Implantation Procedure

In simultaneous kidney-pancreas transplantation, the procedure is usually performed intra-abdominally, with the pancreas placed on the right and the kidney on the left. It is also possible to perform bilateral retroperitoneal dissections. It is believed that there may be more complications with the retroperitoneal approaches but they are more easily managed. In the intra-abdominal approach, a midline incision is usually employed, although some centers use a Pfannenstiel (lower, transverse suprapubic muscle-splitting) incision. For systemic drainage, the colon, cecum, and distal ileum are reflected superiorly. The iliac vessels are exposed after removal of their overlying soft tissue. Mobilization of the iliac vein may involve only a 2-cm length of vein anteriorly, or it may involve circumferential dissection of the vein all the way to the inferior vena cava, with ligation and division of all branches, including the internal iliac. Some believe that the subsequent laxity avoids kinking of the portal iliac anastomosis. The venous anastomosis is performed end-to-side, from donor portal vein to the iliac vein, using continuous 5-0 or 6-0 nonabsorbable suture. The arterial anastomosis is performed in a similar end-to-side fashion from the y graft to the iliac artery. In portal venous drainage, the portal vein of the graft is anastomosed end-to-side to a major tributary of the superior mesenteric vein after lifting the transverse colon cephalad. The donor iliac artery bifurcation graft is brought through a window made in the distal ileal mesentery and anastomosed end-to-side to the right common iliac artery. An innominate artery interposition graft may be necessary to simplify this approach.

For bladder drainage (Fig. 12.1) of exocrine secretions, the projection of the pancreas must be caudal. Dissection proceeds on the surface of the bladder. The duodenocystostomy can be hand sewn with two layers, an inner, absorbable suture and an outer nonabsorble suture. This can be running or interrupted. Alternatively, an end-to-end anastomosis (EEA) stapling device can be employed to perform the duodenocystostomy. For enteric drainage (Fig. 12.2), the projection of the pancreas can be caudal or cephalad. The transplanted duodenum is anastomosed to a segment of distal ileum or a diverted Roux-en-Y limb of recipient jejunum.

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