3. Types of Transplant Heterotopic or Orthotopic different same Autograft: same being Isograft/Syngenetic graft: identical twins Allograft/homograft: same species Xenograft/heterograft: between species
7. Recipient evaluation and preparation Multidisciplinary team including surgeon and physician Determine presence of co morbidity Malignancy and systemic sepsis Evaluate against organ specific criteria for transplantation Psychological evaluation Need for preparative surgery Optimize recipient condition for surgery
8. Living Donor Nephrectomy Loin incision or midline incision Lateral border and upper pole mobilized first On left side adrenal and gonadal veins are divided Traction of renal artery is avoided Ureter mobilization Diuresis Laparoscopic nephrectomy
9. Cadaveric donor Optimisation of donor Midline incision Canulation of aorta Infusion of cold preservation solution Kidneys mobilized Distal aorta and venacava are divided Transfered to cold solution
10. The Recipient Operation Oblique incision- Vascular anastomosis– Artery-end to end (internal iliac) end to side (external iliac) Renal vein- end to side to external iliac vein uretericanastomosis ureteroneocystostomy
17. Outcome after renal transplantation Improves quality and duration of life Chronic rejection is most common cause of graft failure Half life of graft- living donor is longer than cadaveric grafts Deceased donor graft-13 yrs Living unrelated graft -14 yrs Living haploidentical graft-15 yrs Living identical sibling graft-27 yrs
21. Tools Used to Stratify Transplant Recipients MELD/PELD= model for end stage liver disease and pediatric end stage liver disease MELD:>12y.o Cr, Bili, and INR PELD:<12 y.o. Alb, BIli, INR, growth failure and age MELD>15, CTP>9
22. Donor Assesment Respiratory and haemodynamic support Serial follow up of liver enzymes Hepatitis ,transmissible diseases screening History of alcohol intake Marginal and expanded criteria donor Donor and recipient matching- ABO compatibility and size
23. Deceased Donor Liver Recovery Midline incision Expose IVC ,IMV, infra renal aorta Cannulate - Aorta and IMV Dissection of liver done Perfusion with cold preservative solution Liver removed with celiac artery, portal vein,CBD,retro hepatic vena cava
24. Recipient hepatectomy Mercedes Benz incision Ligaments divided Portahepatis exposed Veno-venous bypass IVC is divided between two clamp Liver is explanted
25. Living Donor Hepatectomy Left lobe - children , Right - adults Mercedes Benz incision Liver is mobilized Right hepatic vein -right lobe donation ,middle and left for left lobe donation Hilar dissection Vessels occluded-ischemic plane marked-divided
27. Piggyback Liver Transplant It is a IVC preserving technique Initial steps similar to classic technique Hepatic veins divided , stumps joined to form common cloaca-IVC Donor infrahepatic IVC is closed with ligatures PV, hepatic artery, biliaryanastomosis
28. Pediatric Liver Transplantation Major limiting factor –lack of donors Transplantation of left lateral segments split from cadaveric donor or living donor is standard practice Procedure require precise knowledge of the hepatic anatomy of the donor
33. Pancreatic Transplantation It obviates need of insulin in diabetic patient Reduces the progression of vascular disease retinopathy,nephropathy Reserved for patients with type 1 diabetes mellitus (<55yrs) For most patients simultaneous kidney transplant is also undertaken(SPKT,PAKT,PTA)
34. SurgicalTechnique Transplantation of whole pancreas is done with segment of duodenum SPKT - through midline incision Pancreas graft-intraperitoeally on right side in the pelvis, kidney graft on left Donor vessel -recipient iliac vessels Exocrine drainage (enteric drainage,urinary drainage)
36. Outcome Prolong life in diabetic patients After SPKT 1 year patient survival rate is >95% Most deaths are due to cardiovascular complications or infections Results of PTA graft is not as good (1 year graft survival 70%)
37. Pancreatic islet transplantation Islet of langerhans – scattered throughout pancreas Transplantation restores normal glucose metabolism Problems- isolation ,several donor cells used Pancreas perfused with collagenase ,density gradient purification,in vitro culture Liver infusion-flouroscopiccannulation of PV
40. Bowel transplant Types Small bowel with or without portion of colon Combined liver- Small bowel grafts Multivisceral transplant Should be considered for patients in whom long term TPN has failed
41. Technique SMA of graft is anastomosed to recipient aorta(with a aortic patch) SMV is anastomosed to IVC or to portal vein Proximal end is anastomosed to recipient duodenum or jejunum Distal end is anastomosed to side of colon(with a loop ileostomy) or fashioned as end -ileostomy
42. Outcome 1 year graft survival rate is 65% 3 year graft survival rate is 45% Patient survival is better after isolated small bowel transplantation
