Cadaveric Donor Pancreatectomy 931 Pancreas without Liver Procurement

Pancreas without liver procurement usually includes bilateral kidney procurement. The main technical details include the preservation of the gastroduo-denal artery. The proper hepatic artery, distal to the gastroduodenal artery, and the 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 is transected high in the hilum of the liver to preserve the length of the portal vein.

Briefly, a midline incision from the suprasternal notch to the symphysis pubis is performed. The hepatic flexure of the colon and small bowel mesentery is mobilized. The pancreas should be uniformly pale yellow, with no tissue edema and minimal tissue trauma. The entire duodenum and pancreas are mobilized by an extended Kocher maneuver, with the division of the ligament of Treitz. The supraceliac aorta is encircled with umbilical tape for aortic cross-clamp after division of the diaphragmatic crura. The IMA is divided between ligatures, and the distal aorta is encircled with umbilical tape. The gastrocolic ligament is divided, and the spleen is mobilized by incising the lateral peritoneal reflection and the splenic flexure. The gastroepiploic and short gastric vessels are dissected and divided between suture ligatures. The porta hepatis is dissected, and the proper hepatic artery and the common bile duct are ligated and divided separately, leaving the portal vein intact. Prior to the ligation of the common bile duct, a Prolene suture is placed on the antimesenteric border of the duodenum to mark the position of the ampulla of Vater by passing a probe down the common bile duct. The common hepatic artery is isolated to its origin. The left gastric artery is identified, ligated, and transected. The splenic artery is identified and encircled at the celiac trunk. Dissection of the hepatic and splenic arteries is minimized to avoid vasospasm. Mobilization of the pancreas laterally to medially in the region of the portal vein is aided by using the spleen as a handle to minimize trauma to the delicate pancreas and to avoid posttransplant pancreatitis. All divided structures in the retroperitoneal area are ligated. The IMV is ligated at the distal margin of the pancreas.

Heparin is given and the systemic circulation is arrested by clamping the supraceliac aorta. The IVC and portal vein are incised, and cold UW solution is introduced through the aortic cannula to perfuse the pancreas and kidneys. The celiac trunk and SMA are excised with a patch from the aorta. The inferior pancreaticoduodenal arteries, which originate from the SMA, must be preserved. The SMV is transected as it enters the pancreas and ligated.

The duodenal lumen, previously irrigated with 500 ml of 20% betadine and/ or amphotericin B (50 mg/L) solution through a nasogastric tube, is transected using a gastrointestinal (GIA) stapler 4 to 6 cm proximal and distal to the previously marked ampulla of Vater. The mesenteric vessels at the inferior border of the pancreas are divided using a GIA stapler. The duodenum is opened and the lumen is irrigated with amphotericin B solution (50 mg/L). The pancreatic graft, duodenum, and spleen are then removed (Fig. 9.3). A bifurcated iliac vessel is harvested for transplantation. The external iliac artery is anastomosed to the SMA and the internal iliac artery, to the splenic artery.

9.3.2. Pancreas with Liver Procurement

The main technical difference is isolating the vascular supply to both organs. The gastroduodenal artery is ligated when the common hepatic and hepatic arteries are needed for the liver, without compromising the blood supply to the head of the pancreas. In most cases, it is preferable to keep the entire hepatic artery with the liver graft, the most common hepatic arterial anomalies being a replaced right hepatic (accessory) artery originating from the SMA in the hepatoduodenal ligament inferior and lateral to the common bile duct. If present, this is divided at the origin of the SMA at the take-off of the right hepatic artery. A replaced left hepatic artery originating from the left gastric artery in the gastrohepatic ligament,

Figure 9.3. Anterior view: The pancreas is prepared by splenectomy and ligation of the splenic artery and superior mesenteric artery (SMA) and vein (SMV), and the duodenal stump is transected with GIA staples and reinforced with Lembert silk sutures.

if present, is isolated and preserved. Liver preparation is described in an earlier section of this chapter. The IMV is isolated and cannulated for portal perfusion. After the supraceliac aorta is cross-clamped, 21 of cold UW solution is introduced through each of the IMV and distal aortic cannulas.

Upon completion of organ perfusion, the splenic artery is ligated and divided several millimeters distal to its take-off from the celiac trunk; the aorta is divided above and below the origin of the celiac trunk, and the portal vein is divided 2 cm above the superior border of the pancreas. The SMA is divided distal to the origin of interior pancreaticoduodenal artery with an aortic Carrel patch. An iliac arterial graft is obtained from the donor, with the external iliac artery anastomosed to the SMA, and the internal iliac artery is anastomosed to the splenic artery of the pancreatic graft ex vivo.

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