Detailed discussion of the operative technique is beyond the scope of this discussion. Procurement of the pancreas (and kidney, in the case of combined kidney–pancreas transplant) may be performed using open or laparoscopic techniques. The decision to perform one or the other is dependent on the surgical experience of the center. Generally, the laparoscopic approach is preferred due to the superior cosmetic outcome and more rapid convalescence of the donor.

In general, we try to preserve the spleen in order to prevent the potential immunologic sequelae associated with a splenectomy, such as overwhelming postsplenectomy sepsis (OPSS) . In a series of five laparoscopic donors at the University of Minnesota [14], splenectomy was performed because of a nonviable spleen that was recognized at the time of surgery. Based on the open donor pancreatectomy data, there is an 8.5–25 % rate of splenectomy [15, 16]. At the current stage of evolution of this technique, we prefer the hand-assisted approach, because having tactile feedback greatly facilitates safe dissection and partially overcomes the lack of three-dimensional visualization inherent in laparoscopy.

Postoperative care of the donor is similar to that of any patient undergoing major abdominal surgery. A nasogastric tube is left in place until return of bowel function. Hemoglobin, serum amylase, lipase, and glucose levels are followed serially. Persistently elevated amylase and lipase levels suggest pancreatitis, a leak, or pseudocyst formation. Persistent or severe left upper quadrant or left shoulder pain should be evaluated with CT and ^99mTc-sulfur-colloid scan of the spleen to assess splenic viability. If the spleen appears infarcted, a splenectomy should be performed.

A retrospective study from the University of Minnesota from January 1978 to August 2000 reviewed 115 open LD pancreas transplants : 51 pancreas transplant alone (PTA), 32 pancreas after kidney (PAK), and 32 SPK [16]. There were no donor mortalities. Donor complications can include hemorrhage, splenic infarct, abscess, pancreatitis, and pseudocyst formation. Splenectomy was required in 8 % of donors. A recent review documents a rate of splenectomy of 5–15 % [17]. Pseudocysts occurred in 10 % and percutaneous drainage was necessary in 60 %. Within the subset of SPK donors , 20 % required perioperative blood transfusions. Two donors required percutaneous drainage of a noninfected peripancreatic fluid collection [18]. The median donor age was 44 years (range 26–49). The median operative time was 6.9 hours with a median length of stay of 8 days (range 6–24) [16].

Long-term follow-up was possible in 67 patients. The remaining 48 could not be located, refused to participate, lived outside of the US, or were deceased. Ten donors had abnormal HbA1c levels. Three of them required insulin > 6 years postoperatively. One of these donors had a history of gestational diabetes. The other two had predonation BMI > 27 kg/m^2. Consequently, gestational diabetes and elevated BMI are now considered contraindications to donation. Hyperglycemia, however, may have occurred secondary to development of type 2 diabetes. Since 1996, all donors have maintained normal HbA1c levels (4.9 –6.2 %) following these guidelines [16].

From March 1999 to August 2003, five laparoscopic pancreatectomies were performed at the University of Minnesota [14]. The mean donor age was 48.4 years ± 8.7 with a BMI of 23.7 kg/m² ± 3.0. The mean length of surgery for PTA donors was 4.5 ± 0.13 hours and for SPK donors , 7.9 ± 0.38 hours. Mean blood loss was 330 mL ± 228. Once the learning curve has been overcome, however, the laparoscopic approach may actually have shorter operative times, as less dissection is required compared to the open technique. In two of the SPK cases, the donor surgical team had to wait 1.5–2 hours for the recipient team to receive the organs, thus prolonging the operative time for the donor. One splenectomy had to be performed at the time of the donor surgery for a nonviable spleen. No pancreatic leaks or pancreatitis was observed. The average serum glucose was 112 mg/dL ± 11.7 upon discharge. The amylase and lipase on discharge were 72.2 U/L ± 26.3 and 67.2 U/L ± 34.0, respectively. None of the donors have required oral antidiabetic medications or insulin. At 3 years follow-up, the mean postoperative HbA1c was 5.7 % ± 0.2. One donor refused biochemical follow-up. Postoperative stay for the laparoscopic donors was 8 days ± 2. No obvious statistical advantage was observed in terms of decreased hospital stay. However, based on the first handful of laparoscopic cases performed, this may be a function of over-vigilance on the part of the treating team as tends to occur with new procedures. Certainly, in laparoscopic nephrectomy, the advantages of reduced hospital stay and earlier postoperative recovery have been demonstrated [19, 20]. All the donors have reported that they are back to their preoperative state of health and working. Satisfaction was high in terms of cosmetic result because the donor operation can be performed through a relatively small midline incision and only two trocar sites (Fig. 6.3).