Replaced (Aberrant) Common Hepatic Artery (RCHA)

Aberrant Replaced
Replaced
Leiden University M edical Center

When RHA arising from the SMA should be suspected :

• when the “proper” hepatic artery is too small

• when the common hepatic artery is not present

• when a prominent pulse/thrill is palpated in the posterior side of hepatoduodenal ligament

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 Variations of aberrant hepatic arteries:

B C

D E
Leiden University M edical Center

A – Normal configuration common hepatic artery arises from celiac trunk

B – Aberrant common hepatic artery arises from SMA
C - Aberrant right hepatic artery arises from SMA
D – Aberrant left hepatic artery arises from SMA
E – Aberrant left hepatic artery arises from GDA ( gastroduodenal artery)

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 BILIARY TREE
Leiden University M edical Center

FLUSH -TO PREVENT AUTOLYSIS

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 Liver

Common hepatic artery

Gastroduodenal artery

Duodenum

Common bile duct

Leiden University M edical Center

VCI

Ligate distal part of the common bile duct about 0.5 – 1.0 cm from the head
of the pancreas and cut it with the scissors.
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 Cut and ligated common bile duct

Duodenum

Portal vein

Cut common bile duct

Leiden University M edical Center

Flush under the low-pressure common bile duct and the intra-hepatic biliary tree.
Make use of warm Ringer or 0.9% saline sterile solution .

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 Head

Pancreas head
Flushed common bile duct

Left
Right Portal vein

Left renal vein

Leiden University M edical Center

VCI
Legs

0.5 – 1.0 cm above the pancreas head free from surrounding tissues
about 0.5 - 1 cm the portal vein (landmark)
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 Head

Liver
Right

Left
Gallbladder
Leiden University M edical Center

Legs
To prevent autolysis of the epithelium of the biliary tree open the gallbladder and
wash it thoroughly with sterile Ringer or 0.9%NaCl solution. In total 200 – 300ml.
Second option ligate the cystic duct – sometimes difficult and danger !
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 Perfect flushed gallbladder
Leiden University M edical Center

The gallbladder has to be free of bile.

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 CBD was cut and flushed with preservation solution Ligated cystic duct

Gallbladder intact
Leiden University M edical Center

What procedure was conducted with gallbladder – cystic duct was ligated
it depends on the surgeon or protocol of procurement center .

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 Cholecystectomy
Leiden University M edical Center

Cholecystectomy was performed during organ procurement , common bile was flushed

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 Small bowel

Arteria en vena
mesenterica superior

Pancreas head
Leiden University M edical Center

Duodenum

Last landmak SMA and SMV if you decided also to perform small bowel procurement.
During my presentation we will procure only pancreas, liver and kidneys but not small bowel.
Leiden University M edical Center

Make the final judgment which organs are suitable for procurement .
Inform transplantation coordinator and the acceptor center about that .

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 Liver left lobe

Liver open biopsy

Liver
Leiden University M edical Center

If you not trust : - take open or needle biopsy and perform pathological examination
- perform ultrasonography
- perform bacteriological examination
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Leiden University M edical Center

Allow the other teams to prepare for perfusion thoracic organs.

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 Thoracic Team
Leiden University M edical Center

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 Head

Right
Left
Leiden University M edical Center

Protect all abdominal organs with 3- 4 wet big gauzes. Liver surface is the best
place for the collection of surgical tools for thoracic surgeons !!!!!!!!!!
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 Lungs

Heart
Leiden University M edical Center

Make an agreement with the others thorax procurement team(s) about :

donor heparinization , vessels cannulation , use of unusual medicines
and their side effects.
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Leiden University M edical Center

Donor heparinization: order to give 25 000 - 35 000 IE Heparin i.v. (adult),

or 300-500 IE Heparin/kg donor weight/i.v. (adults and children)
Remember Heparin will start to work after 3 - 5 minutes.
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 Great abdominal vessels cannulation
Leiden University M edical Center

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 Left

Aorta’s cannula
Aorta

Head Inferior vena

Legs
cava
Leiden University M edical Center

Right
Ligate the aorta and the inferior vena cava close to their bifurcations.
As first cannulate the abdominal aorta and ……
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 Left

Aortic cannula
Aorta

Head Legs
VCI Decompression of the VCI
Leiden University M edical Center

Right
…….. the inferior vena cava. Avoid blood leakage around the cannulas.

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 Left

Greater omentum

Head Legs

VCI cannula
Liver
Leiden University M edical Center

Right

Place back in the physiologic position to the abdominal cavity all mobilized organs.
Avoid torsion or kinking of the mesenteric vessels.

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 START - INTERNAL AND EXTERNAL COOLING
Leiden University M edical Center

ABDOMINAL ORGANS PERFUSION

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 HTK

UW
Leiden University M edical Center

Use one of the most popular organ preservation solutions:

- UW about 75 -100 ml/kg - donor weight
- HTK about 150 -300 ml/kg - donor weight
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 Right
Diaphragm

Liver
Heart

Legs Head
Aorta

Diaphragm
Leiden University M edical Center

Left
Close the abdominal aorta with ligature or vascular clamp under the diaphragm.
If it is very difficult choose the another solution: next slides
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 Left thoracic cavity
Left leaflet of diaphragm
Leiden University M edical Center

Close the abdominal aorta with ligature or vessel clamp diaphragm. Start the cold perfusion
of abdominal organs.

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 Left

Cold sterile Ringer solution

Head Legs
Leiden University M edical Center

Right

Begin also an external cooling of the abdominal organs. Use cold sterile Ringer
or 0.9% NaCl solution and…………………………..

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 Right Head

L
Leiden University M edical Center

Legs Left

…………………and sterile ice or ice-slush. Replace them regularly.

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 Thoracic organ procurement
Leiden University M edical Center

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Leiden University M edical Center

HEART LUNGS

The thoracic organs are taken out in the following order : as first heart
en than lungs separately or heart and the lungs together.

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 Abdominal organs procurement
Leiden University M edical Center

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 Head Left

Jejunum

Right liver lobe

Leiden University M edical Center

Right Legs
Close and divide the duodenum from the jejunum with the Gastrointestinal
Stapling Device (GIA).

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 Right lung

Jejunum

Liver left lobe

Liver - right lobe

Leiden University M edical Center

Divided the duodenum from the jejunum

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 povidone iodine
Leiden University M edical Center

Sterilize the content of the duodenum: through the gastric tube order to inject
20- 50 ml povidone iodine water solution

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 Stomach

Duodenum
Liver
Leiden University M edical Center

Replace the gastric tube from the duodenum to the stomach. Below level
of the pylorus close the GIA, divide the stomach from the duodenum at the level of
the pylorus.
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 Diaphragm

Gastrocolic ligament

Stomach

Lung

Pylorus

Liver
Leiden University M edical Center

Cut hepatogastric and gastrocolic ligament close to the stomach wall starting from the
pylorus……………………………..

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 Pylorus

Stomach

Lung Diaphragm
Esophagus
Leiden University M edical Center

Liver

………up to the oesophagus. If present safe left aberrant hepatic artery

( one more time stay with the scissors close to the stomach wall )

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 Stomach
Leiden University M edical Center

Replace the stomach into the thoracic cavity

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 Picture taken from the head of the donor

Legs

olon
erse c
Transv

Greater omentum

Right
Thoracic aorta clamped in the
left thoracic cavity
Transverse mesocolon
Duodenum
Pancreas
Left side
Right liver lobe
Left liver lobe
Leiden University M edical Center

Stomach

Head
Right lung

The transverse colon together the greater omentum pull down to achieve the optimal

visualization of the pancreas and the left side of transverse mesocolon

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 Picture from the head of the donor
Legs

Left

Right
Transparent transverse mesocolon

pancreas

Liver
Leiden University M edical Center

Head

Use the stapling device (GIA) or scissors and make a small hole in the middle of transverse
mesocolon 4 - 5 cm beneath the lower part of the pancreas

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 Picture taken from the right side of the donor

Left

Transverse
colon

Head
Legs
Pancreas

Stomach
Leiden University M edical Center

Liver
Right

Use the stapling device or scissors and make a small hole in the middle part of
transverse mesocolon 4 - 5 cm beneath the lower part of the pancreas
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 Liver

Duodenum

Transverse mesentery

Transverse colon Pancreas

Leiden University M edical Center

Use the stapling device or scissors to cut the transverse mesocolon 4 - 5 cm

beneath the lower part of the pancreas from the distal part of the duodenum to
the right patient’s side including mesenteric vessels

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 Head Left

Diaphragm

Liver
Spleen

Divided mesenteric vessels

(uncinate process)
Leiden University M edical Center

Duodenum
Right Legs

Divided mesenteric vessels 4 - 5cm below the uncinate process of the pancreas
Try to perform it with small steps using the vascular stapling device.

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 Uncinate process – ventral pancreas -
variations

Reaches across SMV, no SMA

Does not reach SM vessels

Reaches beyond SMV&SMA

Leiden University M edical Center

Uncinate process: - highly variable in size and shape,

- lies between the aorta, SMA and SMV
- present in 90% in 10% maybe absent*
* Skandalakis’ Surgical Anatomy. The Embryologic and Anatomic Basis of Modern Surgery 1st ed. 2004, Paschalidis Medical Publishers, Athens
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VENOUS DRAINAGE OF THE PANCREAS
ANTERIOR SIDE

Contemporary Surgery 1979

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 Splenic flexure of the colon

Spleen
Liver
Leiden University M edical Center

Use the stapling device or scissors to cut the transverse mesocolon 4 - 5 cm

beneath the lower part of the pancreas to the left side up to the spleen and
splenic flexure of the colon.
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 Spleen

Splenic flexure of the colon

Leiden University M edical Center

With the scissors free the splenic flexure and descending colon up to the end
of the sigmoid colon . Pay a special attention for the left ureter

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 Donor’s legs

Bowels

Liver
Leiden University M edical Center

Replace the bowels outside the abdomen, put them on the upper legs of the
donor

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 Picture from the legs of the donor
Head

Left

Left liver lobe

Diaphragm

Sple
en

Pancreas

Gallbladder
Leiden University M edical Center

Aorta
Right Legs

The operation field is clear and stable.

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 Picture from the right side of the donor

Stomach

Spleen

re a s
Liver

Panc
Aorta’s cannu
la

Duodenum
Gallbladder
Leiden University M edical Center

The operation field is clear and stable. Almost no blood.

Start vascular splitting between the liver and the pancreas.

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