| Abstract|| |
Abdominal organ recovery has undergone important changes in concepts and practice in recent years, most importantly in the combined approach to retrieve the liver and pancreas by one surgical team. We studied retrospectively 81 organ donors and their respective recipients that were performed from 1996-1997. We compared the results of organ function, morbidity, mortality, and operative time of two different surgical techniques. Besides the standard technique (group 1), we used a new technique (group 2) that involves pre cross-clamp identification of the superior mesenteric artery (SMA). There was no significant difference in organ function parameters between the two groups supporting the safety of the new technique. However, there was a 50% reduction in the time needed to achieve aortic cross clamping with the new technique. We conclude that this new technique is safe to apply, distinct in reducing organ retrieval time, and easy to learn.
Keywords: Organ recovery, organ retrieval, donor vascular injury, retrieval technique
|How to cite this article:|
Issa S, Al-Bishri S. The Role of Early Identification of Superior Mesenteric Artery in a Modified Technique for Retrieval of Abdominal Organs for Transplantation. Saudi J Kidney Dis Transpl 2008;19:389-96
|How to cite this URL:|
Issa S, Al-Bishri S. The Role of Early Identification of Superior Mesenteric Artery in a Modified Technique for Retrieval of Abdominal Organs for Transplantation. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2020 Jan 17];19:389-96. Available from: http://www.sjkdt.org/text.asp?2008/19/3/389/40498
| Introduction|| |
With the increased demand for pancreatic and liver transplants, combined liver and pancreatic recovery should be a routine procedure.  Due to the anatomy of the vascular pedicles of liver and pancreas, it is preferable that one surgical team recovers abdominal organs as this simplifies logistics.  The integrity of the vascular structures in the vicinity of the superior mesenteric artery (SMA) is of primary importance in the successful transplantation of liver and pancreas regardless of an abnormal vascular anatomy. 
The objective of this study is to describe variation of the surgical technique of combined liver/pancreas/kidney organ recovery, highlight the differences between this method and the standard technique, and discuss the advantages of the newly developed approach.
| Materials and Methods|| |
We studied retrospectively 81 organ donors and their respective recipients that were performed at the University of Alberta Hospital, Edmonton from 1996-1997. We compared the results of organ function, morbidity, mortality, and operative time of two different surgical techniques. Besides the standard technique (group 1), we started a new technique in January 1997 (group 2) that involves pre cross-clamp identification of the superior mesenteric artery (SMA).
The reviewed donor data included location of donor surgery, cause of death, vasopressor use, mean arterial pressure (MAP) on arrival to the operating room (OR) for recovery surgery, blood transfusion during the recovery, incision time, cross-clamp time, time for each organ removed, vascular and surgical injuries during recovery, biopsy of the liver and its result, and the surgeon who retrieved the organs.
The reviewed liver recipient data included age, status at time of transplantation, time of reperfusion, hepatic artery reperfusion time, bile on table, intra-operative use of pressors, blood, and fresh frozen plasma (FFP), and intra-operative technical incidents. The laboratory investigations included Asparatate transferase (AST), Alanine transferase (ALT, prothrombin/INR, total bilirubin, and Lactate levels. Postoperative complications were noted and use of FFP was documented. The reviewed kidneys recipients data included reperfusion time, urine output, successive s. creatinine levels, and cases that needed hemodialysis within the first post operation week.
The cell counts after islets isolation obtained from all suitable retrieved pancreases over the two years were compared. Pancreatic islets were isolated according to technique applied routinely in our institute. ,
We excluded from the study, donors of thoracic organs, split liver and cut down liver recipients, and over 55 years old. This would avoid extended criteria donation and partial liver transplantation that may skew AST and ALT levels.
| Description of Technique|| |
- Midline laparotomy and thoracotomy: from sternal notch to pubis.
- Ligation and division of the falciform and round ligaments.
- Intra-pericardial exposure of the right atrium and inferior vena cava (IVC) junction: The pericardial sac is opened and the right pleural cavity is also entered by a vertical incision of the mediastinal parietal pleura from above towards the hilum of the right lung. Care should be exercised to avoid injuring the pulmonary vessels at the lower part of the pleural incision. The right pleural incision permits pooling of the warm blood in the right thorax.
- Vascular anatomy evaluation.
- Left Lateral ligament division and isolation of the supraceliac aorta only if cardiac recovery team objects to cross clamping of the aorta in its thoracic supradiaphragmatic segment.
- Bile duct dissection and irrigation of the gall bladder with warm saline.
- Division of the ligament of Treitz and identification of the SMA: After dividing the ligament of Treitz, the duodenum is pulled down towards the right pelvis, the root of the mesentery is palpated for pulsation of the SMA distally near the duodenum, the artery is exposed by dividing the overlying tissues, a ligature is passed around the SMA.
- Heparinization and infrarenal aortic canulation. Irrigation of the duodenum with iodine solution (through the nasogastric tube).
- Cross-clamping, internal organ cooling by cold preserving solution flush through aortic canula, and division of cavoatrial junction to achieve exsanguinations; external organ cooling using iced slush.
- Division of the gastrocolic ligament, the gastrosplenic ligament, and the splenocolic attachment. This is followed by reflection of the transverse colon and the right and left colonic angles downwards.
- Division of the gastro hepatic ligament on the wall of the lesser curvature and reflection of the left gastric pedicle towards the liver.
- Ligation and division of the SMA after perfusion with a couple of liters of the preserving solution. To do that, the pancreas is lifted upwards and the ligature on the proximal segment of the superior mesenteric artery is also pulled up vertically, the artery is dissected from the ligature point (near first jejunal branch) to its junction with the aorta. All the tissues overlying the left lateral surface of the artery are divided. Performing this as the first step before any further anatomic mobilization ensures that divided tissue will not include any vital structure and will only involve neuro connective tissue surrounding the SMA at its origin.
- Full Kocherisation More Details of the duodenum from the right to the left until nearly reaching the superior mesenteric vein and the area of the previously dissected SMA. This will expose the IVC and the renal veins as well.
- Using the spleen as a handle, the spleen is reflected medially along with the pancreas until the adrenal gland is encountered. The aortic surface near the SMA, which was dissected previously is now visible from the lateral side, and the tissue between the aorta and the adrenal is divided up to the diaphragm; this includes the diaphragmatic cruss.
- Division of the IVC above the renal veins.
- Keeping the right kidney pulled down, all tissue right, lateral, and cephalad to the SMA is divided. This will include the diaphragmatic cruss on the right side of the aorta, and the right adrenal gland.
- Division of the first part of the duodenum left of the hepatic pedicle, and of the fourth part. Division of the root of mesentery distal to the point of ligature of the SMA. If the pancreas is not harvested for whole organ transplant, it is removed with the liver by dissecting it off the duodenal wall. Removing the pancreas in this way protects any acessory right hepatic artery.
- Complete dissection of the structures holding the liver in the chest and abdomen. This includes: The complete transaction of the IVC above the diaphragm and of the pericardium behind it; the diaphragm around the liver IVC pedicle; the aorta above the area of the clamping; the diaphragm around the ligaments of the right lobe down to the Morrison Pouch.
- After completing the dissection as described above, the liver remains attached by the SMA only; it is noteworthy that the preservation of the vascular integrity so far permits the maintenance of core cooling of the liver, pancreas, and kidneys. In order to proceed and remove the liver, a clamp is placed obliquely between the SMA and the renal arteries (to maintain renal core cooling while the liver is dissected out); the aorta is now transected above the clamp and the liver is removed to the back table.
- The kidneys that remained perfused with the cold solution are next removed from the donor.
| Relevant visceral vascular anatomy|| |
The arterial blood supply originates from the celiac trunk and/or superior mesenteric artery, and the left gastric artery. The most important vascular anomalies that need to be considered are blood supply to the liver originating from the SMA and blood supply to the liver originating from the left gastric artery.
The gastroduodenal artery is the principal artery to the head of the pancreas. In 27% of cases the perfusion of the head and uncus is completely territorial,  i.e. no anastomosis takes place between the gastroduodenal (of the main hepatic) and the inferior pancreatico-duodenal (of the SMA).
Venous drainage of the pancreas is totally to the portal vein and the terminal segment of the superior mesenteric vein, mainly through the gastrocolic trunk and the posterior superior pancreatico duodenal vein.
It is to be noted that the venous collaterals are not satellites of the arteries. 
The technical constraints imposed by the above facts dictate that the branches of the SMA, in its first few centimeters, i.e. the inferior pancreaticoduodenal and an acessory right hepatic branch, be harvested intact and that SMA is divided according to guidelines agreed on between the liver and the pancreas teams. It is important to keep in mind that all these surgically important branches originate from the first few centimeters of the superior lateral right surface of the trunk of the SMA.
The integrity of the portal vein, the last segment of the superior mesenteric vein, and their venous pancreatic branches must also be preserved.
| Role of the SMA|| |
The review of the vascular anatomy of the two organs suggests that the superior mesenteric artery should have a central role in the recovery surgery of the liver/pancreas, and kidneys:
- The SMA is the key to the anatomy of recovery of these organs: It outlines the aortic, and subsequently, the tissue line of division between the liver/pancreas bloc and the bloc of the two kidneys.
- It is essential for successful transplantation of the liver and of the pancreas that the initial segment of the SMA be harvested without injury to any of the vessels (arteries or veins) in its vicinity.
- The SMA maintains a very important anatomic relation to the origin of both renal arteries and the course of the left renal vein.
| Results|| |
[Table - 1] shows that the mean dissection time was substantially less in group 2 compared to group 1 (64 minutes and 116 respectively, p< 0.01). The difference was less pronounced when there was thoracic organs recovery (102 and 135 minutes respectively, p< 0.05). The recovery time was not significantly different (35 and 36 minutes respectively, p> 0.05).
[Table - 2] shows that there was no significant difference observed between the two groups in the peak AST, or its levels at oneweek post transplant. the same was observed of the INR ratio of prothrombin time. The two groups were similar in donor age and the donor MAP and the cold ischemia time.
[Table - 3] shows that there was no significant difference in the incidence of acute tubular necrosis (ATN) between the two groups (26% in both groups), or in the level of creatinine at day 7 and 1 and 6 months.
[Table - 4] shows that there were no instances of primary hepatic non-function in both groups. Again, there was no significant difference in the pancreatic cell counts between the two groups. Three vascular injuries were encountered during organ recovery using the new method but none of these injuries resulted in a non-use of organs.
| Discussion|| |
The results of our study demonstrate that the new method of organ retrieval from deceased donors introduce an easy to learn, an anatomically safe, and fast surgical technique for multiple organ recovery.
Previously, the vascular pedicles of the liver and the pancreas were dissected and prepared separately either by one team or by two teams with each team doing its part of the dissection. Most of dissection took place before cross clamping of the aorta. Organ perfusion took place through aortic and portal canulae.
Three vascular injuries were encountered during organ recovery using the new method but none of these injuries resulted in a nonuse of organs. Previous studies reported 17% rate of injuries  that was higher than the above reported rate in our cohort of donors. However, data in uncompiled files shows a much lower rate following the first year of application; 0.5% of celiac injury, none of renal artery.
There was increasing acceptance of the concept of "en bloc liver/pancreas" recovery over the last few years with one surgical team often harvesting both organs. ,,
In many centers, a trend to decrease the pre cross-clamp dissection has developed including the use of a single perfusion canula in the aorta in some centers. Variable amount of dissection has been described prior to cross clamping. Imagawa et al described the least of this dissection that included deflecting the right colon and the duodenum to the right, canulating the portal system through inferior mesenteric vein, irrigating biliary tree, dissecting aorta, and dividing the gastrocolic ligament. 
The approach to the aorta and the SMA varied depending on the surgeon's preference, some teams would approach the vascular structures from the anterior surface of the aorta in the chest. Some surgeons would still approach the aorta after dividing the left renal vein from the IVC and following the anterior aortic surface,  while others would approach it from the lateral surface after deflecting the spleen and the pancreas medially. In all these reports, the identification of the SMA was confirmed post cross-clamp and included a certain amount of dissection of structures which is beyond the line of separation of the en bloc specimens.
The technique that is described in this paper is different from previous approaches in that:
- It centers the surgical procedure on the SMA: the SMA is considered as a guide to the line of division between the liver/pancreas and the kidneys' blocs. The SMA is identified prior to aortic crossclamp.
- It minimizes the necessity for pre crossclamp dissection by identifying aortic cross-clamping points and canulation of the distal aorta, irrigation of biliary tree, and identification of SMA.
- It applies the concept of aortic-only perfusion, which decreases venous pressure on the sensitive pancreas and decreases pre cross-clamp work. Exception to this would be the donor with potential stenotic atherosclerosis of the celiac orifice.
- This approach is realistically done by one team and eliminates multiple teams. The importance of this has already been stressed in other publications. ,,
- The post cross-clamp dissection: is limited to separating the two blocs of tissues namely the liver/pancreas bloc and the kidneys' bloc, and removing them from the donor. Individual organ separation takes place on the back table.
- The integrity of the vascular tree is maintained throughout the pocedure, which preserves the core cold perfusion of the harvested organs until the organs are removed from the abdominal cavity.
| Acknowledgment|| |
We would like to thank Dr. Ali Hajeer, and Dr. Wael O'hali for their critical review of the manuscript, also we extend our thanks to Dr. N. Kneteman and J. Lakey (University of Alberta, Edmonton) for their participation and help in the description of the procedures in this article.
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Head of Transplant Surgery Division, University of Aleppo, P.O. Box 952, Aleppo
[Table - 1], [Table - 2], [Table - 3], [Table - 4]