuno suppressive therapy has no role in chronic graft rejection.
⢠Chronic rejection causes functional deterioration in the graft,
resulting after months or years in complete graft failure.
22. Organ Donors
⢠Deceased donors (DD)
⢠Donation after brain death (DBD) â Brain stem dead heart beating donors.
⢠Donation after circulatory death (DCD)
⢠Living Donors
23. ⢠DBD donors provide almost all organs.
⢠DCD donors provide kidneys, liver , pancreas and lungs.
⢠Living donors â kidney, liver and lung lobe.
24. Donation after brain stem death donors
⢠Also called heart beating deceased donor.
⢠Result from stroke or traumatic brain injury.
25. Brain death
⢠Brain death occurs when severe brain injury causes irreversible loss of
the capacity for consciousness combined with the irreversible loss of
the capacity for breathing.
26. How to diagnose brain death
Pre conditions for diagnosis
⢠The patient must have suffered major brain damage of known
aetiology,
⢠Be deeply unconscious and require ventilatory support.
⢠Particular care must be taken to ensure that muscle relaxant agents
and drugs with known CNS depressant effects are not contributing to
the clinical picture.
⢠Hypothermia, profound hypotension and metabolic or hormonal
conditions that may contribute to CNS depression and confound the
diagnosis of brainstem death must also be excluded.
27. ⢠If the pre conditions are satisfied, formal clinical assessment of the
brainstem reflexes can be undertaken.
⢠The UK guidelines state that the tests should be performed on two
separate occasions by two clinicians experienced in this area. At least
one of the two clinicians should be a consultant and neither should
be connected with the transplant team.
⢠The time that must elapse between the two sets of brainstem tests is
not specified in the guidelines and is determined on the basis of
clinical judgement.
28. Clinical testing for brain stem death
Absence of cranial nerve relexes
⢠Pupillary reflex
⢠Corneal reflex
⢠Pharyngeal (gag) and tracheal (cough) reflex
⢠Oculovestibular (caloric) reflex.
29. Absence of motor response
⢠The absence of a motor response to painful stimuli applied to the
head/face and the absence of a motor response within the cranial
nerve distribution to adequate stimulation of any somatic area is an
indicator of brainstem death. The presence of spinal reflexes does not
preclude brainstem death.
30. Absence of spontaneous respiration
⢠After pre-ventilation with 100% O2 for at least 5 minutes, the patient
is disconnected from the ventilator for 10 minutes to confirm absence
of respiratory effort, during which time the arterial PCO2 level should
be >8 kPa (60 mmHg) to ensure adequate respiratory stimulation. To
prevent hypoxia during the apnoeic period, O2 (6 L/min) is delivered
via an endotracheal catheter.
31. Who should declare brain death (In India)
Panel of 4 doctors need to declare the brain death twice in a
span of 6 hours. 2 of these doctors must be from a panel approved by
the government.
32. This panel includes:
i. Registered Medical Practitioner in charge of the Hospital where brain
stem death has occurred.
ii. Registered Medical Practitioner nominated from the panel of names
sent by the hospitals and approved by the Appropriate
Authority.
iii. Neurologist/Neuro-Surgeon (where Neurologist/Neurosurgeon is
not available, any Surgeon or Physician and Anaesthetist or
Intensivist, Nominated by Medical Administrator In-charge from
the panel of names sent by the hospital and approved by the
Appropriate Authority shall be included.
iv. Registered medical practitioner treating the aforesaid deceased
person.
33. After circulatory death donors
DCD donors can be grouped according to the Maastricht
⢠category 1: dead on arrival at hospital;
⢠category 2: resuscitation attempted without success;
⢠category 3: âawaiting cardiac arrestâ after withdrawal of support;
⢠category 4: cardiac arrest while brain dead;
⢠category 5: cardiac arrest and unsuccessful resuscitation in hospital.
34. ⢠1, 2 and 5 donors are sometimes referred to as uncontrolled DCD
donors. The warm ischaemic time of organs from these three
categories of donor is usually longer and less predictable than in the
case of categories 3 and 4 (controlled) donors.
35. Evaluation of deceased donors.
⢠Contra indications for donation â systemic infections and malignancy
⢠CreutzfeldtâJakob disease is an absolute contraindication to organ
donation.
⢠Organs from HIV-infected donors should not be used for transplantation,
except sometimes in recipients who are already infected by the HIV virus.
⢠Hepatitis B infection and active systemic sepsis, e.g. major abdominal
infection, are contraindications to donation.
⢠The presence of malignancy within the past five years is usually an absolute
contraindication to organ donation with the exceptions of primary tumours
of the CNS, non-melanotic tumours of the skin and carcinoma in situ of the
uterine cervix.
36. The warm ischaemia and cold ischaemia
⢠Warm ischaemia : The warm ischaemic time has been assessed as the
time interval between onset of irreversible asystole and subsequent
cold perfusion.
⢠Cold ischaemia : The time interval between the start of cold perfusion
and subsequent reperfusion in the recipient body.
⢠1 hour of warm ischaemia is equivalent to 6 hours of cold ischaemia
37. Organ recovery from deceased donors
⢠DBD donors
⢠Maintain hemodynamic stability
⢠Chest and abdomen opened by a midline sternotomy and abdominal
incision.
⢠Dissection of organs followed by insitu perfusion of organs.
38. ⢠The heart is perfused with cold cardioplegia solution via a cannula in
the ascending aorta
⢠The lungs are perfused via a cannula in the pulmonary artery.
⢠The abdominal organs are perfused with chilled organ preservation
solution via an aortic and portal cannula.
⢠The cold solution is vented out through inferior vena cava.
39. ⢠Additional surface cooling of the abdominal organs may be achieved
by application of saline ice slush.
⢠The heart and lungs are excised followed by the liver and pancreas
and then the kidneys, either en bloc or separately.
40. Care about Anatomic variations
⢠During recovery of the liver, care is taken to ensure that if there is an
aberrant hepatic artery arising from the superior mesenteric artery it
is included in the aortic patch.
⢠When removing the donor kidneys care is taken to ensure that any
polar renal arteries are included on an aortic patch with the renal
artery.
41. ⢠In DCD donors there is an inevitable period of warm ischaemia (up to
45 minutes is acceptable) between the diagnosis of death
(cardiorespiratory arrest) and cold perfusion of the organs.
⢠The aim during organ recovery is to minimise the period of warm
ischaemia.
⢠After removal from the donor, the organs may undergo a further flush
with chilled preservation solution before they are placed in double or
triple sterile bags and stored at 4°C by immersion in ice while they are
transported to the recipient centre and await implantation.
42.
43. Preservative solutions
⢠University of Wisconsin (UW) solution and Euro-Collins solution are
the most used preservative solutions.
⢠They all contain impermeants to limit cell swelling, buffers to counter
acidosis and electrolytes, the composition of which reflects that of
intracellular rather than extracellular fluid.
44.
45. Living donors
⢠Most common organ donated is kidney, followed by liver.
⢠Occasionally, living donors have provided segments of pancreas, small
bowel and lung for transplantation.
46. Live donor nephrectomy
⢠Traditional method is either through a loin incision and
retroperitoneal approach or through a midline abdominal incision and
transperitoneal approach.
⢠nephrectomy is now undertaken laparoscopically (totally laparoscopic
or hand-assisted).
⢠The mortality rate for live donation is less than 0.05 per cent, and
around one-half of reported deaths are due to pulmonary embolic
disease.
47. Living liver donors
⢠The concept was first pioneered to allow children to receive the left
lobe or left lateral segment from an adult donor.
⢠Adult to adult transplant requires a portion of right lobe of donor.
⢠For adult-to-adult live liver donation, the donor procedure has a
reported mortality rate of around 0.5 per cent and a major
complication rate of up to 15 per cent.
⢠One of the more common donor complications is bile leak.
48. ⢠living donor combined kidney and segmental pancreas
transplantation has been undertaken to treat insulin-dependent
diabetics with end-stage renal disease.
⢠Living-donor small bowel transplantation has been performed using a
small bowel graft, which comprises a length of around 1.5 m of ileum.
⢠A small number of living-donor segmental lung transplants have been
performed. To provide sufficient pulmonary tissue without
compromising the donor, it is necessary to use segments from two
different donors for each recipient.
49. Resumption of function following organ
transplantation
⢠following heart, lung or liver transplantation the transplanted organ
should resumes satisfactory function immediately.
⢠If primary non-function occurs, the only option is rapid re-
transplantation.
⢠After kidney, pancreas or small bowel transplantation, immediate
graft function is desirable but not vital.
50. Organ donation in India
⢠The primary legislation related to organ donation and transplantation
in India, Transplantation of Human Organs Act, was passed in 1994
and is aimed at regulation of removal, storage and transplantation of
human organs for therapeutic purposes and for prevention of
commercial dealings in human organs.
⢠In India, matters related to health are governed by each state.
51. The main provisions of the Act
A. Brain death identified as a form of death. Process and criteria for
brain death certification defined.
B. Allows transplantation of human organs and tissues from living
donors and cadavers (after cardiac or brain death).
C. Regulatory and advisory bodies for monitoring transplantation
activity and their constitution defined.
52. Regulatory bodies consists of
⢠Appropriate Authority
⢠Advisory Committee
⢠Authorization Committee
⢠Medical board (Brain Death Committee)
53. ⢠Appropriate Authority (AA): inspects and grants registration to
hospitals for transplantation enforces required standards for
hospitals, conducts regular inspections to examine the quality of
transplantations. It may conduct investigations into complaints
regarding breach of provisions of the Act, and has the powers of a
civil court to summon any person, request documents and issue
search warrants.
⢠Advisory Committee: consisting of experts in the domain who shall
advise the appropriate authority.
54. ⢠Authorization Committee (AC): regulates living donor transplantation
by reviewing each case to ensure that the living donor is not exploited
for monetary considerations and to prevent commercial dealings in
transplantation. Proceedings to be video recorded and decisions
notified within 24 hours. Appeals against their decision may be made
to the state or central government.
55. ⢠Medical board (Brain Death Committee): Panel of doctors responsible
for brain death certification. In case of non-availability of neurologist
or neurosurgeon, any surgeon, physician, anaesthetist or intensivist,
nominated by medical administrator in-charge of the hospital may
certify brain death.
56. D. Living donors are classified as either a near relative or a non-related
donor.
(i) A near-relative (spouse, children, grandchildren, siblings, parents
and grandparents) needs permission of the doctor in-charge of the
transplant center to donate his organ.
(ii) A non-related donor needs permission of an Authorization
Committee established by the state to donate his organs.
E. Swap Transplantation: When a near relative living donor is medically
incompatible with the recipient, the pair is permitted to do a swap
transplant with another related unmatched donor/recipient pair.
57. F. Authorization for organ donation after brain death
(i) May be given before death by the person himself/herself or
(ii) By the person in legal possession of the body. A doctor shall ask the
patient or relative of every person admitted to the ICU whether any
prior authorization had been made. If not, the patient or his near
relative should be made aware of the option to authorize such
donation.
(iii) Authorization process for organ or tissue donation from unclaimed
bodies outlined.
58. G. Organ retrieval permitted from any hospital with ICU facility once
registered with the appropriate authority. Any hospital having Intensive
Care Unit (ICU) facilities along with manpower, infrastructure and
equipment as required to diagnose and maintain the brain-stem dead
person and to retrieve and transport organs and tissues including the
facility for their temporary storage, can register as a retrieval center.
59. H. Cost of donor management, retrieval, transportation and
preservation to be borne by the recipient, institution, government,
NGO or society, and not by the donor family.
I. Procedure for organ donation in medico-legal cases defined to avoid
jeopardizing determination of the cause of death and delay in retrieval
of organs.
60. J. Manpower and Facilities required for registration of a hospital as a
transplant center outlined.
K. Infrastructure, equipment requirements and guidelines and standard
operating procedures for tissue banks outlined.
L. Qualifications of transplant surgeons, cornea and tissue retrieval
technicians defined.
M. Appointment of transplant coordinators (with defined
qualifications) made mandatory in all transplant centers.
61. N. Non-governmental organisations, registered societies and trusts
working in the field of organ or tissue removal, storage or
transplantation will require registration.
O. The central government to establish a National Human Organs and
Tissues Removal and Storage Network i.e. NOTTO (National Organ &
Tissue Transplant Organisation).
P. The central government shall maintain a registry of the donors and
recipients of human organs and tissues.
62. ⢠Q. Penalties for removal of organ without authority, making or
receiving payment for supplying human organs or contravening any
other provisions of the Act have been made very stringent in order to
serve as a deterrent for such activities.
63. ⢠Since the health is included in the state list, each state can adapt the
central guidelines.
65. ⢠The Zonal Coordination Committee of Karnataka for Transplantation
has been constituted by the Government of Karnataka (Government
Order No. 264 PTD dated, 13th April 2004) for a sustained cadaveric
transplantation programme in the state of .
⢠ZCCK is the body appointed to oversee the implementation of the
Transplantation of Human Organs Act of 1994.
⢠ZCCK oversees all the cadaveric organ transplantation in Karnataka.
66. Functions of ZCCK
⢠Maintain a recipient waiting list of patients referred by hospitals. The
recipients will be registered at ZCCK office.
⢠Allocate organs when available as per the criteria laid down. These
criteria will be revised from time to time in consultation with the
medical fraternity.
⢠Facilitate organ retrieval & transport.
⢠Conduct public awareness programs.
67. ⢠he only organisation in Karnataka through whom organ donations and
transplants are co-ordinated is ZCCK
⢠A list of patients awaiting transplant is maintained. On receiving
information about potential donors, ZCCK will assess suitability for
organ donation. Based on the blood group and other criteria for the
organ matching, the recipients will be selected, brought into hospital
and prepared for the operation.
69. Functions of NOTTO
⢠Apex centre for co ordination of activities regarding procurement and
networking between different centres.
⢠Registry of Organs and tissue donation and transplantation.
⢠Monitoring of transplantation activities.
70. Guidelines for managing brain dead donors
⢠Management in ICU
⢠Mangement in Operation Theatre
71. Management of brain dead donors in ICU â
NOTTO Guidelines
⢠A number of physiological changes which occur in the brain dead
patient lead ultimately to hypoperfusion of the various organs.
⢠The guidelines which follow attempt to provide a road map to allow
for the largest possible yield of organs.
⢠these guidelines are frequently based on low grade evidence,
opinion and anecdote. There is therefore substantial room for
variations in practice.
75. Specific Management of brain dead patients
Communication
⢠It is important to state to the relatives without ambiguity and
equivocation the fact of the patient's brain death. Following this,
time should be given for the families to adjust to the fact of the
patient's brain death.
⢠Hierarchy of the family of the donor should be ascertained so that
the person responsible for giving consent for organ donation is
established.
⢠It is preferable that the ICU team which has conveyed the news of
brain death, should not be involved in counselling the relatives.
76. Nursing care
⢠The general nursing care of the brain dead organ donor
(Prevention of decubitus ulcers, skin care, dressing changes,
urinary and intravascular catheters and catheter site care).
⢠This will aid in preventing the brain dead patient from developing
systematic sepsis.
⢠Use of active or passive warmers.
77. Monitoring.
The brain dead organ donor requires extremely close monitoring to
detect decompensation and treat it urgently.
Parameters to monitor
a. Core temperature (Either Nasopharyngeal, esophageal, rectal
or indwelling bladder catheter)
b. ECG
c. Invasive Blood Pressure (Arterial Catheter),
d. CVP (Subclavian or IJV)
e. Sp02
f. End-tidal C02
g. Hourly urine output
78. Investigations required
⢠a. CBC
⢠b. Blood grouping and cross matching
⢠c. Coagulation profile- PT/PTTK
⢠d. RFT-BUN, Creatinine e.
⢠E. Complete LFT
⢠f. S Electrolytes- Ca, Mg, N a, K, Phosphate g.
⢠G. Blood Sugar
⢠h. Urine analysis
⢠i. ABG with lactate
79. j. Cardiac evaluation
ECG
Echocardiography
K. Imaging
i.CXR
ii. USG for abdominal organs-liver, kidney, pancreas
L. Microbiology
Surveillance cultures of ET Asp, Blood, urine, ascetic fluid
m. Viral markers
1. HBsAg
2. AntiHCV
3. HIV 1&2
80. Specific Infection Prevention:
Aseptic precautions to be continued and antibiotics if required for
organ donation to be decided on centre/organ specific basis.
81. ⢠Fluid Management:
Replacement of volume deficit: With balanced salt solutions like Ringer
lactate. May require large boluses of fluid depending on blood
pressure.
Maintenance fluid : Depending on the urine output on hourly basis.
With balanced salt solutions or with 5%dextrose if the patient is
hypernatremic due to diabetic insipidus.
Fluid targets should be monitored by CVP and pulmonary artery wedge
pressure.
82. Vasopressors
⢠Vasopressors need to be started if the patient continues to be
hypotensive after adequate fluid resuscitation.
⢠There is little evidence to show the superiority of one pressor over
the other in this particular setting.
⢠Dopamine may improve kidney survival and nor adrenaline may
prevent arrhythmias.
⢠May require physiological doses of vasopressin 0.4-2.5 Units/Hour
83. ⢠Norepinephrine and Vasopressin are the first line vasopressors
whereas dopamine, dobutamine and epinephrine are used
selectively in some patients.
⢠T3 hormone supplementation may be required for optimum action of
catecholamines.
84. ⢠Ventilatory management:
⢠Standard lung protective ventilation strategies are suggested, in
conjunction with closed suctioning, and targeting of PEEP to allow
the Fi02 to be kept as low as possible to allow an Sp02 of >94%
especially if lung transplantation is considered.
85. Management of Endocrine Dysfunction And
Hormone Replacement
⢠Vasopressin : To treat diabete insipidus administer nasal puffs or
intravenous desmopressin presumptively if two hours of urine
output >4 ml/kg/hr have passed.
⢠Methylprednisolone : 15 mg/kg every 24 hours to supplement
corticosteroids also extra benefit of increasing organ retrieval rate.
⢠Insulin: It is important to avoid extreme hyperglycemia, especially
when pancreatic harvesting is considered. A blood sugar of 120-
180 mg% should be aimed for with the judicious use of a low dose
insulin infusion.
86. ⢠Triodothyronine / Thyroxine: 4 microgram bolus followed by infusion
at 3 micrograms/hour in the brain dead patient improving
vasopressor responsiveness and organ salvage rates. intravenous
tridothyronine is generally not available in India. Oral thyroxine
in the dose of 300-400mcg/8hourly is an alternative to
triiodothyronine.
87. Targets for resuscitation
Parameter Target
Heart Rate 60-120 beats/mt
Arterial Pressure Systolic pressure> 100 mm Hg
Central Venous Pressure 6-10 mm Hg
Urine Output 0.5-3 ml/kg/hr
89. Organ Retrieval in OT
⢠The main aim of management is to avoid ischemia of the donor
organs and retrieve these organs in an optimal state.
⢠All the documents including brain death certificate, consent from the
relatives and certificate from judicial authorities in case of MLC cases
should be verified.
⢠The ICU management should be continued on table.
90. Anaesthetic management
⢠Anaesthesia is required ?
⢠There is as yet no way to know whether these cases indeed
have no sensation.
⢠Isoflurane and sevofluranecan cause ischemic preconditioning of
organs and this may improve graft organ function.
⢠Inhalational anaesthetic may have a beneficial effect by causing
peripheral vasodilation.
91. Muscle relaxants
⢠Mandatory as to prevent mass reflex and lazarus reflex.
⢠Vecuronium O.1mg/kg is given to allow adequate surgical
exposure and suppress the possibility of spinal-reflex-induced
patient movement.
⢠Analgesia can be provided with Narcotic analgesic-Fentanyl 1-5
ug/kg.
⢠Air and oxygen mixture can be given.
92. Surgical steps in organ harvesting surgery
⢠After preparing the donor from neck to pubis and a long midline
incision is made from the suprasternal notch to the pubis.
⢠In a haemodynamically stable donor, organ dissection is done
insitu. It may even be possible to plan in-situ splitting of the liver
graft.
⢠In an unstable donor with imminent haemodynamic collapse,
harvesting of thoracic organs is abandoned, the abdominal organs
should be rapidly flushed and cooled and organs are removed en
bloc for further dissection on bench.
93. ⢠If the pancreas is to be harvested, the duodenum is flushed
with an antibiotic or betadine solution through a nasogastric tube.
⢠The portal circulation is cannulated.
⢠The abdominal aorta is ligated and cannulated just above the
bifurcation.
⢠The heart is arrested, the aorta is clamped at the diaphragm,
and the organs are flushed with preservative solution.
⢠In general the order of organ removal is as follows: heart and lungs
first, followed by removal of liver, pancreas and both kidneys.
Corneas are the last to be retrieved.
94. Retrieval of Heart - Standard operative
procedures
⢠Instruments required
⢠a sternal saw,
⢠a sternal spreader,
⢠aortic cross clamp,
⢠long vascular clamp for IVC,
⢠needle holders for 3'0' and 4'0'prolene sutures,
⢠long scissors,
95. ⢠large right angle clamps and long forceps.
⢠Long silk ties, one 4 -'0' prolene suture,
⢠one aortic root or root-vent cannula.
⢠Cotton tapes. Two sterile packed basins.
⢠Three nos bowel bags.
⢠Additional few 3'0' and 4'0'prolene sutures.
⢠Silk sutures for pericardial cradle and needle holders.
96. ⢠CUSTODIOL or St. Thomas cardioplegia solution 4 Ltrs
⢠3-5 litres of ice slush and chilled saline solution in an ice chest.
⢠Triple bag technique
⢠a. First bag contains 1 litre chilled custodiol and heart
⢠b. Second bag contains first bag and 1 litre of ice slush
⢠c. Third bag contains the second bag.
⢠The first bag is placed in the second bag face down and second
bag is placed in the third bag face down.
97. Steps for Heart retrieval
⢠Heparinize with 30000 IU Heparin
⢠Secure tie the azygous between triple ties.
⢠Ask the anaesthetist to withdraw CVP line, Tie SVC above
the Azygous.
⢠Clamp IVC flush with the diaphragm (be aware of abdominal
surgeons commencing perfusion prior to IVC clamp, the right
heart would distend and heart would be rendered unusable.)
⢠aortic cross clamp.
⢠Infuse with Custodiol solution (30-40 mLlkg) at a hydrostatic
pressure of 50 mm Hg for 6 to 8 minutes
98. ⢠Hemisect the IVC anteriorly to vent the right heart.
⢠Cut left superior pulmonary vein to vent the left heart.
⢠Submerge the heart in slush solution
⢠Place a sucker in the IVC to collect warm effluent.
⢠Once the cardioplegia is completed excise the heart
99. Liver harvest
⢠Instruments required
⢠Large Finochietto retractor
⢠Very large self-retaining abdominal retractor
⢠30" long Artery forceps
⢠Laparotomy set
⢠Cannulae for aortic and portal vein perfusion
⢠Cannulae for bench perfusion.
⢠Satinsky and bulldog clamps
⢠Gigli/Sternal Saw
⢠4 plastic bowls and sets of plastic bags with strings
⢠Ice box
102. ⢠The order of organ retrieval is as follows.
⢠I. Heart/lung
⢠II. Liver
⢠Ill. Pancreas/intestine
⢠IV. Kidneys
⢠v. Corneas
103. Steps
⢠Incision: Long midline laparotomy
⢠Complete exploratory laparotomy
⢠Divide falciform ligament and check that the liver is suitable for
donation.
⢠Check for accessory hepatic arteries
⢠I. Right hepatic artery from superior mesenteric artery behind the
bile duct
⢠II. Left hepatic artery from left gastric in the hepatogastric ligament
104. ⢠mobilizing the colon on both sides to expose the
retroperitoneum
⢠Identify Ureters at pelvic brim
⢠Pass ties around the origin of common iliac arteries
⢠Prepare iliac veins and inferior vena cava for venting
105. Warm Phase dissection
⢠Divide peritoneal attachments to the base of the liver
⢠Expose retroperitoneum up to right/left renal vein and superior
mesenteric artery
⢠Mobilise duodenum to expose infra-hepatic inferior vena cava.
⢠Expose renal capsules on both sides and check kidneys for
cysts/tumours.
⢠Pass two silk ties around the superior mesenteric vein at the
root of the tranverse mesocolon or around the inferior
mesenteric vein.
106. ⢠Ligate the inferior mesenteric vein
⢠Pass a finger through the foramen of Winslow and open the
lesser omentum
⢠Divide the common bile duct just above the duodenum and
ligate the duodenal side
⢠Open the gall bladder and wash and such out bile with saline
using a 50 ml bladder syringe.
⢠Identify and loop the common hepatic artery between the
gastroduodenal and splenic artery.
107. Cold perfusion
⢠Ligate left common iliac artery
⢠Cannulate right common iliac artery - INPUT
⢠Cannulate superior/inferior mesenteric vein: place catheter tip
at level of the pancreas.- OUTPUT
108. Cold dissection
⢠Mobilise duodenum downwards, dividing gastroduodenal artery
and expose portal vein
⢠Divide neck of pancreas anterior to portal vein/superior mesenteric
vein.
⢠Removal portal cannula and divide confluence of superior mesenteric
vein/splenic vein.
⢠Divide left gastric artery distal to any accessory left hepatic artery
⢠Then divide superior mesenteric artery distal to right hepatic artery
and carefully dissect right hepatic artery off head of pancreas.
109. ⢠Divide infrahepatic inferior vena cava above renal veins by opening
in midline and visualizing renal vein onsite clearly.
⢠Mobilise right lobe of the liver exposing right adrenal and cutting
through it (requires gentle traction by the assistant to avoid tearing
the liver capsule).
⢠Divide remaining attachments and remove liver and inferior vena
cava with attached tissues.
110. Retrieval kidney
⢠Kidney and vessel removal with aortic patches and inferior
vena cava patches by splitting both vessels in midline.
⢠Divide ureters below pelvic brim.
⢠Perfuse renal artery with' 200 ml HTK and pack in double bags in
ice box
