Liver Procurement

Category

Description

Dead on arrival: corneas, heart valves, skin, bone, etc., can be recovered since there are no immediate time constraints to minimize tissue injury and there is no requirement for a precisely timed approach to tissue recovery

Unsuccessful resuscitation: patients who suffered a cardiac arrest outside the hospital and underwent unsuccessful cardiopulmonary resuscitation (CPR). Following declaration of death, CPR is continued until the transplant team arrival

III

Awaiting cardiac arrest following withdrawal of care: after the consent of the donor family, organs may be recovered after death is declared from patients with irreversible brain injury or respiratory failure in whom treatment is withdrawn

Cardiac arrest after brain death: a consented brain dead donor has a cardiac arrest before scheduled organ recovery

Cardiac arrest in a hospital patient: like category II originating in hospital

In addition to these general criteria, there are organ-specific criteria for guiding the acceptance of a liver for transplantation. A history of hepatitis or alcoholism is certainly a warning sign, but both livers from HBsAg-positive and/or HCV-positive donors are currently used worldwide, and suitability for transplant must be judged on a case-by-case basis [2–4]. In general, in the case of a marginal liver donor, the intraoperative assessment by the donor surgeon, in addition to liver biopsy pathological evaluation, is the best single piece of information. A 1.5-cm² subcapsular wedge or 2.0-cm-long needle core biopsy from the anterior inferior edge of the liver is advocated in the literature for various processes; a summary of pathological findings in association with suitability of the liver donor for transplant is reported in Table 7.2 [5].

Table 7.2

Features affecting acceptability of liver graft

Pathological finding	Acceptable	Unacceptable
Macrovesicular steatosis	<30 %	≥60 %
Microvesicular steatosis	Any degree	N/A
Fibrosis	Stage 1: mild fibrosis, enlargement of hepatic portal as a result of fibrosis	Stage 3: severe fibrosis with many bridges of fibrosis that link up portal and central areas of the liver
Fibrosis	Stage 2: moderate fibrosis, extending out from the portal areas with rare bridges between portal areas	Stage 4: cirrhosis
Viral hepatitis activity	Grade <5 (Ishak/Knodell)	Grade ≥5 (Ishak/Knodell)
Presence of granulomas	Fibrotic/calcified granulomas	Active granulomas, caseating or noncaseating
Necrosis	<10 %	≥10 %

Once these aspects have been taken into account, the transplant team can start the liver procurement.

7.2 Technical Aspects of Liver Procurement

There are fundamentally two techniques for liver procurement: the traditional standard technique developed by Starzl and the rapid en bloc technique. The standard technique for procurement of the liver (and pancreas) advocates the use of more extensive dissection of the vasculature of abdominal organs prior to cross-clamping. This method has been criticized as being time-consuming and potentially adversely affecting organs, mainly the liver. In addition, a complete dissection of the porta hepatis, and of the pancreas in the case of multiorgan donors, cannot be possible when recovering the liver from hemodynamically unstable donors [6, 7]. A rapid en bloc technique was developed in the mid-1990s to overcome these aspects. For both techniques, excellent exposure is achieved through a complete midline sternal-splitting and abdominal incision.

7.2.1 Standard Technique

A midline laparotomy from the xyphoid to the pubis is performed and the round ligament divided. The intra-abdominal organs are explored to check for eventual malignancies, and the quality of the liver is assessed (Table 7.2): in the absence of contraindications for a transplant, a sternotomy can be performed. Of note, in the presence of prior heart surgery, the complete warm dissection should be made prior to the sternotomy. It is also prudential to isolate and encircle the aorta prior to sternotomy in order to be ready to cannulate in the event of cardiac arrest/injury at thoracotomy. A blunt dissection behind the sternum just below the jugular notch should be performed until the fingertip can be placed retrosternal around the jugular notch. The sternotomy is then performed in a cranial to caudal direction with the sternum saw to avoid left innominate vein injury.

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