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The Donor Operation
The expeditious assessment and recovery of cadaver organs without surgical injury will always be the central mission of the donor surgeon; however, the current climate of organ scarcity has placed increasing demands upon the donor surgeon that require enhanced skill and experience to routinely perform these procedures so as to extract the maximal potential from the existing cadaver donor pool. Organ procurement organizations (OPOs) have responded to the relative plateau in cadaver donation by expanding potential donor criteria with respect to age, medical comorbidities, high-risk social behaviors, prolonged hospitalization, known congenital anomalies, and partial brain-death criteria. Donors outside traditional donation criteria, termed extended criteria donors , currently represent the largest potential expansion of the existing donor pool. Furthermore, procurement agencies desire maximal utility from each existing donor through the procurement of all possible organs with clinical or research potential. These practices increase demands upon the donor surgeon for skilled assessment, diagnosis, and management of clinical conditions outside the donor organ of interest in addition to the performance of advanced procurement techniques. These techniques must be widely applicable to a broad patient population at a variety of donor facilities and require no specialized equipment or staff.
Evaluation of the Potential Recipient
The donor process begins with complete evaluation of the recipient candidate before departure for the donor medical facility. The potential recipient is evaluated for medical/surgical history, physiological condition, and size of the abdominal compartment. Pertinent medical/surgical history includes blood group, results of serum serological studies (hepatitis B, hepatitis C, human immunodeficiency virus, Epstein-Barr virus, and cytomegalovirus), and intra-abdominal procedures that could affect vascular inflow/outflow. The physiological condition of the recipient candidate is assessed with respect to encephalopathy, coagulopathy, hemodynamic stability, pressor requirements, and potential need for additional organ(s). The goal of this survey is to determine the anticipated needs of the recipient with respect to immediate graft function so that the donor organ can be assessed from this perspective. The potential recipient’s abdominal cavity is assessed for capacity; specifically, the potential of previous intra-abdominal operations to reduce overall abdominal capacity through adhesions, decreased intra-abdominal organ mobility, or scarring of the abdominal wall.
Evaluation of the Potential Donor
It is imperative that the procurement team demonstrate the highest regard for the suffering of donor families and the medical professionals who have valiantly cared for their patient. They have referred their patient to us, and the family has consented to a procedure that will inevitably prolong the grieving process. Procurement teams must recognize these sacrifices and reciprocate through friendly, courteous, and professional conduct at the donor facility. Patient confidentiality must be vigorously upheld, because inadvertent and unknowing contact with donor family members during the course of transporting highly recognizable procurement equipment to the operating room or in other areas of the facility is always possible. By the nature of their illness, donors frequently use many components of the hospital, including emergency services, intensive care, radiology, and surgical services. Thus the donor team is scrutinized from arrival to departure. Arrogant, condescending, or unfriendly actions by a group of individuals who arrive via a high-profile vehicle do immeasurable disservice to the transplant community and belittle the efforts of the donor’s health care professionals and family.
Initial donor assessment addresses hemodynamic stability, support services, and vascular access. The current condition of the donor with respect to oxygenation, hemodynamic stability, vasopressor requirements, urine output, and laboratory data, particularly serum electrolyte levels, is evaluated and optimized. Support equipment and personnel for critical care transport to the operating room are verified. Donor surgeons should participate in transport to the operating room to assist in care and be immediately available in the case of a donor arrest. Lastly, adequate vascular access at sites that will not be affected by the donor operation are verified and secured by the donor surgeon as necessary. Our preference is vascular access above the diaphragm with the use of a central line in the setting of vasopressors or hemodynamic instability. Femoral arterial catheters are acceptable with the caveat that information will be lost with interruption of the infrarenal aorta.
As the donor is prepared for surgery, the donor surgeon has the opportunity to review the medical chart to confirm pertinent details of the past medical history, social history, appropriate documentation of brain death, blood type, and results of serum serological studies. Of particular note is a history of liver disease, diabetes, hypertension, or malignancy in addition to previous intra-abdominal surgery. Is there a behavioral high-risk history?
The hospital course of the donor is reviewed, including date of admission, traumatic injuries, performance of surgical procedures, documented infections, vasopressor requirements, cause of death, and period of cardiac arrest with duration of cardiopulmonary resuscitation. Lastly, a photocopied chart containing all essential clinical and laboratory data is available for packaging with the allograft. The chart should also contain copies of any reports of pathological findings with slides for review.
The Donor Operation: Conventional Adult Liver Procurement
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