Small Bowel Procurement

Small bowel retrieval can be a part of multivisceral procurement.17 The principles of multivisceral procurement were described by Starzl.18 In brief, a complete multivisceral specimen is removed as a grape cluster with a double central stem consisting of the celiac axis and superior mesenteric artery. If only the small bowel is to be procured then only the superior mesenteric artery is preserved. Venous outflow of the grafts that include the liver is with a segment of the retrohepatic inferior vena cava which is used either to replace the recipient vena cava at the resected segment or anastomosed piggyback to the anterior wall of preserved recipient vena cava with ligation of its lower end. If the intestines are to be procured without the liver, the venous drainage of the graft is by the portal vein. Before intestinal procurement, selective bacterial and fungal decontamination is performed. The intestines are flushed with a hyperosmolar cathartic solution (polyethylene glycol), amphotericin B, tobramycin and polymixin E through a nasogastric tube. Additionally, the donor may also be treated prior to procurement with antilymphocyte antibody to the CD-3 receptor (OKT3).

Combined Hepatic and Intestinal Procurement

The abdomen and chest are opened with midline laparotomy and median sternotomy.19,20 The right colon and small bowel mesentery are mobilized.

The duodenum is Kocherized. The distal and supraceliac aorta are encircled in the usual manner. The portal vein is cannulated through the inferior mesenteric vein. The hepatoduodenal ligament is dissected out. The gastroduodenal, splenic and left gastric arteries are ligated and divided to isolate the celiac axis. If a left hepatic artery arising from left gastric artery is found, it is preserved. The common bile duct is encircled and transected distally. The gall bladder fundus is incised and the bile is washed out with saline irrigation. The gastrocolic omentum is divided between ligatures. The right and middle colic vessels are divided sparing ileal branches of the ileocolic artery. The right and transverse colons are mobilized completely. The jejunum is divided with a GIA stapler just distal to ligament of Treitz.

The peritoneum at the inferior border of the pancreas is incised. The neck of the pancreas is encircled with blunt dissection and divided between heavy ligatures. The pancreas and duodenum are dissected from the intestinal graft with ligation of potentially numerous small branches of the superior mesenteric artery and vein at this location. The distal small bowel is transected with a GIA stapler at the ileocecal valve.

The distal aorta is cannulated after systemic heparinization.

The supraceliac aorta is cross-clamped. The vena cava is incised in the pericardium close to its junction with the right atrium. One liter of UW solution flushed through each cannula serves as cold perfusion. Overperfusion should be avoided. After cold perfusion, the inferior vena cava is divided above the renal veins. An aortic patch including the celiac axis and the superior mesenteric artery is removed with the composite liver-small bowel graft. The rest of the procurement is completed as described previously. The intestinal lumen is flushed at the back table (Table 8.3).

An alternative method is en bloc removal of liver-small bowel graft with pancreas and duodenum. In this technique the small bowel is separated from the pancreas and duodenum ex vivo. This involves dissection of the portal vein from the posterior surface of the pancreas and division of the splenic and pancreatic tributaries between ligatures. Then the superior mesenteric artery is dissected free of

the posterior surface of the pancreas. This technique minimizes the in vivo surgical dissection and is particularly useful in unstable donors.

Small Bowel Procurement Alone

If the intestine is to be transplanted alone, the liver can be separated from the small bowel during procurement or on the back table.21,22 The celiac axis remains on the liver graft and the superior mesenteric artery is retained with the small bowel. The portal vein is shared between liver and small bowel grafts and divided 2 cm above the upper border of the pancreas.

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