Initially, chest and liver surgeons work simultaneously. Following a complete midline incision from the suprasternal notch to the pubis, evaluation of thoracic and abdominal organs is performed, and their viability is confirmed. Some surgeons use a cruciform abdominal incision. It is essential that a full manual and visual exploration is performed to exclude unknown primary or secondary tumors in the abdomen. Ligation of the round ligament and division of the falciform ligament up to the coronary ligament allows the surgeon to analyze the liver for aspect, color, texture, signs of steatosis or ischemia, and visible or palpable lesions. Two anatomical variations are important in liver transplantation : a right accessory hepatic artery or a total hepatic artery replacement originating from the superior mesenteric artery (SMA), which runs posterior or lateral to the portal vein, and a left accessory hepatic artery originating from the left gastric artery by the gastrohepatic ligament (Abid et al. 2008; Hiatt et al. 1994; Todo et al. 1987). The surgeon will check for both anomalies. First, tactile assessment with the index finger of the posterior aspect of the hepatoduodenal ligament is performed to feel the pulse of the anomalous right hepatic artery (present in around 15 % of total cases). However, despite its existence, the pulse is not always perceivable. Therefore, a principle in liver procurement is to act assuming that a right accessory or replaced hepatic artery is present. Second, the left triangular ligament of the liver is incised to allow exploration of the gastrohepatic ligament for the presence of the left accessory hepatic artery, which is present in between 10 % and 13 % of cases.

The Cattel-Braasch and Kocher maneuvers mobilize the cecum, right colon, duodenum, and small bowel en bloc to the left, allowing exposure of the retroperitoneum and inferior vena cava, renal veins, SMA, and infrarenal aorta down to the iliac bifurcation (Cattel and Braasch 1960). The inferior mesenteric artery is identified and divided between ligatures to facilitate later aortic cannulation. The infrarenal aorta should be dissected from right to left to avoid injury of the vena cava and should be encircled with two umbilical tapes for the eventual insertion of a cannula for preservation solution infusion, with special care taken to avoid damage and bleeding of the lumbar arteries that originate on the posterior aortic wall. In certain cases, a polar renal artery may have its origin in this portion of the aorta and can also be injured. In addition, the inferior mesenteric vein (IMV) is identified in the inframesocolic retroperitoneum, lateral to the ligament of Treitz, and referenced with two ligatures for posterior cannulation and portal perfusion.

The SMA, located above the left renal vein, is identified and encircled. The intestine is then repositioned inside the abdomen to allow exploration and dissection of the hepatic hilum. The common bile duct is localized, mobilized, and transected as far as possible, always below the cystic duct. Then, the common hepatic artery is identified and freed of the surrounding tissues; the origin of the gastroduodenal artery is identified and carefully ligated to avoid intimal dissection or stricture of the common hepatic artery. The common hepatic artery is followed till the origin of the splenic and left gastric arteries, which are encircled. In situations in which either an accessory right or left hepatic artery, or both, are found, those arteries require dissection and individualization until their origin with posterior reconstruction during bench surgery.

The portal vein is beneath the gastroduodenal and common hepatic arteries. The portal vein dissection extends down to the confluence of the splenic and superior mesenteric veins (SMVs), providing another site for further cannulation and venous perfusion. Once the portal vein has been cleaned, no further dissection is required in the liver hilum. The SMV, splenic vein, and IMV can also be used for cannulation and portal vein perfusion (Fig. 1). The choice of vein is based on surgeon preference, the organs procured (avoid the SMV in cases of pancreas retrieval), and unstable donor condition (IMV being the preference in this case).

The last step prior to perfusion and cooling is exposure of the supraceliac aorta, which is cross clamped to prevent the cold preservative solution going to the cephalic part of the body and to the extremities, so that the flush can be concentrated into the abdominal organs. The types of supraceliac aortic cross-clamping are shown in Fig. 2. The most frequent site of aortic cross-clamping is at the level of the diaphragmatic crura (Fig. 2a). The most common technique for its exposure is to retract laterally toward the right of the left lateral segment (the left triangular ligament of the liver has already been sectioned) and for an assistant to retract the esophagus and stomach toward the left to expose the diaphragmatic crura. Next, the diaphragmatic crura is longitudinally sectioned, exposing the preaortic fascia, followed by encirclement of the supraceliac aorta with an umbilical tape to allow cross-clamping later. Intercostal or lumbar branches are ordinarily not encountered in this location. In the case of a replaced or accessory left gastric artery, this maneuver might add undue tension, which can injure the accessory left gastric artery. To avoid such tension, the left lateral segment, gastroesophageal junction, and stomach can be retracted to the right side and the spleen retracted downward to expose the right diaphragmatic crura, followed by aortic encirclement (Desai et al. 2014).

Another option is to perform supraceliac aortic cross-clamping at the thorax (Fig. 2b). The stomach is retracted to the right, the spleen is retracted down, and the posterior abdominal side of the left diaphragm is incised. Following division of the left pulmonary ligament, the thoracic aorta is easily identified. In cases in which the thoracic organs are not retrieved, an easier way to encircle the thoracic aorta is to eviscerate the left lung through the sternotomy (Fig. 2c).

Finally, before cannulation and in situ cooling, the gallbladder is incised and washed out with saline solution in order to prevent autolysis of the mucosa of the biliary tract.

Following full heparinization of the donor with 350 units/kg of intravenous sodium heparin, the infrarenal aorta and either a portal, splenic, SMV, or IMV cannula are inserted. The tip of the aortic cannula must be introduced with caution below the origin of the renal arteries for adequate perfusion of the intra-abdominal organs (Fig. 2). Where there is severe aortic atherosclerosis, the cannula is inserted in one of the iliac arteries instead of the aorta. Also, for adequate perfusion of the whole liver, it should be confirmed that the tip of a portal vein cannula is placed in the portal vein trunk instead of one of its branches (left or right portal vein) (Fig. 1a). When the cannula is inserted in the IMV, the tip is advanced superiorly approximately 5 cm. To optimize portal perfusion, the surgeon must be certain that the tip of the cannula is in the portal vein and not directed toward the splenic hilum (Fig. 1b).

The cross-clamping and perfusion sequence is initiated by the cardiac/pulmonary team. Immediate cardioplegic, pulmoplegic, and chilled preservation solution is then perfused through the cannulas for the heart, lungs, and abdominal organs. The vena cava is then immediately vented at the junction with the donor right atrium to permit venous drainage of the abdominal organs, avoiding their congestion. In those situations in which the chest cannot be approached through sternotomy (i.e., previous heart surgery) and the thoracic organs are not retrieved, vena cava venting is performed through the right diaphragm, which is incised following retraction of the liver downward with the surgeon’s left hand.

The donor heart and lungs are immersed in cold solution. Simultaneously, the encircled supraceliac aorta is cross clamped, and perfusion of the abdominal organs with preservation solution starts through the cannula inserted in the infrarenal aorta (18–22 F) and portal vein, splenic vein, or IMV (12–14 Fr) (Figs. 1 and 2). The abdominal organs are immersed in an ice-slush cold solution. The total amount of preservation solution used is guided by blanching of the organs and when the effluent solution through the vented cava changes to a light color. The liver requires 2–4 L of preservation solution through the aorta and 2 L through the portal system. The organs remain in situ until the cold infusion is completed (Renz and Yersiz 2005; Starzl et al. 1984).

The majority of liver procurement teams still consider portal system cold infusion to be mandatory for liver cooling. However, the method of only cannulation and perfusion through the aorta is also effective (de Ville de Goyet et al. 1994; El-Rassi et al. 2005). In this method, the portal system is perfused after the preservation solution crosses the intestinal circulatory bed via the SMA (which is not ligated) and splenic artery. The author has performed such a technique in more than 200 donors (unpublished data) without deleterious effect and with correct post-transplant graft function. This technical modification requires less dissection and cannulation, making it safer in critically unstable donors. The same technique is performed in cases of retrieval of multivisceral grafts, which include the intestine (Abu-Elmagd et al. 2003).