Donor and recipient blood types are confirmed. Time-out is performed according to current UNOS guidelines. After consent is achieved, the donor is placed on the operating table in the supine position and ventilated with 100% oxygen. Exposure for organ harvesting is provided by a longitudinal midline incision that extends from the suprasternal notch to the symphysis pubis (Fig. 109.1A). This incision provides sufficient exposure of and access to the heart, lungs, and abdominal viscera.

The sternum is split with an electric saw or a Lebsche knife; hemostasis of the cut surface is achieved with electrocautery
and bone wax. A sternal retractor with spikes is placed in the lower third of the sternum and spread laterally. A special large Balfour retractor with teeth is used for the abdomen (Fig. 109.1B). The heart and liver teams usually start the dissection simultaneously. The kidneys can be dissected free and easily removed after flushing of the graft and the liver and pancreas are removed.

Generally, left and right medial visceral rotations will already have been completed by teams procuring liver, pancreas, or bowel. However, if not done, Mattox maneuver and Kocher–Cattell maneuver at this stage (prior to heparinization) facilitate kidney dissection later in the procedure. Dissection to expose the left renal vein insertion into the inferior vena cava is desirable. Dissect the terminal aorta free. Divide the inferior mesenteric artery between ligatures and place two umbilical tapes around the terminal aorta (Fig. 109.2A). As a last step in the preparatory dissection, encircle the supraceliac aorta with an umbilical tape after separating the muscle fibers of the diaphragmatic crura longitudinally in a blunt fashion and incising the preaortic fascia. This step is omitted if the heart is not procured because the descending aorta can be cross-clamped in the left pleural cavity without preliminary dissection.

Heparin at a dose of 300 to 500 U/kg should be administered intravenously 3 minutes before cross-clamping. For a nonheart-beating donor, the dosage of heparin should be doubled. Tie the terminal aorta with an umbilical tape. Insert the aortic cannula into the terminal aorta (Fig. 109.2B) while controlling the aorta with the left hand proximal to the aortotomy. Position the tip of the aortic cannula below the renal artery to avoid blocking perfusion of renal artery. Secure the aortic cannula with the other, more proximal umbilical tape.

Apply a vascular clamp on the supraceliac aorta and perfuse the kidneys through the terminal aortic cannula with 2 L of preservation solution. At the same time, vent the supradiaphragmatic vena cava, to prevent venous engorgement and to drain flush solution from the operative field. Apply slush to the abdominal and thoracic cavities to cool the organs.

The paracolic gutters lie lateral to the colon and are limited medially by the retroperitoneal colon (ascending or descending) and its serosal covering, which became fused with parietal peritoneum during development. The white line of Toldt, visible in the angle between the parietal peritoneum and the lateral colon, marks the location of the fusion plane between original serosa or mesocolon and parietal peritoneum. Dissection in the fusion plane, from colon to midline, results in no damage to structures and minimal blood loss.

The gonadal vessels are the first major retroperitoneal structures encountered just superior to the pelvic brim. The right gonadal vein (a tributary of the inferior vena cava) and artery (an anterolateral branch of the aorta slightly inferior to the renal arteries) should be encountered as they cross the external iliac vessels somewhat lateral to the ureter. The ureter is just medial to these vessels.

More superiorly, Gerota fascia (enclosing the right kidney, suprarenal gland, and perirenal fat) will be exposed as the hepatic flexure is mobilized. Further medial mobilization of the colon will expose the C-loop of the duodenum, encompassing the head of the pancreas. These retroperitoneal structures are in direct contact with the anterior surface of Gerota fascia. Further
medial mobilization of the right colon, terminal ileum, duodenum, and head of the pancreas will expose the entire infrahepatic inferior vena cava lying to the right of the midline.

Encirclement of the distal aorta, just proximal to its bifurcation, is aided by lateral retraction of the inferior mesenteric artery because this parallels, to the left, the distal aorta. Skeletonization of the distal aorta; however, should be done with some care to avoid inadvertent laceration of the left fourth lumbar vein, which passes to the left posterior to the aorta.

As the abdominal aorta is skeletonized from inferior to superior, the first structure to be encountered should be the inferior mesenteric artery. More superiorly, again from the anterior surface of the aorta, small gonadal arteries can be identified. These may arise as a common trunk, separately and at the same or different levels, or they may arise from a renal or suprarenal artery. The next structure to be encountered should be the left renal vein, which typically crosses the anterior surface of the aorta just inferior to the origins of the superior mesenteric artery and left renal artery. However, retroaortic left renal veins or circumaortic left renal veins do occur, as commonly as 6% of the time. The superior mesenteric artery usually originates about 1 cm distal to the celiac artery; however, both of these major arteries can arise from a common trunk. Rarely, one or more of the three celiac artery branches (left gastric, splenic, or common hepatic) arise independently from the aorta and the procurement surgeon needs to be aware of these anatomic variations.