Pancreas retrieval is usually a part of a multiple intra-abdominal organ procurement. Combined liver and pancreas procurement requires meticulous surgical technique.14 The main technical consideration in combined liver and pancreas procurement is preservation of arterial blood supply and adequate length of portal vein for both organs.15 As the liver and pancreas share the same arterial supply and arterial anomalies are common, careful dissection and good communication between pancreas and liver procurement teams are necessary.
The tail and most of the body of the pancreas are supplied by the splenic artery which is a branch of the celiac axis. The head of the pancreas and duodenum have a dual arterial supply: the superior pancreaticoduodenal arcade off the gas-troduodenal artery and inferior pancreaticoduodenal arcade off the superior mesenteric artery. Hence, preservation of both the splenic and superior mesenteric arteries is critical for this organ. In combined liver and pancreas procurement the gastroduodenal artery is ligated and divided to keep the entire celiac axis with an aortic patch on the liver graft. In this case, the superior pancreaticoduodenal arcade is fed by the inferior pancreaticoduodenal arcade. The venous drainage of the pancreas is by the splenic vein and superior mesenteric vein that come together as the portal vein.
A midline incision with electrocautery from the suprasternal notch to the sym-physis pubis is made. The right colon and small bowel mesentery are mobilized. The inferior mesenteric artery is divided between ligatures and the distal aorta is encircled. The supraceliac aorta is encircled after division of diaphragmatic muscle fibers. The bile duct is divided close to the duodenum. The hepatic artery is identified and isolated as described previously. The gastroduodenal, right gastric and left gastric arteries are divided between ligatures. The splenic artery is preserved. The portal vein is dissected free.
The inferior mesenteric vein is dissected and cannulated for portal perfusion. The cannula is advanced into the portal vein. The splenic vein is preserved and should not be used for cannulation.
The greater omentum is divided between ligatures along its entire length. The short gastric vessels between the stomach and spleen are ligated and divided. The spleen is mobilized by dividing the splenocolic and splenorenal ligaments and diaphragmatic attachments. The spleen is used as a handle to minimize trauma to the pancreas. The stomach is retracted upward and to the right exposing the lesser sac and anterior surface of the pancreas. The peritoneum at the superior and inferior borders of the pancreas is incised. Ligation of identifiable blood vessels prevents pancreatic injury that may happen during the control of bleeding from these vessels. This also avoids bleeding after implantation. The spleen is retracted medially and the tail of the pancreas is dissected free off the retroperitoneum. Care should be taken to carry out the dissection away from the surface of the pancreas. An extended Kocherization is performed for mobilization of the pancreatic head with duodenum. The ligament of Treitz is divided. The duodenum and pancreas are retracted to the left until the aorta is exposed.
The stomach and duodenum are irrigated with an antibiotic or povidone-io-dine solution through a nasogastric tube. The duodenum is transected just distal to pylorus with a GIA stapler. The proximal jejunum just distal to the ligament of Treitz is cleared circumferentially and divided in the same way. Spillage of intestinal content should be prevented. Next, the root of small bowel mesentery is divided after ligation of mesenteric vessels. We favor individual ligation of the major branches of the superior meseteric veins and arteries. We are concerned that mass ligature (or stapling) of their vessels could lead to the development of large arterio-venous fistulas in the implanted pancreas. This dissection is carried out away from the pancreas to avoid injury to the proximal superior mesenteric artery that supplies the pancreas.
After this preliminary dissection the pancreas is ready for cold perfusion. The rest of the dissection is completed in the bloodless field. The donor is heparinized systemically and the distal aorta is cannulated. The supraceliac aorta is cross-clamped. The inferior vena cava is divided in the pericardium. Cold perfusion with UW solution is initiated through aortic and portal cannulas. The portal vein is ligated over the previously placed cannula leaving 2 cm of portal vein on the pancreas side. The portal vein is incised just below the ligature for venous decompression of the pancreas. Topical cooling is performed with slushed-ice saline. After completion of cold perfusion, the liver is retrieved. During liver procurement, the splenic artery is ligated close to the celiac axis and divided leaving as much length of splenic artery with the pancreas as possible. The free end of the splenic artery is marked with a fine polypropylene suture for its later identification. The portal vein is divided between the liver and pancreas. Nerve bundles and lymphatic tissue around the superior mesenteric artery are divided and the superior mesenteric artery is dissected free down to the aorta. The superior mesenteric artery with a narrow cuff of aorta is excised. Care should be taken to avoid injury to renal arteries.
Table 8.3. Suggested compositions of luminal flush at the back table a) Pancreaticoduodenal graft
1. Povidone-iodine 10% 250 mL
2. Amphotericin B 50 mg in 50 mL 5% dextrose solution b) Small bowel graft
1. Lactated ringers 1000 mL
2. Amphotericin B 50 mg
3. Gentamicin 80 mg
4. Polymyxin E 100 000 U
5. Povidone-iodine 10% 40 mL
If an anomalous right hepatic artery originating from the superior mesenteric artery is encountered, this does not necessarily preclude simultaneous liver and pancreas procurement. Often, careful dissection with good cooperation between liver and pancreas procurement teams can salvage both the liver and pancreas vasculature particularly when the anomalous right hepatic artery takes off close to the SMA take-off. In this case the replaced right hepatic artery is dissected free down to the superior mesenteric artery and the SMA is divided to the take-off of the right hepatic. After removal, the pancreaticoduodenal graft is taken to the back table and placed in a basin of cold saline.16 The duodenum lumen is irrigated with a cold povidone-iodine and amphotericin solution (Table 8.3). The effluent is drained outside of the basin. The rest of the dissection is left to the recipient surgeon. The organ is packed in a plastic bag filled with UW solution. It is then packed in a second plastic bag and placed in a cooler and covered with ice for transportation.
This procedure is easier than combined pancreas and liver procurement. The gastroduodenal artery is preserved. The proper hepatic artery distal to the gas-troduodenal artery and left gastric artery are ligated and divided. A cuff of aorta, including the celiac axis and superior mesenteric artery in continuity, is excised with the pancreaticoduodenal graft. The portal vein can be transected high in the hilum of the liver leaving a long portal vein on the graft. The rest of the procedure is completed as described above.
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