Deceased-donor kidney and multiorgan retrieval

Operative visualisation

UrOops3D · UroRef · © Nity G

Operative steps

1. Who: the donor after brain death or circulatory death Two donors. The donor after brain death, DBD, has had brainstem death confirmed by two doctors on two sets of tests to the Academy of Medical Royal Colleges code of practice; the heart beats, the ventilator runs, and the retrieval is a controlled operation with a warm dissection before the circulation is stopped. The donor after circulatory death, DCD, is the patient in intensive care in whom treatment is to be withdrawn: death is confirmed after five minutes of absent circulation, and only then does the team begin, against a clock, because the organs have been warm and unperfused since the blood pressure fell. Kidneys tolerate that warm period better than the liver or the pancreas, which is why the kidneys are so often the DCD organs.
2. The team, the consent and the clock The specialist nurse for organ donation has taken consent from the family and checked the register, under deemed consent in England, Wales and Scotland where it applies, with the family still able to object. The National Organ Retrieval Service abdominal team, a lead surgeon, an assistant, a scrub practitioner and a perfusionist, travels with its own instruments, cannulae and preservation fluid; a cardiothoracic team joins for a DBD heart or lungs. Before the knife: a briefing naming the donor, the organs consented, the blood group, the virology, and for DCD the point at which the team stands down, usually if death has not occurred within about three hours of withdrawal, and the functional warm ischaemia limits for each organ.
   where it bites: in DCD the clock runs from the fall in blood pressure, not from the knife; the team is scrubbed and the trolley open before treatment is withdrawn.
3. The incision and the exploration A long midline incision from the xiphisternum to the pubis, extended as a cruciate incision or joined to a sternotomy when the chest is being taken, gives the exposure. In the DBD donor the abdomen is explored first: the liver, the pancreas and the bowel are inspected and palpated for tumour, the kidneys felt through the peritoneum, and any finding that might change allocation is telephoned to the duty office at once. In DCD the exploration waits: the aorta is cannulated within minutes and the inspection is done under cold perfusion. The right colon and the small bowel are then mobilised medially on the root of the mesentery, the Cattell-Braasch manoeuvre, exposing the aorta, the cava, both kidneys and the ureters in one field.
4. The aorta and the cava: dissection and cannulation The infrarenal aorta is dissected just above the bifurcation and encircled with two ties, the inferior mesenteric artery ligated, and the cava beside it exposed for venting. In the DBD donor the supracoeliac aorta is also encircled through the crus of the diaphragm, or the descending thoracic aorta reached through the chest, so that a cross-clamp can go on quickly later. Heparin, about 300 units per kilogram, is given by the anaesthetist and allowed to circulate. The aortic cannula is placed through a transverse aortotomy between the ties, secured, and connected to the perfusion line, air free. In DCD the whole sequence, from skin to aortic cannula, is done in the first few minutes without any other dissection.
   where it bites: a cannula passed up into a renal artery or the superior mesenteric perfuses one organ and starves the rest; it sits in the aorta with the tip below the renal arteries.
5. Cross-clamp, cold perfusion and ice The supracoeliac or thoracic aorta is clamped, the cava is vented into the chest or through a wide cannula into a bag, and the cold preservation fluid runs into the aorta under gravity or pressure: University of Wisconsin or histidine-tryptophan-ketoglutarate solution for a multiorgan retrieval, hypertonic citrate for a kidney-only retrieval, several litres, until the effluent from the cava runs clear and the kidneys are pale and cold. Sterile ice slush is packed around every organ as the perfusion runs. The cold ischaemia clock starts at the cross-clamp. In the DBD donor the ventilator is stopped at this point; in DCD the heart has already stopped and this moment ends the functional warm ischaemia.
   where it bites: a kidney that stays pink and warm while the others blanch has an unperfused artery, accessory or main; it is looked for now and the cannula or the clamp adjusted.
6. The kidneys en bloc or separately The liver and the pancreas leave first, on planes agreed with the team leader so that the coeliac axis, the superior mesenteric artery and the portal vein go with their organs and the renal arteries are never encroached on. The kidneys are then taken en bloc: the ureters are divided low near the bladder with all the tissue between the lower pole, the ureter and the gonadal vein preserved, the aorta and the cava are divided below the cannula and above the renal vessels, and the block of both kidneys, Gerota's fascia intact, is lifted off the posterior abdominal wall by dividing the lumbar vessels behind it. In a small child both kidneys are kept on the aorta and cava for en bloc implantation.
   where it bites: the tissue between lower pole, ureter and gonadal vein carries the ureteric blood supply; a ureter stripped clean here necroses in the recipient.
7. The bench and the packing On the bench in a bowl of ice the block is separated: the aorta is opened along its posterior wall between the lumbar orifices to show both renal artery ostia and any accessory, then divided anteriorly so that each kidney keeps a patch of aorta; the cava is left with the right kidney to lengthen its short vein. Each kidney is inspected for tumour, cysts, scars and injury, the vessels for atheroma and intimal tears, the ureter for length and its tissue. Any doubt is described exactly. Spleen and nodes go for tissue typing, and a biopsy is taken if the donor was marginal. Each kidney is triple-bagged in cold fluid, packed in ice in a labelled box with its side, and the box sealed.
8. Documentation and the recipient centres The kidney is only as good as the paper that travels with it. The retrieval form records the donor identity and blood group, the times of withdrawal, asystole, knife, cross-clamp and cold perfusion, the fluid and its volume, the anatomy of each kidney including every artery and vein and any injury, the ureter length, the biopsy, and the surgeon's judgement of quality. The duty office allocates through the national kidney offering scheme and the recipient centre is telephoned directly about anything unusual. The donor is closed with a running suture and treated with the same respect as any patient, and the family is told the operation is complete. The ischaemia times, warm and cold, decide how long the recipient centre can safely wait.

Complications and immediate saves

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FRCS viva questions

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Evidence and guidance