Navigation

Surgery

This page is based on information taken from two chapters in Dr. Ingemar J. A. Davidson's book Kidney-Pancreas Transplantation: Detailed Surgical Procedures and Management Protocols, 2nd Edition.

Because Dr. Davidson treats the kidney transplant in a separate chapter from the pancreas transplant, and because I seek to convey the simultaneous nature of the process, I have tried to arrange items according to a rough chronology. The two reference citations ((11)and (12)) indicate which chapter contains each quote. Any text in square brackets [ ] indicates my addition to (or “…” ellipsis from) Dr. Davidson's text.

Also, because the text is designed for surgeons, I skip a great deal of highly technical material, such as suture types, needle sizes, descriptions of hemostats and retractors, et cetera. I hope that what I quote can give an impression of the speed, precision and coordination required of the surgical team.

[Various sources give non-heart beating (NHB) preservation times for pancreas grafts as 12 - 24 hours, and kidney grafts as 24-48 hours. While kidney-pancreas transplants are retrieved from the cadaveric donor with virtual simultaneity, the greater delicacy of the pancreas, and its somewhat longer graft preparation time make pancreas graft procurement the preferred starting point for the entire procedure.]

THE MULTI-ORGAN PROCUREMENT PROCEDURE

The kidney and pancreas organ excision from the brain dead cadaver donor is uniformly part of a larger multi-organ procurement effort. Due to the effect on seven human lives in one surgical setting, the multi-organ procurement procedure is perhaps the most important surgical intervention ever to be performed. (12) …

THE TWO STAGES OF BACK-TABLE WORK

The back-table work takes place at two stages and in two different settings. The first part takes place in the procurement operating room immediately after the removal of the kidneys [as well as the pancreas and liver] en bloc and involves separation of the kidneys, documentation of anatomy and possible reperfusion with the UW solution [the University of Wisconsin Universal Organ Preservation Solution (13)] and packaging. … The second back-table part occurs in the recipient operating room for each individual kidney, immediately prior to the transplant procedure. (12) …

BACK-TABLE WORK IN THE ORGAN RECOVERY [PROCUREMENT] OPERATING ROOM

If the liver and pancreas have been excised separately, there is no need for back-table work in the organ recovery operating room, beyond inspection and packing the pancreas. … The spleen is left attached to the pancreas, to be removed in the recipient operating room. Small pieces of the spleen, however, may be taken and sent with the various organs for tissue typing and crossmatch purposes. In cases of en bloc liver and pancreas excision, the organs have to be separated on the back-table before being packed and shipped. … The procurement surgeon must be familiar with variations in procurement technique. (11)…

Immediately after the kidneys have been removed en bloc, they are placed the back-table in ice slush (Ringer's Lactate or NaCl) solution. The overall anatomy is inspected. The authors prefer to place the kidneys in their normal anatomical position… . The ureters, attached to mosquito hemostats are also placed in their normal anatomical location. The en bloc kidney preparation contains the aorta, divided immediately above the superior mesenteric artery (SMA). In cases of simultaneous pancreas procurement the SMA has been divided next to the aorta. Occasionally, the origin of the SMA with a cuff of anterior wall of aorta is removed with the liver during the final excision in order to preserve a replaced right hepatic (accessory) artery. In such instances, great care is taken not to injure the renal arteries, which may originate at or only a few mm below the SMA. … Rarely, a lower pole artery arises from the common iliac artery. Likewise, a renal artery may originate from the aorta above the SMA, or even [from] the celiac artery, in which case injuries are common to the artery during the final organ excision. Multiple arteries occur in 15-20% of the population, with multiple veins considerably less common. (12) …

ORGAN ANATOMY DOCUMENTATION

The purpose of the back-table work in the procurement OR is 2-fold. First, the kidneys are separated. Second, individual renal anatomy is determined and documented accurately onto appropriate forms for the organ procurement organization (OPO) and the transplant center receiving the kidney. Any injuries or abnormalities must be reported in great detail. … If a transplant surgeon does not think that a kidney is usable for anatomical/technical reasons, then the kidney should not be offered to others unless the exact anatomy and circumstances are reported. (12)

KIDNEY BIOPSY

The back-table work in the procurement operating room usually involves removal of some excess perirenal tissue. Sometimes, when the kidney quality is in question, as in the case of an older hypertensive donor, or in donors with marginal laboratory findings, a biopsy should be performed either using the needle or open biopsy…. (12)

BACK-TABLE WORK IN THE RECIPIENT OPERATING ROOM

The pancreas requires fairly extensive back-table preparation. It is imperative that the surgeons sit down and are comfortable. It is very helpful to place the pancreas in a flat bowl with ice slush, with an OR lap to stabilize the pancreas and prevent it from unnecessary movements. ... One pair donor iliac arteries and vein must be available, and preferably packed with the pancreas, to avoid inadvertently losing this vital tissue. The container with the pancreas is opened under sterile conditions. It is advisable to culture the perfusion fluid surrounding the pancreas as a guide for treatment should fever develop in the recipient's first few post-transplant days. …

A summary of back-table pancreas reconstruction work needed is given. … The spleen is removed by tying individual vessels with 2-0 silk ligature, only towards the pancreas. It is imperative that these are firmly tied since there is a tendency to bleed through these ligatures as the tissues warm up. … The distal portion (Treitz ligament) of the duodenum usually requires further mobilization and shortening by separating it from the pancreas. In cases of bladder anastomosis this excess portion of duodenum is utilized for insertion of the circular stapler prior to its removal. … The catheter used for portal vein cold perfusion from the inferior mesenteric vein (IMV) is removed and the IMV is ligated at the inferior edge of the pancreas. … The arterial reconstruction is performed using a Y graft from the donor iliac arteries…. Usually, the donor hypogastric artery size will match to the splenic artery. The hypogastric artery also naturally makes an appropriate curve, which further makes this artery fit well to the splenic artery. (11)…

If the pancreas has been procured by another team or has been separated on the back-table in an en bloc liver/pancreas removal package, careful attention must be given to the vessels that have been cut. In the author's experience, marked severe bleeding may occur at reperfusion if meticulous tying of multiple cut vessels has not been done during the procurement dissection or at the back-table work. (11)

LEFT RENAL VEIN DISSECTION

The left renal vein is mobilized and divided next to the IVC…. No cuff of the IVC should be taken with the left vein, since this will make right renal vein reconstruction more difficult. Also, the left renal vein is long and needs no extra length; in fact, it often has to be shortened. This will leave the right renal vein ready for reconstruction, depending on the transplant surgeon's preference….

By mobilizing the left renal vein, the anterior aspect of the aorta is entirely exposed…. The authors prefer to divide the anterior wall of the aorta, starting at the SMA, using sharp scissors (i.e., Metzenbaum or Jamison) carefully dividing between the renal arteries, making sure that enough aorta is left on either side to create a patch for the arterial anastomosis. … (12)

Next, the back wall of the aorta is divided between the lumbar arteries…. At this point, the presence of multiple renal arteries is easily assessed. (12)

THE LEFT RENAL ARTERY

The left renal artery is usually attached to the long square aortic patch. If there is a single artery or two arteries close together, these are carefully dissected towards the hilum [the area through which ducts or blood vessels enter and leave an organ or a gland]. … Uniformly there is a branch to the adrenal gland, often arising from an upper pole artery. The adrenal artery is ligated, but the upper polar arteries must be preserved. Should a small upper polar artery inadvertently be injured or ligated, the kidney is still fine for use, but there will be a black area after reperfusion representing a small infarct, depending on artery size. The aortic patch can be created at this time or later, at the time of the implant. Suspicion of a missing lower pole artery…should arise if a single main artery seems to be coming into the kidney a little too high, or is smaller than one would expect in relation to the kidney size. (12)

[Dr. Davidson's description of the somewhat different techniques in handling the right kidney and its vascular structure is omitted since a patient would only receive a single kidney, in my case the left kidney, which is described.]

[ORGAN IMPLANTATION]

… The kidney is most commonly placed in the left iliac fossa as part of this intraperitoneal procedure. Some surgeons place the kidney extra-peritoneally by creating and dissecting a pocket between the peritoneum and the abdominal wall. This technique may facilitate a safer kidney core needle biopsy. In the author's experience involving more than 20 biopsies under ultrasound guidance in kidneys placed intraperitoneally, no technical complications have occurred. The pancreas is usually placed in the right iliac fossa, since the right iliac vessels are slightly more accessible. Also, the authors prefer to use the left kidney in case of simultaneous kidney/pancreas transplant because of the longer vein and the shorter operative time needed to prepare the left kidney. The right kidney is, of course, perfectly fine as well. The pancreas is transplanted first. <11

SKIN INCISION

The authors use a midline incision from the pubic bone to 5 cm above the umbilicus…. Prior to surgery the bladder should be expanded with saline containing an antibiotic (i.e., cefalexin 500 mg in 500 cc 0.9% NaCl) with 200-300 ml usually infused easily in the often enlarged diabetic bladder. The round ligaments in females are ligated and divided. A vessel loop is placed around the spermatic cord in males. … The authors also prepare the midline cystostomy down to the bladder mucosa at this point. The Foley clamp is removed to empty the bladder, which markedly improves exposure and facilitates the often deep placement of the pancreatic portal vein anastomosis. (11)

The intended skin incision is marked with a marking pen. …While the initial skin incision is made with a knife, electrocautery is used through subcutaneous tissue, down to the external iliac muscle fascia. A starting point is obtained through the external iliac fascia, and using a finger, the fascia is divided approximately 2 cm from insertion to the rectus muscle anterior fascia both upwards and downwards…. Towards the pubic bone, the loose connective tissue attached to the lower portion of the rectus muscle is divided. Usually, the authors divide 1-2 cm of the tendinous portion of the rectus muscle insertion on the pubic bone to improve bladder exposure. The rectus muscle is attached again during wound closure. …With a finger under the transversalis fascia, the peritoneum is pushed medially to avoid inadvertent entrance of the abdominal cavity. (12)

MOBILIZATION FOR PANCREAS IMPLANTATION

Two malleable retractors are placed, one to retract the small bowel towards the upper abdomen, and a second to hold the mobilized, empty bladder and the sigmoid colon to the left…. The cecum is usually mobilized by incising the peritoneum and also 5-6 cm along the ileum, which facilitates placement of the tail of the pancreas in the right flank. The cecum mobilization may not be necessary, depending on the anatomy of the individual recipient. …(11)

Some surgeons routinely ligate and divide the hypogastric artery and vein to improve the exposure and facilitate the vascular anastomoses. In the author's experience, this may be necessary in only about 10-15% of the cases…. Some transplant surgeons prefer to make a donor external iliac vein interposition elongation graft on the portal vein. The authors do not think that this is necessary; in fact, it may contribute to venous thrombosis formation or other technical problems. In contrast, a shorter portal vein will fit better when the pancreas is finally set down in the iliac fossa. (11)

THE PORTAL VEIN ANASTOMOSIS

It has been the authors' preference that after the corner stitches have been placed and tied, a retention suture is placed through the back wall to pull it through the front wall to facilitate suturing the back wall from the inside (from the patient's right side). This technique could be used in any vascular anastomosis as dictated by local circumstances and anatomy. In this particular situation, it is usually easier than trying to sew the medial side suture line from the outside. Once the back wall is completed, the retention suture is cut and pulled. … The authors leave the vascular clamps on the external iliac vein while completing the arterial anastomosis. (11)

THE ARTERIAL ANASTOMOSIS

This anastomosis is an end donor common iliac artery to side recipient external iliac artery. Only a short segment of the donor Y graft is used…. The artery is usually placed in an approximately 60 angle to the external iliac artery…. Only a small portion, or approximately 1-2 cm of the common iliac artery from the donor, is used…. After completion of the anastomosis, the authors place Heifetz clamps or velcro bulldogs on the Y graft before releasing the distal external iliac artery velcro clamp. If there is no significant bleeding, then the proximal arterial velcro clamp is removed. A velcro clamp is now placed on the portal vein. Next, the proximal velcro clamp on the external iliac vein is removed. If there is no bleeding the distal iliac clamp is removed. The order in while the clamps are removed is important. By removing the proximal venous clamp first, only slight pressure is applied to the portal vein anastomosis. This allows occasional large leaks or missed branches to be repaired or ligated. Removal of the distal clamp first, while the proximal clamp is still on, may potentially rupture the anastomosis from the high pressure built up in the leg. The temporary clamps on the artery and portal vein are removed to let the pancreas reperfuse. Usually, there are a few significant bleeders on the pancreas needing immediate attention. Hemoclips, mosquito hemostats and sutures are used depending on location, access and the surgeon's preference. Most oozing will stop within a few minutes after letting the pancreas rest, packed in an OR lap. When complete hemostasis is obtained, the exocrine drainage procedure follows. (11)

EXOCRINE DRAINAGE / BLADDER DRAINAGE

According to the UNOS registry, in the United States, the urinary bladder is currently used in 96% of cases as the route for exocrine secretion drainage from the transplanted pancreas. In the simultaneous kidney/pancreas transplant procedure, the bladder is, therefore, used for both the exocrine and ureteral drainage. There are several different techniques described to accomplish this. Perhaps most surgeons use a two-layer handsewn donor duodenum [into which the pancreatic duct empties] to [the] dome of bladder cystostomy. … The excess duodenum is now removed, using a … stapler. … During the kidney implant, the bladder midline cystostomy is left open and packed with gauze to absorb the pancreatic secretions and prevent it from leaking into the abdominal cavity. (11)

[Dr. Davidson goes on to describe the enteric drainage option, which I omit because it is used less frequently, and it does not apply to my case.]

SELECTION OF TRANSPLANT SITE

In an unaffected abdomen, the right iliac fossa is usually chosen for a first kidney transplant…. For patients with a Tenckhoff catheter in place, the contralateral side is usually preferred. … (12)

VASCULAR DISSECTION:

EXTERNAL ILIAC ARTERY

The external iliac artery is mobilized first. The lymph vessels crossing the artery are ligated with 4-0 silk and divided. For the majority of cadaver renal transplants with an available and usable aortic cuff, the external iliac artery is used as the anastomosis site. When there is no aortic cuff available, as is the case in living related transplants, the surgeon may choose to use the hypogastric artery for an end-to-end anastomosis to the renal artery. An end renal artery to side external iliac artery anastomosis without the cuff is technically more challenging and prone to vascular stenosis. (12)

EXTERNAL ILIAC VEIN

The external iliac vein (EIV) is mobilized in a similar fashion. Distally, the circumflex iliac vein is a consistent vessel, which runs across the artery in an upward and lateral direction. Ligation of this vein sometimes will improve the exposure and length of the iliac vessels. During the dissection of the EIV, care should be taken not to tear small venous branches sometimes directed laterally into the psoas muscle or in the retroperitoneal space. If torn, such veins can cause severe bleeding which may be difficult to control. The authors prefer to ligate and divide these veins to increase the mobility of the EIV and avoid inadvertent tearing. (12)

[RENAL] VASCULAR ANASTOMOSES

The kidney is brought into the operating field resting in an OR lap with the vessels dropping through a small hole cut in the middle. The ureter and the lower kidney pole are directed towards the patient's feet. Ice slush is placed around the kidney to keep it cool at all times. This technique is identical to that used for the pancreas….(12)

THE RENAL VEIN ANASTOMOSIS

A small incision is made in the vein, large enough to accommodate an angiocatheter or an angled perfusion cannula attached to a syringe with heparinized saline. By injecting heparinized saline into the vein, it expands slightly and cleans any remaining blood from it. The venotomy is extended using...scissors to match the size of the renal vein…. The correct orientation of the renal vein is assessed using the previously tied adrenal and gonadal veins as markers. The corners are now tied while the assistant slowly drops the kidney into the wound to allow the renal vein to reach the anastomotic site…. Each side is sutured using a running technique. Ideally, one corner is run midway, to be met from the other corner and tied in the middle…. This final midway knot is tied in 6-8 square knots. …It is helpful to tilt the operating table as needed to increase exposure, both for the surgeon and the assistant. … The corner stitches and retention stitches are kept under constant tension by letting rubber shods hang outside the Bookwalter retractor, contributing to the ease of suturing. The venous clamp is kept in place while the arterial anastomosis is completed. (12)

RENAL ARTERY ANASTOMOSIS

If not done previously, the Carrell patch is prepared by appropriate trimming of the aorta around the renal artery…. When there is no aortic patch available, as in the case of living related transplantation, an end renal artery to end hypogastric artery anastomosis is preferred, using a two or four corner stitching technique…. Occasionally, a thromboendarterectomy of a stenotic plaque in the recipient at the bifurcation of the common iliac artery into the hypogastric artery is needed for a technically acceptable end-to-end anastomosis to take place. The end renal artery to side external iliac artery without a patch is technically more challenging and is associated with a higher incidence of post-transplant renal artery stenosis. …

The suturing technique for the arterial anastomosis is similar to that described for the vein…. (12)

REPERFUSION STEPS

Before the vascular clamps are removed, the authors prefer to make sure that the anastomosis is secure by applying a Heifetz clip or a velcro clamp to the renal artery and releasing the distal iliac artery velcro clamp…. If there is significant bleeding or identifiable defect, this is addressed by a single stitch…. Bleeding from needle holes in the external iliac artery will stop with a few minutes of compression. If there is no significant bleeding, the proximal external iliac artery clamp should now be removed.

Similarly, the vein may be checked with a velcro clamp applied close to the hilum, while the venous vascular clamp is removed…. If two separate velcro clamps are used on the vein as shown for the pancreas transplant…, the proximal clamp is removed first. Should the distal venous clamp be released while the proximal is still occluding, potential anastomotic rupture may follow due to high venous pressure build up in the femoral vein. …

Normally, if exact suturing technique was used, extra stitches should not be needed. Again, oozing from needle holes is normal and stops within minutes by packing the wound with gauze or an OR lap. The authors warn against attempting to stop needle hole bleedings with extra stitches, as this will only increase bleeding...and potentially cause major technical problems. Application of a laparotomy sponge with slight pressure for a few minutes will uniformly stop the bleeding and prevent the surgeon from engaging in unnecessary stitching. (12)

[Dr. Davidson next describes the Intravesical Ureteral Implantation technique; however since my surgery uses the technique below, I omit description of the alternative procedure.]

THE EXTRAVESICAL URETERAL IMPLANTATION

The extravesical implant is preferred by many transplant surgeons. The ureter is sewn into a submucosal tunnel in the lateral part of the dome of the bladder from the outside. Even though the steps are similar to that of the intravesical approach, there are several important differences. First, the ureter is spatulated from the posterior view in contrast to the anterior spatulation utilized in the intravesical implant for approximately 10 mm. The final length of the ureter must be determined at this time. The bladder serosal and muscular layers are divided for approximately 5 cm in the lateral upward direction towards the kidney side…to create a mucosal trough as in the Lich-Gregoir reimplant. The mucosa is exposed and opened for about 5 mm…. A proximal corner stitch is placed, as was the case for the intravesical approach, but now, the anastomosis is sewn from the outside…. Next, two distal anchoring corner stitches are placed, both involving bladder muscle to prevent the ureter from dislodging. The two sides between the corners are then addressed. One side maybe sewn from the inside…. Depending on the surgeon's preference, the stitches, intermittent or running, are in close enough proximity to prevent urine leaks. Three or four stitches are also needed between the two distal corner stitches. The proximal corner stitch has to be passed between the bladder and the ureter, (if sewn from outside) to the contralateral side, to complete the other side of the anastomosis, which must also be sewn from the outside…. Next, the muscular layer is folded on top of the ureter and continued for some distance beyond the anastomosis itself constituting the tunnel. It is hard to decide how tight the tunnel can be made. The seromuscular edges are closed over the ureter while a clamp presses the ureter downward toward the bladder lumen…. In this way, the ureter remains free to peristalse within the tunnel. One or more sutures are placed between the ureter and the proximal end of the tunnel in the bladder wall to prevent ureteral retraction…. At this point, the surgeon cannot test the patency of the ureter or inspect urine flow.

Some surgeons prefer slightly different approaches. One variation is a modification of the Barry reimplant. In this case, two transverse incisions are made. The ureter is passed between the two incisions, under the muscular layer, but outside of the bladder mucosa. This is achieved by passing an instrument (such as a tonsil hemostat) and pulling the ureter to the distal exit where the implant is performed as described above. This exposure at the implant site may be less optimal because of the transverse bladder incision compared to the Lich-Gregoir modification. Also, the tunnel is created blindly with some risk of inadvertently placing part of the tunneled ureter inside the bladder. Advantages of the extravesical reimplants compared to the intravesical technique include less bladder dissection leading to less postoperative hematuria, clots and bladder spasm than the intravesical technique. Also, a shorter length of ureter is allowable with the extravesical technique. One disadvantage of the extravesical implant is that they are more tenuous and may require Foley catheter drainage for 6-8 days to minimize the risk of urine leak. (12)

URETERAL STENTS

Some surgeons place ureteral drains, either through the urethra tied to the Foley catheter (outside the urethra) or through the bladder dome as a suprapubic tube. It is the author's opinion that ureteral stents are unnecessary in routine uncomplicated transplants. In fact, we believe these catheters may cause complications such as infection, urine leaks and hematuria, with kidney pelvis clot formation and obstruction. The overall rate of ureteral leak or obstruction in the author's experience at Parkland Memorial Hospital, Dallas, Texas between 1985 and 1990 has been only 2.4% ((11)/451) despite avoidance of routine ureteral stent. In the rare cases when ureteral complications do occur and reimplantation is required, ureteral stenting is recommended for maximal safety and healing of the secondary repair…. (12)

CLOSING TECHNIQUE

The midline incision is closed using interrupted… sutures…. Any absorbable suture material is advised against, since the wound healing process may take many weeks to months. (11)

…Hernia formation, although rare, is likely related technical error and/or inherent fascial weakness rather than the suture material used. The first and inner layer includes the transversalis fascia and muscle and the internal oblique muscle. Great care must be exercised not to inadvertently include peritoneum and the underlying bowel. The authors have been involved in two such cases in 15 years, resulting in one graft loss and one fatality. To avoid such a devastating error, the authors recommend separating the peritoneum off the back wall or the rectus muscle for about 2 cm, giving space for adequate suture bites during closing….

For adequate exposure and safe closure of this inner layer, the authors use two sutures starting in each corner and meeting at the midpoint, tied to each other. The second layer also utilizes a running…suture for the external oblique muscle and fascia. Suturing the subcutaneous tissue or fat is not needed in most cases. The skin is closed with staples or any preferred suture technique.

…Meticulous, atraumatic, exact surgical technique and hemostasis are key components to success. Also, by using restricted electrolyte fluid infusion during the procedure with more colloid administration, the patient will experience less intestinal edema and an earlier return of bowel function…. (12)

[COMPLICATIONS OF BLADDER DRAINED PANCREAS TRANSPLANT]

Bladder drained pancreas transplants are plagued with urological and metabolic complications requiring enteric conversion in 15-20% of most reported series. Hematuria is almost universal and requires intervention in about 30% of cases, such as Foley catheter placement, irrigation and/or cystoscopy for evacuation of clots. Urinary tract infections occur in up to half of all cases, and are likely induced by the irritating effect of the exocrine secretion on the bladder mucosa. The burning pain from urethritis, especially in males, is a severe complication leading to urethral strictures. This requires urological expertise in addition to enteric conversion. Bladder stone formation may occur on the staple or suture line and may be a cause of hematuria. The diagnosis is confirmed and stone removal is performed during a cystoscopy procedure. …Early urine leaks are technical in nature and usually require surgical correction in addition to prolonged Foley catheter urinary drainage. Small urine leaks may be hard to diagnose, and therefore, are sometimes treated with a Foley catheter based on a high degree of suspicion related to symptoms. In cases of infection and sepsis from urine leaks leading to abscess formation, removal of the pancreas at an early stage may be wise in order to avoid major morbidity including death from septic complications. Late leaks occur from the staple line sites at the duodenum and are caused by high pressure in the duodenum during urination. These are, again, usually small leaks and they are often hard to diagnose with a cystogram…. The treatment is Foley catheter placement for six weeks, or enteric conversion, depending on the patient's condition, degree of leak and the surgeon's personal preference. (11)

SURGICAL AND VASCULAR COMPLICATIONS [OF PANCREAS TRANSPLANTATION]

Major surgical complications after pancreas transplantation in our experience have occurred in 10% (4/39) of patients…. The main cause of pancreas losses is vascular thrombosis, which has also occurred in 10% (4/39) of patients. …There seems to be no difference in the incidence of nonurological complications between bladder and intestinal drainage. (11)