Deceased Donor Liver Procurement

A midline incision is made, and the abdominal contents explored to determine the presence of any previously undetected pathologies. A median sternotomy is also performed in order to improve exposure and maximize venous drainage into the chest at the time of cold perfusion.

The first goal in a procurement procedure is to ensure quick vascular access in case of sudden hemodynamic instability. The aorta is dissected above the bifurcation, and encircled with two umbilical tapes. Subsequently the superior mesenteric artery (SMA) is identified at the level of the left renal vein and encircled with a vessel loop. The supraceliac aorta is exposed by mobilizing the left lateral segment of the liver and dividing the diaphragmatic crura.

The hilum of the liver is addressed. The bile duct is identified, tied near to the pancreas, and transected. The gallbladder is incised and flushed with preservation solution. The hilum is also inspected for anatomical variations, such as replaced or accessory left, right, or proper hepatic arteries. In hemodynamically stable patients, the hepatic artery and celiac axis are dissected proximally to the aorta. In addition, the SMA and splenic artery are partially dissected and encircled with vessel loops.

In cases where the pancreas is being procured, the duodenum is flushed via nasogastric tube with approximately 300 mL of iodine solution, mixed with antifungal and antibiotic agents. The gastrointestinal stapler is used to divide the first and fourth portions of the duodenum from the stomach and proximal jejunum respectively.

Once the dissection is completed, heparin (300 Units/kg) is administered intravenously. The distal umbilical tape at the bifurcation of the aorta is then tied. A cannula is placed in the proximal end that will allow for retrograde perfusion of preservation fluid through the aorta into the abdominal organs. A smaller cannula is placed into the inferior mesenteric vein (IMV) or superior mesenteric vein (SMV) toward the portal vein for antegrade cold perfusion.

The aorta is clamped at the supraceliac level and the inferior vena cava (IVC) is incised above the diaphragm in order to allow for drainage of blood and perfusate into the chest. Simultaneously, chilled preservation fluid is instilled through the aortic and IMV/SMV cannulas in order to perfuse the organs that will be extracted. The abdominal cavity is also filled with ice to cool the organs.

The liver is removed by transecting the aorta above and below the celiac trunk and SMA respectively. The diaphragm is transected and removed with the liver. The pancreas is separated from the liver in situ by transecting the splenic artery, proximal vena cava, and tissues in between them. The liver can also be procured together with the pancreas and separated ex situ in the back table. The iliac vessels of the donor are removed for potential later use as arterial and venous conduits. If the surgeon prefers, the liver can be perfused again ex situ with preservation solution through the hepatic artery and portal vein. The bile duct is also flushed.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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