pericardium, inspect the heart and encircle the superior vena cava, suprahepatic vena cava, and the aorta. The pleural spaces will also be opened and the lungs inspected if being considered for transplantation.

The intraabdominal portion of the organ procurement commences once the heart team has inspected the heart and lungs. It is important to note that as organ procurement has evolved, less dissection has been shown to be advantageous since it reduces vasospasm, warm ischemia, and decreases the length of operation and donor instability. Liver dissection is performed first and usually involves encircling the supraceliac aorta, dividing the common bile duct, gastroduodenal artery, and encircling the portal vein. If the pancreas is being used by a center other than the liver center, dissection of the entire celiac artery to the aorta may be performed with the left gastric and phrenic arteries being ligated and the splenic artery encircled. However, prior to ligating the left gastric artery, the donor surgeon must be sure the left hepatic artery does not arise from the left gastric artery. This arterial anomaly is seen in 15% of cases and is visualized in the gastrohepatic omentum. Another hepatic arterial anomaly is the presence of a right hepatic artery arising from the superior mesenteric artery (SMA). This occurs in approximately 10% of cases and can be palpated posterior to the portal vein and common bile duct. Both hepatic arterial anomalies are compatible with hepatic and pancreatic procurement in all cases. Several techniques of vascular reconstruction are available and usually require the use of donor iliac artery grafts.

A new technique of liver procurement involves in situ donor liver splitting for two recipients. Although some centers perform ex vivo liver splitting, in situ splitting may be associated with less bleeding and fewer biliary complications after transplantation. However, a major disadvantage of in situ liver splitting is the additional 1-2 hours required to perform the procedure.

Pancreas dissection involves a Kocher maneuver to mobilize the duodenum as well as dissection of the posterior pancreas to the level of the inferior mesenteric vein (IMV) which is ligated. The first portion of the duodenum and the small bowel just distal to the ligament of Treitz are stapled and the mesenteric vessels are ligated. If the intestine is being recovered for transplantation, the SMA and superior mesenteric vein (SMV) are dissected but not ligated. Also, since the liver and intestine are both transplanted in some patients with short bowel syndrome, the liver, pancreas, and intestine are recovered en bloc without dissection. The pancreas is usually transplanted with the liver and intestine in order to keep the donor porta hepatis intact.

Renal dissection should be minimal and limited to identification and division of the distal ureters. Dissection of the renal arteries and veins as well as mobilization of the kidney should be done only after the intraabdominal organs are infused with preservation solution. This minimal dissection technique helps to limit renal artery vasospasm and subsequent delayed graft function.

Once preparation of each organ to be retrieved is complete, the patient is given 20,000-30,000 units of heparin followed by cannulation of the distal aorta with a chest tube for eventual administration of preservation solution. Also, just prior to organ retrieval, some teams will administer an a-adrenergic antagonist, such as

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