ORGAN TRANSPLANTATION Definition Donor Recipient Graft Organs usually transplanted Tissues, cells usually transplanted Types of organ donors HISTORY OF TRASNPLANTATION HISTORY OF TRANSPLANTATION IN SRI LANKA Transplantation procedure Live donor nephrectomy Organ preservation Renal transplantation Donor Post operative management RECIPIENT – SURGERY POST-OPERATIVE CARE Cadaveric Transplantation Organ ischemia Immunological complications

1. Joel Arudchelvam
MBBS, MD ( SUR ), MRCS (ENG), FCSSL
ConsultantVascular andTransplant Surgeon
ORGAN
TRANSPLANTATION

2. Transplantation
Removal of organs or tissues from one individual
and placing it in another individual
 Recipient

3. Transplantation
Removal of organs or tissues from one individual
and placing it in another individual
 Recipient

4. Transplantation
Removal of organs or tissues from one individual
and placing it in another individual
 Recipient

5. Transplantation
Removal of organs or tissues from one individual
and placing it in another individual
 Recipient
GRAFT

6. TRANSPLANTATION
The Miracle surgery of Cosmas &
Damian AD 287

7. Organs usually transplanted
 Kidney
 Liver
 Pancreas
 Heart
 Lungs
 Intestine

8. Tissues, cells usually
transplanted
 Skin
 Cornea
 Islets of Langerhans
 Bone marrow
 Heart valve
 Bone

9. Types of organ donors
 Live Donor
 Deceased / Cadaveric Donor
 Donation after brain death (DBD)
 All Brain stem functions are absent/ patient on
ventilator support
 Donation after cardiac death (DCD)
 Patient who has irreversible or an injury
incompatible with life.
 Does not fulfill the brain death criteria

10. Types of organ donors
 Live Donor
 Deceased / Cadaveric Donor
 Donation after brain death (DBD)
 All Brain stem functions are absent/ patient on
ventilator support
 Donation after cardiac death (DCD)
 Patient who has irreversible or an injury
incompatible with life.
 Does not fulfill the brain death criteria

11. HISTORY OF TRASNPLANTATION
 1902 Experimental transplants and
anastomosis techniques in animals -
Alexis Carrel
 1954 First successful kidney transplant
 1963 First liver transplant

12. HISTORY OF TRANSPLANTATION
IN SRI LANKA
Organ Year Surgeon
Kidney 1985 Prof. A. H. Sheriffdeen
Liver 2010 Prof Mandika Wijeratne
Lungs 2011 Japanese and SL
surgeons
Pancreas (Simult. Panc / Kid) SPK 2016 Dr . Joel Arudchelvam
En bloc Kidney Transplantation 2017 Dr . Joel Arudchelvam
HeartTransplantation 2017 Kandy team
Lower LimbTransplantation 2017 Dr . Joel Arudchelvam

13. Transplantation procedure
Suitable Donor
Organ retrieval
Organ preservation
Transplantation

14. Live donor nephrectomy
 Lateral decubitus
position
 lower costal margin
over the kidney rest
 kidney rest is raised
and the operating table
is flexed

15. Live donor nephrectomy
 Incision in line with
the 12th rib.
 Kidney, ureter,
vessels mobilised

16. Donor nephrectomy
 Removal of kidney [* nurse to note down
renal artery clamp time]

17. Organ preservation
 Kidney perfused with
cold preservation
solution
 HistidineTryptophan
Ketoglutarate (HTK) solution

18. Organ preservation

19. Organ preservation
Histidine-tryptophan-
ketoglutarate (Custodiol HTK
solution)
Composition

20. Donor nephrectomy
 Closure with ‘1’ PDS - half circle , 36 mm to 48
mm / ‘1’Vicryl - half circle , 36 mm to 48 mm

21. Renal transplantation
• Curved supra inguinal
incision (Modified Gibson)
• Inverted ‘J’/ ‘Hockey stick’

22. Renal transplantation
• Iliac vessels and bladder
dissected extra peritoneally’

23. Renal transplantation –
Iliac vessel mobilisation

24. Renal transplantation
 Renal vessels
ananstomosed to
iliac vessels

26. Renal transplantation
Ureter anastomosed to the
bladder
(Ureteroneocystostomy)

27. Surgical aspects

28. Donor
On arrival to the theatre check
 Documents
 Investigations
 Renal angiogram
 DTPA
 TED stockings

29. Donor Nephrectomy -
Equipment
 Ligaclips (medium and large)
 Right angle * 3
 Silk ties (0 /3-0)
 4-0 or 5/0 Polypropylene sutures ,round body /
taper point needle ½ , double arm , 17 mm ( for
R nephrectomy)
 Rib spreader
 1 PDS

30. Back table - for perfusion
of kidney
 Large basin
 2 L of sterile slush (prepared by freezing saline and crushing)
 Fine needle holder
 Mosquitoes * 4
 De Bakey * 2
 Dissecting scissors
 KidneyTray
 SilkTies (3-0)
 5-0 Prolene sutures
 18 G cannula
 HTK solution – 1L with perfusion set

31. Donor
Post operative management
 D0
 IV Fluids
 MonitorVital Signs
 Monitor IP / OP
 D1
 Mobilise
 Remove catheter
 Enoxaparin S/C
 Start oral

32. RECIPIENT
On arrival to the theatre check
 Documents
 Investigations
 Immunosuppressive drugs
 Basiliximab 20mg IV
 Methylprednisolone 1000mg IV on induction
 Antibiotics - Cefuroxime 750mg IV or co amoxyclav on
induction
 Netilmicin / Gentamicin
 TED stockings

33. RECIPIENT - SURGERY
 Heparinised saline (2500 units in 500ml N-
saline)
 Thompson retractor / bookwalter retractor
 5F 0r 4.8F double J stent - 12cm, with guide
wire

34. RECIPIENT - SURGERY
 5/ 0 Polypropylene sutures ,round body / taper
point needle ½ or 3/8 circle, double arm , 17 mm * 5
 6/0 Polypropylene sutures ,round body / taper
point needle ½ circle,double arm Prolene 13mm needle
* 2
 5/0 PDS round body / taper point needle ½ or,double
arm Prolene 17 mm needle * 3

35. RECIPIENT - SURGERY
 Prior to re-perfusion of the kidney
 125ml of 20% Mannitol (25g) and frusemide
100mg IV
 Keep warm saline ready

36. POST-OPERATIVE CARE
 ICU
 HR 60 -90 bpm
 BP - 130/80 - 150 - 90 mmHg(MAP 90- 100
mmHg)
 CVP - 4 - 8 mmHg or 8 -12 H2O

37. Post operative fluid
replacement protocol
 Following live donor renal transplantation
polyuria is common
 UOP less than 50 ml/hour - UOP + 40ml of fluid
 UOP more than 100 ml/hour give volume to volume
replacement of fluid
 UOP more than 500 ml/hour - UOP - 50ml of fluid
 UOP more than 1000 ml/hour - UOP -100ml of fluid

38. POST-OPERATIVE CARE
 SE, Urea, Creatinine, FBC daily
 Analgesics - Fentanyl
 Cefuroxime – 750mg IV 8-hourly for 48 hours
 Mycophenolate mofetil 1g po bd
 Cyclosporin 5mg/kg po bd or tacrolimus
0.05mg/kg po bd.

39. From D1
 Mobilise
 Immunosuppression [ from D1 to 7]– discuss
with nephrologist
 Methylprednisolone or prednisolone daily
 Mycophenolate mofetil
 Cyclosporin or tacrolimus .
 Basiliximab 20mg IV – Day 4.

40. From D1
 IV fluids ( N saline) is given to replace urine output until
the oral intake improves to more than 1000mls per day.
 Start oral diet from D1
 Co-trimoxazole
 Valganciclovir
 Remove catheter on D5 - discuss with surgeon
 Clip removal at 3 weeks
 Stent removal at 1 month by urologist

41. Cadaveric Transplantation
 Keep Ice ready ( frozen hartmann solution /
Saline, at least 16 and slush ice from OTJ )
 Back table ready when kidney arrives

42. Organ ischemia

43. Organ ischemia

44. Immunological complications
 Hyperacute -
 Occur due to the pre- existing antibodies
 Occurs soon after the organ is reperfused.
 Due to ABO incompatibility / pre-existing HLA
antibodies.
 Acute rejection –
 3 to 5 days following transplantation
 The immune system newly recognises the graft
 Generally T cell mediated (acute cellular rejection)
sometimes due to antibodies (acute humoral
rejection)

45. Immunological complications
 Chronic rejection –
 Due to accumulation of injuries over long period
 Graft gradually loses its function

46. Rejection diagnosis
 How to recognise
 Deteriorating renal function
 Evidence of increased resistance to blood flow
within the kidney – increased RI
 Confirmation renal biopsy

47. ThankYou !