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Fig. 63.6 Liver steatosis macroscopic aspect (left), normal (right) (from the photo collection of Genadyi Vatachki Roumenov)
F. Botea et al.
• focal liver lesions (a biopsy with freeze section examina­tion is required).
Fatty liver grafts carry an increased risk of primary non-
function (PNF). Steatosis between 10% and 30% is accept­able as a marginal graft; some centers may even accept steatosis up to 60% [13].
Next, the colon, rectum, kidneys, and pelvic organs (in
female donors) are inspected for malignancies. Any abnor­mal nding should be documented and reported to the trans­plant center, including biopsies.
Once the inspection is complete, the surgeon may proceed
with the sternotomy. Then, the pericardium is opened for an appropriate exposure of the pericardial IVC; even if the heart is not procured, this step is also essential for keeping track of the heart movements and taking adequate measures in case cardiac arrest should occur.
The left lobe is mobilized, and the lesser sac is inspected
for an aberrant left hepatic artery (ALHA) (Fig.63.7a), then incised, preserving the artery if present. The right aspect of the porta hepatis is palpated for detecting an aberrant right hepatic artery (ARHA).
Possible arterial variations at this level are best classied
by Varotti etal. [14]:
• Type 1—a single hepatic artery (HA) emerging from the celiac trunk;
• Type 2A—HA from the celiac trunk, giving both right and left HAs; left accessory HA emerging from the left gastric artery (LGA);
• Type 2B—HA from the celiac trunk, giving only a right HA; left HA from the LGA (replaced left HA);
• Type 3A—HA from the celiac trunk, giving both right and left HAs; right accessory HA from the superior mes­enteric artery (SMA);
• Type 3B—right HA from SMA, and left HA from LGA;
• Type 4A—HA from the celiac trunk, and two accessory HAs: right accessory HA from SMA, and left accessory HA from LGA;
• Type 4B—HA from SMA, giving both right and left HAs; left accessory HA from LGA;
• Type 5—a single HA from SMA (Fig.63.7b) [15].
According to a meta-analysis, classic branching of the com­mon HA from the celiac trunk is seen in 55–60% of cases, while variations in hepatic arterial anatomy are observed in 40–45% of cases.
The liver hilum can be palpated from the left through the
lesser sac. The presence of a posterior pulsation suggests a right HA originating from the SMA.Placed posterior to the duodenum, the right HAs stemming from the SMA come in several trajectory variations, in relation to the head of the pancreas: in the sagittal plane—posterior to the pancreatic head or through it, and in frontal plane—more lateral or medial in relation to the portal vein and splenomesenteric conuent, respectively. In this area, a HA originating from the celiac trunk or even from the aorta should be considered. (Fig.63.7c and d).
Early proper identication of liver arterial anatomy is the
key to a safe retrieval procedure. For example, a right HA coming from a low bifurcation of the proper HA may be con­fused with an aberrant right HA originating from the SMA.An aberrant right HA has a cranio-caudal trajectory, whereas in case of a low bifurcation, the right HA presents
63 Liver Graft Retrieval inDeceased Donors
a b
cd
479
Fig. 63.7 (a) Aberrant left hepatic artery originating from left gastric artery. (b) Common hepatic artery originating from the superior mesenteric
artery. (c) ARHA originating from celiac trunk. (d) Common hepatic artery originating directly from the aorta (from the photo collection of Genadyi Vatachki Roumenov)
an angulation from medial to lateral, followed by an ascend­ing trajectory. The angulation spot is predisposed to acciden­tal injury if the two variations are not identied correctly. A low bifurcation of the HA, below the emergence of the gas­troduodenal artery, may be present in 6% of cases (Fig.63.8).
By placing a ne bulldog clamp on a suspected aberrant artery, the surgeon can distinguish between an aberrant right HA and an artery of the common bile duct (CBD): clamping the aberrant artery may cause a visible ischemic delimitation
on the liver parenchyma. The same method may identify an accessory left HA emerging from the LGA: the presence of a pulse distal to the bulldog placed on the aberrant HA indi­cates anastomotic arterial collaterals in the hilum.
The line of Told is incised to mobilize the colon and small bowel completely from the retroperitoneum (Cattell­Braasch maneuver), exposing the IVC, towards the left renal vein, and the aorta, up to the origin of the SMA (Fig.63.9) [16]. Dissection continues cephalad from the right iliac
480
Fig. 63.8 Low bifurcation of common hepatic artery exposed after
mobilization of the pancreatic head (from the photo collection of Genadyi Vatachki Roumenov)
artery towards the portal vein, and medially, to completely mobilize the head of the pancreas. Last, the surgeon places the index nger through the foramen of Winslow, posterior to the liver hilum, to expose and incise the connective tissue medially to the origin of the SMA, completing the mobiliza­tion maneuver [1].
If the donor is hemodynamically unstable, the surgeon may proceed with aortic cannulation at this point and com­plete dissection in the cold phase.
After cholecystostomy, the CBD is identied, ligated above the head of the pancreas, as distally as possible, sec­tioned, and ushed through the gallbladder followed by cho­lecystectomy. The pyloric and gastroduodenal arteries are identied and ligated; it is recommended to keep the gastro­duodenal artery stump if possible, to facilitate blood ow assessment of the HA in the recipient, or even thrombec­tomy. Next the common HA is dissected along its axis, the LGA and splenic artery are identied and ligated preserving 5–10mm stumps, followed by a good exposure of the celiac trunk. The extensive dissection of the celiac trunk must be done with utmost attention to avoid injuring the diaphrag­matic arteries, which stem from its base. Exposure of the infra-diaphragmatic aorta is achieved by transversely sec­tioning the right diaphragmatic crus, and a vascular tie is passed around the aorta at this level (Fig.63.10).
Alternatively, a tie may be passed around the aorta above the diaphragm by sectioning the inferior portion of the left pulmonary ligament, called the transpericardic transpleural approach. Circumferential dissection of the aorta at this level
F. Botea et al.
Fig. 63.9 Cattell-Braasch maneuver exposing the major vessels in the
retroperitoneum (from the photo collection of Genadyi Vatachki Roumenov)
is preferably done under digital control, to prevent injuring any vertebral arteries.
The inferior mesenteric vein is then dissected at the Treitz’s ligament and cannulated; after insertion, the portal cannula is placed in the PV.Alternatively, the cannula may be placed directly into the PV (Fig.63.11). This maneuver should be followed by cross-clamping, to minimize the lack of portal blood ow. Alternatively, the cannula may be inserted directly into the PV (in the portion located posteri­orly to the duodenum, or via the superior mesenteric vein. The patency of the portal cannula is conrmed by aspiration, followed by heparinized saline solution bolus infusion.
The dissection of the aorta is carried out above the iliac bifurcation by ligating and sectioning the inferior mesenteric artery. At this level, the aorta is ligated distally and cannulated (Fig.63.11). The patency of the aortic cannula is checked by aspiration, followed by heparinized saline solution bolus infu-
63 Liver Graft Retrieval inDeceased Donors
Fig. 63.10 Celiac trunk dissected circumferentially (left). Aortic ties positioned for cross-clamping (right) (from the photo collection of Genadyi
Vatachki Roumenov)
481
sion. Bleeding from the aortic cannulation level may originate from a lumbar artery, which must be identied and sutured.
The IVC must also be identied and dissected at this level. A systemic heparin bolus is administered (300 UI/kg), followed by a 3-minute waiting time, allowing a full sys­temic circuit.
63.4.1.1 Cross-clamping
This maneuver consists of several steps that isolate the arte­rial and portal pathways of the abdominal organs in a closed circuit that is ushed with preservation solution and emptied through the IVC:
• clamping the infra-diaphragmatic aorta (by ligation);
• ushing the abdominal organs with cold preservation
solution through the cannulas placed in the PV (1ml/g of
liver tissue, or 2 liters) and aorta (3ml/g of liver tissue, or
5 liters);
• the IVC is sectioned inferior to the right atrium and above
the iliac veins;
• topic cooling for the abdominal organs is applied by ll-
ing the abdomen with sterile ice;
• a clamp may also be placed on the mesentery root to
exclude the intestines from the circuit.
After cross-clamping, the liver graft is detached en-bloc with a diaphragm patch. The retrohepatic IVC is dissected cau-
dally and sectioned above the renal vein ostium. The PV is sectioned above the pancreas head, leaving a 1-cm stump distally if the pancreas is also retrieved. The aorta is sec­tioned above and below the celiac trunk, and completely dis­sected from its posterior attachments. The liver graft is now removed from the donor.

63.4.2 Technical Variants

63.4.2.1 Split Liver Retrieval
This type of retrieval is used to split the graft between 2 recipients. The split may be done between segments II-III and the rest of the liver (pediatric and adult split), or between segments II-III-IV and the rest of the liver (adult and adult split). Splitting may be difcult due to varying vascular and biliary anatomy. It is worth mentioning that certain arterial anatomical variants favor the splitting, such as types 2B and 3B according to Varotti’s classication.
In-situ splitting requires separation of the liver before cross-clamping. The donor must meet the following criteria: optimal liver quality, medium-large size graft, and stable donor. The advantages of in-situ over ex-situ splitting are:
• optimal hemostasis of the liver cut surface, especially
when transection is carried out with an ultrasound
dissector,
482
F. Botea et al.
Fig. 63.11 Cannulation of the portal vein (left) and aorta (right) (from the photo collection of Genadyi Vatachki Roumenov)
• allows the assessment of the viability of both hepatic grafts.
• allows a meticulous transection facilitating the identica­tion of veins with caliber larger than 5mm (requiring recon­struction), and of aberrant vascular and biliary anatomy.
retrieved and separated on the back-table. For pancreas retrieval, the GDA and splenic artery are not ligated. The organs may be transplanted together, as a ‘cluster’ transplant, which has very few indications. During this type of retrieval, the ‘no touch technique’ is used for the pancreas, which is indirectly mobilized by using the spleen as “handle” (which
In ex-situ split liver retrieval, the liver graft is split after
is later removed on the back-table). retrieval, on the “back-table”. The advantages of ex-situ splitting are the reduced operating time and the diminished
63.4.2.3 En-bloc Liver-bowel Retrieval
demand for resources.
This type of retrieval involves bowel preparation and lavage
63.4.2.2 En-bloc Liver-pancreas Retrieval
En-bloc retrieval of the two organs requires an aortic patch that includes the celiac trunk and SMA (Fig.63.12). After mobilization of the organs and cross-clamping, the grafts are
through a nasojejunal tube with saline solution and antibiot-
ics. The jejunum is sealed with stapler close to the angle of
Treitz, marking the area with a suture thread for later orienta-
tion. The transvers mesocolon is sectioned and the right
63 Liver Graft Retrieval inDeceased Donors
483
colon vascularization is ligated. The pancreas is separated from the portal and superior mesenteric vein and then tran­section at level of the pancreatic isthmus. In the event of an unstable donor, separation from the pancreas may also be done on the back-table. Stapling the ileum is performed as late as possible, to allow the complete evacuation of the intestinal content into the colon. The hepatic and intestinal grafts are lifted together with celiac trunk, SMA and aortic patch (Carell patch), which can be extended on the back-
table using an iliac graft [17]. An “in-vivo” dissection of the
liver hilum is recommended by some authors, to reduce the
back-table organ separation time by early identication of
anatomical variants [18].

63.4.3 Back-table

The graft is then moved to the back-table and positioned. The
liver graft is perfused on the back-table with preservation
solution through the PV and HA (Fig.63.13). Flushing the
CBD is also done in order to avoid autolysis of the biliary tree
epithelium under the effect of the remnant bile during cold
Fig. 63.12 En-bloc liver and kidney retrieval in pediatric donor (from
the photo collection of Genadyi Vatachki Roumenov)
Fig. 63.13 Back-table dissection and perfusion (from the photo col-
lection of Genadyi Vatachki Roumenov)
Fig. 63.14 Varotti 4A reconstruction on the back table and in recipient (from the photo collection of Genadyi Vatachki Roumenov)
484
F. Botea et al.
ischemia time. Uniform discoloration of the liver and outow of clear preservation uid through the hepatic veins are proof of a proper ushing of the liver graft [17, 19]. The excess of connective tissue and the portion of diaphragm attached to the liver graft are also removed on the back-table.
The IVC is prepared for anastomosis depending on the technique used in the recipient: a termino-terminal (T-T) anastomosis between the recipient’s and donor’s and IVCs, a termino-lateral (T-L) anastomosis between the cranial extrem­ity of the donor’s IVC and the recipient’s IVC anastomosis, after sealing both ends of the latter (the piggy back tech­nique), a latero-lateral (L-L) anastomosis (the Belghiti tech­nique), or a L-L anastomosis using the triangulation technique (the triangle is fashioned by an transversal incision on the anterior wall of the recipient’s IVC, uniting the ostiums of the hepatic veins, combined with a longitudinal incision).
The hepatic pedicle elements are prepared for anastomo­sis. The portal vein and hepatic artery are checked again to assure all branches are properly sealed, by infusing sterile saline solution with a relative pressure.
If arterial variations are present, they are reconstructed and prepared for implantation (Fig. 63.14). The common
practice in arterial anatomical variations is to reduce the anastomotic partner to a single arterial trajectory of conve­nient caliber. When a right HA originates from SMA, the celiac trunk and SMA aortic patches are sutured together. The distal portion of the SMA is connected to the recipient’s HA.The right HA can also be T-T anastomosed to the GDA or splenic artery stumps; in this case, the anastomotic partner of the recipient’s HA is the aortic patch corresponding to the celiac trunk. There is no need for arterial reconstruction in case of a left HA stemming from the LGA.
If the recipient’s HA does not achieve an acceptable blood ow, the liver can be vascularized by an arterial graft interposi­tion (donor’s iliac artery) or implant the celiac trunk patch of the graft directly into the aorta distal to the origin of the renal veins.
After the preparation of the graft is completed, the liver is packed in three separate sterile bags with saline solution between each one for extra protection during transportation.
The recommended period of cold ischemia (the interval between cross-clamping and nishing the cavo-caval and porto-portal anastomoses with subsequent declamping) is less than 12hours, since the liver graft quality declines after this period [19].
Fig. 63.15 Abnormal trajectory of the IVC (left). Horse-shoe kidney (with 4 arteries, 3 veins and 2 urethers), positioned anterior to the aorta and
IVC; a surprising obstacle during Cattell-Braasch maneuver (right) (from the photo collection of Genadyi Vatachki Roumenov)
63 Liver Graft Retrieval inDeceased Donors
485
63.4.3.1 Incidents: Accidents
In a multiorgan retrieval, a wide array of unforeseen situations may arise due to donor instability, challenges generated by shar­ing the vascular capacity of the donor between retrieval teams, failure to recognize the anatomical vascular variants with conse­quent vascular injuries, or issues related to logistics (Fig.63.15).
In case of an unstable donor or even cardiac arrest during
retrieval, the next steps should be followed:
• systemic heparin administration—a bolus of 300U/kg;
• aorta cannulation only (portal vein cannulation and perfu­sion are done on the “back-table”)
• cross-clamping as fast as possible in order to avoid pro­longed organ ischemia;
• cold phase dissection of the vessels followed by hepatic graft extraction [18, 20].
If cardiac arrest occurs, the donor status changes to a type IV cardiac arrest donor (according to the Maastricht classica­tion). Cardiac arrest in a DBD donor is followed by section­ing of the IVC (venting), aortic cannulation and infusion with cold preservation solution, followed by clamping of the aorta, sterile ice cooling, portal vein cannulation, and liver graft extraction.
In case of a damaged or short IVC, the liver graft can be
salvaged by reconstructive augmentation with venous grafts from the iliac veins.
During retrieval, if an accessory branch of right HA origi-
nating from SMA is injured, the management depends on when the injury was produced—before or after cross-clamping:
• before cross-clamping: proceeds with cross-clamping and separate infusion of the injured vessel through a thin cath­eter, to obtain a uniform ushing of the liver graft. After graft extraction, the injured branch will be re-attached to the GDA or splenic artery stump, on the back-table;
• after cross-clamping: the above-mentioned vascular reconstruction will be carried out on the back-table.
Sometimes, due to logistic or transportation reasons, the retrieval time must be cut short. For a shorter retrieval time, the surgeon may also exclude back-table time completely and carry it out at the transplantation center [12, 21].
The procedure must always be adapted to all contributing
factors linked to the donor.
In conclusion, the key points of a successful retrieval are
optimal retrieval technique, thorough ushing of the graft, and minimal warm and cold ischemia time.

References

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deceased- organ- donor- rate- in- europe/.
3. https://www.odt.nhs.uk/deceased- donation/best- practice- guidance/
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4. Thuong M, Ruiz A, Evrard P, etal. New classication of donation after circulatory death donors denitions and terminology. Transpl Int. 2016;29:749–59. https://doi.org/10.1111/tri.12776.
5. Goila AK, Pawar M.The diagnosis of brain death. Indian J Crit Care Med. 2009;13(1):7–11. https://doi.org/10.4103/0972- 5229.53108.
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8. Nair A, Hashimoto K. Extended criteria donors in liver transplantation- from marginality to mainstream. Hepatobiliary Surg Nutr. 2018;7(5):386–8. https://doi.org/10.21037/hbsn.2018.06.08.
9. Mergental H, Laing RW, Kirkham AJ, et al. Transplantation of discarded livers following viability testing with normothermic machine perfusion. Nat Commun. 2020;11:2939. https://doi.
org/10.1038/s41467- 020- 16251- 3.
10. Imagawa DK, Olthoff KM, Yersiz H, et al. Rapid en bloc tech­nique for pancreas-liver procurement. Improved early liver function. Transplantation. 1996;61(11):1605–9. https://doi.
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13. McCormack L, Petrowsky H, Jochum W, et al. Use of severely steatotic grafts in liver transplantation: a matched case-control study. Ann Surg. 2007;246(6):940–6.; discussion 946-8. https://doi.
org/10.1097/SLA.0b013e31815c2a3f.
14. Varotti G, Gondolesi GE, Goldman J, et al. Anatomic variations in right liver living donors. J Am Coll Surg. 2004;198(4):577–82.
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18. Di BF, De RN, Masetti M, et al. Hepatic hilum manage­ment in 250 liver-multivisceral procurements. Transplant Proc. 2006;38(4):1068.
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Deceased Donor Liver Transplantation: ThePendulum ofVisions andIdeas
JanLerut andQuirinoLai
64
Abstract
During the second half of the twentieth-century, liver transplantation (LT) became a clinical reality. Many tech­nical, medical, physiologic, and immunological hurdles needed to be taken to make this endeavour successful. Starzl stated already in 1989 that “the conceptual appeal of liver transplantation would become so great that the procedure should come to mind as a last resort for virtu­ally every patient with lethal hepatic disease.” Technical perfection and the introduction in the 80s of the selective immunosuppressive drugs cyclosporine A and tacrolimus transformed LT into a routine procedure. Since then, signs of progress have been spectacular. The number of proce­dures applied to more than 50 different benign and malig­nant liver diseases has grown exponentially, reaching the 400,000 marks nowadays.
This chapter deals with different aspects of this medi­cal adventure, such as developed in the context of deceased donor LT experiences. The concept of this chap­ter is based on the “pendulum” of visions and ideas. Indeed, nearly all historical observations and descriptions made and written down by Starzl in his 1969 classical textbook, “Experience in Hepatic Transplantation,” have been conrmed many decades later. This “closing circle concept” will be highlighted at the beginning of each sec­tion by recalling a visionary quote of Starzl followed by the current status of LT (Starzl, Experience in liver trans­plantation. WB Saunders Company, Philadelphia, 1969).
J. Lerut (*) Institute for Experimental and Clinical Research [IREC], Université catholique Louvain (UCL), Brussels, Belgium e-mail: Jan.lerut@uclouvain.be
Q. Lai General Surgery and Organ Transplantation Unit, Sapienza University of Rome, Rome, Italy

64.1 Introduction

There are clear signs that homotransplantation of the liver will be a valuable means in the future of treating patients who have otherwise hopeless prognosis from hepatic disease
(Th. E. Starzl foreword book Experience in Hepatic Transplantation)
Liver transplantation (LT) has turned from a dream into a reality. The rst attempts of canine LT covered a one-page short letter by St.Welch in 1955 in the ‘Transplantation Bulletin,’ a supplement of the Journal of Plastic and Reconstructive Surgery. At that time, a transplantation jour­nal did even not exist! Later on, it was discovered that the Milanese surgeon V.Staudacher had realized the rst experi­ments in 1952. Starzl’s large animal experience resulted in the “rst LT experiment in human” on March 26, 1963 [1]. Twenty years later, the National Institute of Health Consensus Development Conference based on only 540 LTs performed in Denver-Pittsburgh, Hannover, Cambridge, and Groningen, concluded that LT was “a promising alternative to current therapy in the management of late phase of several forms of severe liver diseases.” Moreover, the Committee declared that LT had the potential to become a “clinical service” instead of an experimental procedure. This consensus con­ference’s results represented the starting point for the high­speed implementation of LT as a curative treatment of many livers and liver-based diseases [14]. From 1960 to 1990, knowledge was almost exclusively based on deceased donor LT experiences. From 1990 onwards, living donor LT (LDLT) expanded further knowledge about surgical tech­nique, physiology, and peri-operative care [5]. The LDLT experience will undoubtedly lead to the full development of all other technical LT variants, badly needed to overcome allograft shortage and optimize liver recipients’ surgical and medical care [5].
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 M. Makuuchi et al. (eds.), The IASGO Textbook of Multi-Disciplinary Management of Hepato-Pancreato-Biliary Diseases,
https://doi.org/10.1007/978-981-19-0063-1_64
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