C. Procurement of the Pancreaticoduodenal Graft There are several standard surgical methods for procurement of the pancreas for transplantation. The general principles are similar irrespective of the specific techniques utilized. The pancreas must be procured with an intact vascular supply that does not compromise the vascularity of the liver. The pancreas is procured with the spleen and duodenum intact. The organ is perfused with preservation solution and cold-stored. The donor iliac vessels and sometimes the portal vein are obtained for revascularization of the arterial supply.

There are two general methods of organ procurement. Many programs prefer to perform an en-bloc removal of the liver and pancreas together and separate the two organs at the backbench. Other programs prefer to perform a more deliberate dissection of the pancreas and liver by mobilizing the relevant vasculature prior to preservation. The liver and pancreas are separated in-situ. The relevant components of the in-situ procurement process are briefly described.

1. Long midline incision (+/- cruciate incision);

2. Mobilization of ascending colon, control of infrarenal aorta, and identification of superior mesentaric artery;

3. Control of supraceliac aorta;

4. Identification of hepatic artery (ligation of gastroduodenal artery), splenic artery, portal vein, and division of common bile duct;

5. Identification of replaced and/or accessory left and right hepatic arteries;

6. Exposure of the anterior aspect of the pancreas for visual and manual inspection;

7. Mobilization of the spleen by division of short gastric vessels and dissection of its ligamentous attachments;

8. Mobilization of head, tail, and body of the pancreas;

9. NG tube positioning into the proximal duodenum and irrigation of antibiotic solution;

10. Removal of NG tube and division of the proximal duodenum just distal to the pylorus;

11. Heparinization of the donor and infusion of intra-aortic (± intraportal) preservation solution;

12. Division of proximal jejunum, middle colic vessels, and superior mesen-teric vessels distal to the pancreatic uncinate process;

13. Division of celiac, SMA, splenic arteries; and portal vein;

14. Procurement of liver, pancreaticoduodenosplenic allograft, and kidneys;

15. Procurement of donor iliac vessels;

16. Closure of incision.

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