A Cattel-Braasch maneuver extending across the midline, with complete mobilization of the distal small bowel, right colon, and duodenum (Fig. 1.3) brings the distal aorta and inferior vena cava (IVC) into view (Fig. 1.4).

Division of the inferior mesenteric artery (IMA) aids in the dissection of the distal aorta, which is encircled with two umbilical tapes (Fig. 1.5). This will ultimately be the site for aortic cannulation and flushing. The IVC lies just to the right.

The inferior mesenteric vein (IMV) is identified lateral to the ligament of Treitz and encircled with two silk ties (Fig. 1.6) in preparation for cannulation and flushing via the portal venous circulation (Fig. 1.7). The left renal vein and its junction with the IVC are seen posterior and medial to the IMV.

The third portion of the duodenum is retracted cephalad, and the superior mesenteric artery (SMA) (Fig. 1.8) is identified and encircled with a vessel loop (Fig. 1.9). The SMA is selectively occluded with the vessel loop soon after flushing is initiated in order to minimize overflushing of the pancreas.

The supraceliac aorta is approached by dividing the left triangular ligament of the liver and the right diaphragmatic crus. An umbilical tape is used to encircle the aorta; if this maneuver proves to be technically challenging, it is best to simply dissect out an area that will allow for vascular clamping (Fig. 1.10).

The gastrohepatic ligament is examined and divided if no aberrant left hepatic artery is noted (Fig. 1.11). Unless very diminutive, all aberrant left hepatic arteries should be preserved.

The next step involves dissection of the hepatoduodenal ligament. This begins by first investigating for an aberrant right hepatic artery. This will be palpated at the right edge of the ligament, posterior to the bile duct and lateral to the portal vein. The course of an aberrant right hepatic artery is shown (Fig. 1.12, black broken line). If present, the extent of dis Our practice is to anastomose the aberrant right hepatic artery to the donor gastroduodenal artery (GDA); this obviates the need for extensive dissection to the level of the SMA and minimizes the risk of injury to the pancreatic allograft.

With conventional anatomy, the common hepatic artery is identified and traced to the celiac axis; during this dissection the GDA and splenic artery will be readily identified. The hepatic artery does not need to be completely dissected out at this time—rather, just the origin of the above branches need to be identified (Fig. 1.13).

Limited dissection of the common bile duct (CBD), which lies just to the right and anterior to the main portal vein, is performed, followed by ligation of the distal CBD just superior to the pancreas. The CBD is transected with a scalpel and the proximal end is left open (Fig. 1.14). The gallbladder is incised and flushed with saline to clear the CBD of retained bile (Fig. 1.15).

The donor is heparinized (300 units/kg). After 3 min, the distal aorta is ligated and a 24 Fr aortic cannula is placed into the distal aorta and secured with the umbilical tape (Figs. 1.16 and 1.17). The IMV is ligated distally and a 14 Fr cannula is placed. Alternatively, portal flushing (via the portal vein) can be deferred until after removal of the liver.

The supraceliac aorta is ligated and cold preservation fluid is infused via the two cannulas. The suprahepatic IVC is transected at its entrance to the right atrium in order to vent the perfusate (Fig. 1.18). If heart procurement is also performed, the thoracic surgeon will incise the IVC just cephalad to the diaphragm. In adults, 5 l of preservation fluid is flushed via the aortic (3 L) and IMV (2 L) cannulas. Slushed ice is placed into the peritoneal and pericardial cavities to complete the cooling process (Fig. 1.19). The SMA is occluded by pulling up the vessel loops after 1 L of perfusate is infused. Thoracic organ excision occurs once flushing has been initiated.